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Effective Date: 



Updated: 1/2011


To provide Health and Human Services Commission (HHSC) staff:

  • an employer-completed verification of employment, wages and job-related health insurance information for Medicaid Buy-In for Children (MBIC); and
  • a source for verification of earned income and projecting changes in income when other methods are unavailable or insufficient.


When to Prepare

Form H1028-MBIC is used to obtain verification of income and/or health insurance information. The form is included with applications or redeterminations. The parent gives the form to the employer to complete. The form may be returned to the parent to forward to HHSC or the employer may mail or fax the form to HHSC.

If the form is not returned, staff send the form to the parent with Form H1020, Request for Information or Action, as a missing information item. It is the parent’s responsibility to see that the information is provided. Enclose a self-addressed, postage-paid envelope for the Document Processing Center.

Staff may also need to send the form to the parent if the Form H1200-MBIC, Application for Benefits – Medicaid Buy-In for Children, employment section is checked "no," but information and verification of employment and employment-related health insurance was not provided.

If it is necessary for staff to send Form H1028-MBIC to the employer, provide a self-addressed, postage-paid envelope for the Document Processing Center.

Number of Copies

The system sends Form H1028-MBIC with the application or redetermination.


Form H1028-MBIC and Form H1200-MBIC are sent to the client at the client's address or that of the authorized representative. A prepaid return envelope is enclosed. If necessary, the form can be sent with Form H1020 as missing information to the parent or the employer.

Form Retention

Form H1028-MBIC will be imaged and available in the electronic case record.

Detailed Instructions

Enter the employee's name and Social Security number in the appropriate spaces.

The employer completes the rest of the form. All items are self-explanatory.

The employer returns the form to the employee to be returned to HHSC, mails it to the Document Processing Center in the prepaid self-addressed envelope provided, or faxes it to the number indicated on the form.