Revision 21-1; Effective March 1, 2021


Medicaid Buy-In (MBI) Program forms include:

  • Form H0051, Medicaid Buy-In Premium Payment Notice – Use to inform a recipient that an MBI premium is due.
  • Form H0052, Medicaid Buy-In Refund Notice – Use to notify a recipient that a partial premium payment was received and will be returned within 60 days because the full month's premium must be received in one payment.
  • Form H0053, Medicaid Buy-In Potential Eligibility Notice – Use to notify an applicant of potential eligibility for the MBI program.
  • Form H0054, Medicaid Buy-In Eligibility Notice – Use to notify an applicant of eligibility for the MBI program.


Form H1200-MBI, Application for Benefits – Medicaid Buy-In, is the application form for the MBI program. Applicants may also use Form H1200, Application for Assistance — Your Texas Benefits, and write in “MBI” on the top of the form to apply for the MBI program.

Missing Information

Form H1020, Request for Information or Action – use to request missing information or verifications.


Form TF0001, Notice of Case Action - use to notify an applicant or recipient of ineligibility for the MBI program.

Note: Staff must manually add the correct reason for denial in the comments section before generating the TF0001.

Related Policy
Missing Information Due Dates, B-6420
Denials, B-6500
Denial Reasons, M-8500
MBI Screening Tool and Worksheet, Appendix XXXIX


M-9100 Replacement Medicaid Card

Revision 16-3; Effective September 1, 2016


Your Texas Benefits Medicaid ID card will only be replaced if the card is damaged, lost or stolen. If an individual requests a replacement of their Your Texas Benefits Medicaid ID card, issue a Form H1027-A.

Note: Inform the recipient to call 1-855-827-3748 for a replacement card.