Form H1113, Application for Prior Medicaid Coverage

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Documents

Effective Date: 4/2018

Instructions

Updated: 11/2024

Purpose

Provides a person with an application form for prior Medicaid coverage.

Procedure

When to Prepare

Complete Form H1113 when:

  • unpaid medical bills are claimed; or
  • when Medicaid services are provided by the DSHS for a month before the application month;
  • the advisor gives the form to the person before or during the interview;
    • the form may also be mailed to the person when the interview is conducted by phone; or
    • when processing an application for a type of assistance not requiring an interview;
  • the person or their authorized representative completes and signs the form and if necessary, the advisor helps complete the form.

Number of Copies

Save a copy in the electronic case record and upon request provide the household with a copy or a Form H1800, Receipt for Application, Medicaid Report, Verification, Report of Change (PDF).

Transmittal

H1113 can be submitted:

Households may fax the form to 877-477-2839 or mail it to:

Texas Health and Human Services Commission
P.O. Box 149025
Austin, TX 78714-9025

Detailed Instructions

How to Prepare

  • the advisor documents in the Case Comments if:
    • the current eligibility factors for Medicaid, including income, are the same as those during the prior period and current eligibility is documented; or
  • the worker documents the reason for ineligibility if:
    • any factor of eligibility is different and prevents eligibility for the prior period.

Note:

  • For Children's Medicaid only, request income verification for prior Medicaid coverage for what is required for ongoing eligibility, such as:
    • at least one paycheck stub for each working family member for each prior month; or
    • require Form H1113 if the family provides enough information to determine eligibility for prior months.
  • For Medicaid for Breast and Cervical Cancer (MBCC), do not require Form H1113 or verification of unpaid medical bills when processing a request for prior months.

For Agency Use Only — The staff records the date of application and the month(s) involved in the prior Medicaid application.

Item 1 — The client answers yes or no to the question specific to the three months listed in the Agency Use Only section. Then the client completes the box for the other people who need to be included in the household based on their tax filing status.

Item 2 — The client answers yes or no to the question specific to the three months listed in the Agency Use Only section. The client only fills the box out if question is answered yes.

Item 3 — The client answers yes or no to the question specific to the three months listed in the Agency Use Only section. The client only fills the box out if question is answered yes.

Item 4 — The client lists unpaid medical bills for anyone listed on page 1 specific to the three months listed in the Agency Use Only section. Verification of unpaid bills is required. The worker must verify income for each month that there are unpaid medical bills.