Form H1833, Your Medicaid Benefits Are Ending - Cover Letter

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Effective Date: 12/2015


Updated: 6/2016


  • To notify former Medicaid for Breast and Cervical Cancer (MBCC) applicants or recipients certified on another Medicaid program that their benefits will be ending within two months so that they can reapply for MBCC using Form H2340, Medicaid for Breast and Cervical Cancer Renewal, if they still need treatment for breast or cervical cancer and 12 months or less has passed since the latter of their breast or cervical cancer diagnosis date or the date their active treatment was last verified.
  • To tell former MBCC applicants or recipients that to reapply for MBCC that they must complete and return Form H2340.
  • To inform former MBCC applicants or recipients of the supporting documents that need to be returned with Form H2340.
  • To inform former MBCC applicants or recipients where they can locate a Breast and Cervical Cancer Services contractor.


When to Prepare

  • The Texas Integrated Eligibility Redesign System (TIERS) generates Form H1833 to send with the MBCC reapplication packet.
  • TIERS pre-populates the following basic client information:
    • name,
    • address, and
    • Eligibility Determination Group (EDG) number.


  • The form is only generated by TIERS and is mailed to the clients with Form H2340.
  • Staff may reprint the form if a household requests a copy from TIERS History Correspondence.
  • TIERS will not allow staff to generate the form in Manual Correspondence.

Form Retention

TIERS maintains a copy of the form in History Correspondence.