B-3100, Application Process

Revision 20-2; Effective June 1, 2020

For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:

Form H1200 , Application for Assistance — Your Texas Benefits , for all MEPD programs;

Form H1200-EZ , Application for Assistance — Aged and Disabled , for Medicare Savings Programs (MSP) programs;

Form H1200-PFS , Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement , for state supported living centers, state hospitals, and state centers;

Form H1200-MBI , Application for Benefits — Medicaid Buy-In , for the MBI program only; or

Form H1200-MBIC , Application for Benefits — Medicaid Buy-In for Children (MBIC) , for the MBIC program only.

If requested, give the applicant a receipt ( Form H1800 , Receipt for Application/Medicaid Report/Verification/Report of Change) to verify they provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.

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B-3100, Application Process

Official source

Revision 20-2; Effective June 1, 2020

For Medicaid for the Elderly and People with Disabilities (MEPD), the application for assistance is based on one of the following versions of Form H1200:

Form H1200 , Application for Assistance — Your Texas Benefits , for all MEPD programs;

Form H1200-EZ , Application for Assistance — Aged and Disabled , for Medicare Savings Programs (MSP) programs;

Form H1200-PFS , Medicaid Application for Assistance (for Residents of State Facilities) Property and Financial Statement , for state supported living centers, state hospitals, and state centers;

Form H1200-MBI , Application for Benefits — Medicaid Buy-In , for the MBI program only; or

Form H1200-MBIC , Application for Benefits — Medicaid Buy-In for Children (MBIC) , for the MBIC program only.

If requested, give the applicant a receipt ( Form H1800 , Receipt for Application/Medicaid Report/Verification/Report of Change) to verify they provided an application. An applicant may request Form H1800 by fax or mail. Mail the receipt to the applicant’s listed address.