Revision 24-4; Effective Dec.1, 2024

Revision 22-3; Effective September 1, 2022

The Medicaid Buy-In for Children (MBIC) program is a Medicaid program for children with disabilities up to 19 years old with family income up to 300% of the federal poverty level (FPL). A family may have to pay a monthly premium as a condition of eligibility. The amount of the premium is based on the family’s income and if a child is covered under a parent's employer-sponsored health insurance plan.

MBIC recipients receive regular Medicaid benefits, a Medicaid ID card and an MBIC member handbook. The handbook is a guide that provides basic information about MBIC and explains what to do if a person has questions or needs help while on the program.

All regular Medicaid for the Elderly and People with Disabilities (MEPD) policies apply to this program except for the eligibility items specifically identified in this chapter. For example, citizenship and Texas residency are not addressed in this chapter. Therefore, follow regular MEPD policies for citizenship and Texas residency.

All eligibility requirements for this program must be verified. MBIC is not a client-declaration program.

N-1310 MBIC and Nursing Facilities

Revision 21-4; Effective December 1, 2021

Medicaid Buy-In for Children (MBIC) is a community-based Medicaid program. If an MBIC recipient enters a nursing facility or an intermediate care facility for people with intellectual disability or related condition (ICF/IID), contact the authorized representative (AR) to determine how long the recipient’s is expected to remain in the facility. 

If the facility stay is expected to be less than 90 days, no action is required. 

If the facility stay is expected to be more than 90 days, obtain any additional eligibility verifications needed and complete a program transfer to facility Medicaid.

N-1320 MBIC and Home and Community-Based Services Waivers

Revision 21-3; Effective September 1, 2021

Home and Community-Based Services waiver services such as Community Living Assistance and Support Services, are not paid under the MBIC systems eligibility codes. The exception is Texas Home Living (TxHmL). Therefore, if a referral for any other waiver is received, get a new Form H1200, Application for Assistance – Your Texas Benefits (PDF). Then gather any other verification needed to determine eligibility for ME-Waivers and complete a program transfer if all eligibility criteria are met.

Note: Medicaid Buy-In for Children (MBIC) will pay for TxHmL waiver services under MBIC systems eligibility codes.

N-1330 MBIC and Medicare Savings Programs

Revision 11-3; Effective September 1, 2011

An MBIC-eligible applicant/recipient can also have:

• Qualified Medicare Beneficiary (QMB)
• Specified Low-Income Medicare Beneficiary (SLMB)

An MBIC-eligible applicant/recipient cannot have:

• Qualifying Individuals-1 (QI-1). The applicant/recipient must choose between MBIC and QI-1.
• Qualified Disabled Working Individuals

Reminder: Resource information is required for Medicare Savings Programs (MSP). Parental deeming of income and resources and support and maintenance applies to MSP.

N-1340 Medicaid Estate Recovery Program (MERP)

Revision 11-3; Effective September 1, 2011

Due to the age of these recipients, the Medicaid Estate Recovery Program (MERP) does not apply to MBIC.

Revision 11-3; Effective September 1, 2011

Although MEPD policy does not require a date of birth for an applicant/recipient's family members, the Texas Integrated Eligibility Redesign System (TIERS) requires an entry in the date of birth (DOB) field for all members of the family unit for file clearance purposes. If a non-MBIC family unit member does not provide a DOB, use a default DOB of 02-29-1988. The date will automatically make any siblings' age over 22 so they will not be included in either the family unit or budget group. Do not request the DOB for a non-MBIC family member if it is not provided.

Revision 11-3; Effective September 1, 2011

Eligibility is available through the end of the month of the child's 19th birthday. If an application is received in the month of the 19th birthday, process the MBIC application and determine eligibility for that month and the three months prior to that application.

Example: Application is received on April 5. Applicant turns 19 on April 17. Determine eligibility for the application month of April and three prior months of January, February and March.

Revision 11-3; Effective September 1, 2011

An applicant/recipient must meet the Supplemental Security Income (SSI) definition of disability. If an applicant/recipient has not had a disability determination made by the Social Security Administration, use HHSC's Disability Determination Unit for disability determinations. Follow regular MEPD policy for disability determinations.

Revision 11-3; Effective September 1, 2011

An applicant/recipient must not be married.

Revision 11-3; Effective September 1, 2011

Verification of school or job training attendance for siblings age 18 through age 22 is required.

Revision 11-3; Effective September 1, 2011

There is no resource test for this program.

There is no parental deeming of resources for this program.

Revision 11-3; Effective September 1, 2011

Even though there is no resource test for this program, the income from income-producing resources is considered. Determine if the income from income-producing resources is countable using regular MEPD policy.

There is no support and maintenance considered for Medicaid Buy-In for Children. Do not develop support and maintenance.

There is no parental deeming of income for this program.

Revision 11-3; Effective September 1, 2011

The following chart outlines the eligibility treatment for various situations involving ESI:

Revision 22-3; Effective September 1, 2022

Medicaid Buy-In for Children (MBIC) has two budgeting concepts: family unit and budget group.

Family unit is used to determine the appropriate federal poverty level (FPL) to use as an income limit. Budget group is used to determine the countable income of the family unit to compare to the FPL for eligibility.

The total number of members in the family unit is used in eligibility income budgeting to determine the income limit for the family.

Related Policy

Determining the Budget Group, N-6340

Revision 15-4; Effective December 1, 2015

To determine a family unit, count the:

• MBIC applicant or recipient, and
• applicant's or recipient's parents living in the same household (see definition of parent in the Glossary), and
• applicant's or recipient's siblings (eligible or ineligible) living in the same household (see definition of sibling in the Glossary).

For a stepparent to be included in the family unit and the stepparent’s income to be considered in the budget group, a stepparent must:

• be the current spouse of a natural or adoptive parent, and
• live in the same household as the MBIC applicant or recipient and the natural or adoptive parent.

If neither a stepparent nor the stepparent's income is considered because these criteria are not met, do not consider a stepsibling or their income.

Revision 22-3; Effective September 1, 2022

Eligibility income budgeting for Medicaid Buy-In for Children (MBIC) is different from other MEPD programs.

The family gross income (earned and unearned) must not exceed 300% of the FPL. 

Due to substantial income exclusions, the income limit used for the eligibility determination is equal to or less than 150% FPL for the family size. The income limit for each case may be different depending on the family size.

Related Policy

Budget Reference Chart, Appendix XXXI

N-6310 Income Treatment

Revision 11-3; Effective September 1, 2011

Treat earned and unearned income the same in MBIC budgeting. Do not deduct:

• the $20-general exclusion, or
• the earned income exclusion of $65 plus one-half of the remaining income.

N-6320 MBIC Income Exclusion

Revision 11-3; Effective September 1, 2011

The MBIC income exclusion is $85 plus one-half of the remaining income and is deducted at the end of the budget calculation.

N-6330 Ineligible Sibling Exclusion

Revision 26-2; Effective June 1, 2026

Allow an exclusion from an ineligible sibling's income before counting the ineligible sibling's income in the eligibility budget. Allow this exclusion for each ineligible sibling in the family unit. The base exclusion amount changes each year and is equal to two times 150% FPL for a family of one plus $85.

Effective March 1, 2026, the ineligible sibling's exclusion amount is $4,075. Deduct this amount from the ineligible sibling's total income and count any remaining income in the budget. If the ineligible sibling's income is less than the total exclusion, disregard all the ineligible sibling's income in the budget.

Related Policy

Examples of Budgeting Steps, N-6351

N-6340 Determining the Budget Group

Revision 15-4; Effective December 1, 2015

The budget group is determined by identifying the members of the family unit whose income is countable in the eligibility budget. The number of people in the family unit and in the budget group may be different.

Do not count any of the income of a family unit member that:

• has needs-based income, such as veteran's pension or Supplemental Security Income (SSI); or
• is a Medicaid-eligible person, such as another MBIC applicant/recipient in the household.

For a stepparent's income to count, the stepparent must:

• be the current spouse of a natural or adoptive parent, and
• live in the same household as the MBIC applicant or recipient and the natural or adoptive parent.

If a stepparent's income is not considered because these criteria are not met, do not consider a stepsibling's income either.

Reminders:

• If school or job training attendance has not been verified for an ineligible sibling between ages 18 and 22, that sibling is not part of the family unit and, therefore, is not included in the budget group.
• Consider absences due to active military assignments as temporary and include that individual in the budget group.

N-6350 Budgeting Steps

Revision 22-3; Effective September 1, 2022

Income related budget steps:

1. Determine the family unit members.
2. Determine the appropriate FPL based on the family size. The FPL that corresponds to the total number of family unit members is the income limit for the family. Example: For a family unit of five, the income limit is 150% of the FPL for a family of five.
3. Determine the budget group members.
4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.
5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.
6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount. If the exclusion amount is greater than the ineligible sibling's income, disregard all of that ineligible sibling's income.
7. Total the income amounts determined in steps 4-6.
8. Subtract $85 from the total in step 7.
9. Divide the amount in step 8 by two.

The remainder is countable income. Compare this to the income limit determined in step 2.

Related Policy

Budget Reference Chart, Appendix XXXI

N-6351 Examples of Budgeting Steps

Revision 26-2; Effective June 1, 2026

The figures used in these charts are examples only. They may not reflect the current federal poverty level (FPL) limits or the deduction amounts that are based on FPL.

Example 1

The members of the household are:

• Applicant — no income
• Applicant's parent — gross earnings $2,400 monthly
• Applicant's stepparent — gross earnings $3,000 monthly
• Applicant's ineligible 16-year-old sibling — no income
• Applicant's ineligible 19-year-old sibling, non-student — gross earnings $800 monthly
• Applicant's ineligible 14-year-old stepsibling — no income

Note: Since the 19-year-old ineligible sibling is over 18 and not a student, do not consider the sibling or the sibling's income.

1. Determine the family unit members.
   • Applicant
   • Applicant’s parent
   • Applicant’s stepparent
   • Applicant’s ineligible 16-year-old sibling
   • Applicant’s ineligible 14-year-old stepsibling

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of five = $4,835

3. Determine the budget group members.

   Budget group is the same as the family unit.

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant’s monthly gross countable income = $0

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parents' monthly gross countable income = $5,400

6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount.

   Income of each ineligible sibling that exceeds $4,075 = $0

7. Total the income amounts determined in steps 4–6.

   $0 applicant’s monthly gross countable income + $5,400 parents’ monthly gross countable income + $0 ineligible siblings’ gross countable income = $5,400 total budget group income

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   $5,400 – $85 = $5,315

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   $5,315/2 = $2,657.50 ≤ $4,835

Eligibility result: Eligible

Example 2

The members of the household are:

• Applicant — Retirement, Survivors, and Disability Insurance (RSDI) $167
• Applicant's parent — gross earnings $4,500 monthly
• Applicant's ineligible 16-year-old sibling — gross earnings $100 monthly
• Applicant's 20-year-old ineligible sibling, student — gross earnings $400 monthly
• Applicant's 10-year-old stepsibling — no income

Stepparent died one year ago.

Note: Since the stepparent is deceased, do not consider the ineligible stepsibling or the ineligible stepsibling's income.

1. Determine the family unit members.
   • Applicant
   • Applicant’s parent
   • Applicant’s ineligible 16-year-old sibling
   • Applicant’s ineligible 20-year-old sibling (student)

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of four = $4,125

3. Determine the budget group members.

   Budget group is the same as the family unit.

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant’s monthly gross countable income = $167

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parent’s monthly gross countable income = $4,500

6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount.

   Income of each ineligible sibling that exceeds $4,075= $0

7. Total the income amounts determined in steps 4–6.

   $167 applicant’s monthly gross countable income + $4,500 parent’s monthly gross countable income + $0 ineligible siblings’ gross countable income = $4,667 total budget group income

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   $4,667 – $85 = $4,582

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   $4,582/2 = $2,291 ≤ $4,125

Eligibility result: Eligible

Example 3

The members of the household are:

• Applicant — RSDI $88
• Applicant's stepparent — gross earnings $5,925 monthly
• Applicant's ineligible 2-year-old sibling — no income
• Applicant's ineligible 19-year-old sibling, non-student — gross earnings $800 monthly
• Applicant's ineligible 7-year-old stepsibling — no income

Applicant’s parent died two years ago.

Note: Do not consider the stepparent and the ineligible stepsibling or their income since the natural parent died and the stepparent is not a current spouse of the natural parent. Do not consider the sibling or the sibling's income since the 19-year-old ineligible sibling is over 18 and not a student.

1. Determine the family unit members.
   • Applicant
   • Applicant’s ineligible 2-year-old sibling

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of two = $2,705

3. Determine the budget group members.

   Budget group is the same as the family unit.

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant’s monthly gross countable income = $88

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parents' monthly gross countable income = $0

6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount.

   Income of each ineligible sibling that exceeds $4,075= $0

7. Total the income amounts determined in steps 4–6.

   $88 applicant’s monthly gross countable income + $0 parent’s monthly gross countable income + $0 ineligible siblings’ gross countable income = $88 total budget group income

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   $88 – $85 = $3

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   $3/2 = $1.50 ≤ $2,705

Eligibility result: Eligible

Example 4

The members of the household are:

• Applicant — RSDI $88
• Sibling, 7-year-old, also an applicant — RSDI $88
• Applicant's parent — gross earnings $8,700 monthly
• Applicant's ineligible 2-year-old sibling — no income

Applicant's other parent died two years ago.

Note: Count a sibling in the family unit size if the sibling is also applying for MBIC. Calculate separate budgets since one eligible sibling's income is not counted in the other eligible sibling's budget group.

1. Determine the family unit members.
   • Applicant
   • Applicant's 7-year-old sibling, who is also an MBIC applicant
   • Applicant's parent
   • Applicant's ineligible 2-year-old sibling

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of four = $4,125

3. Determine the budget group members.
   • Applicant
   • Applicant’s parent
   • Applicant's ineligible 2-year-old sibling

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant One’s monthly gross countable income = $88

   Applicant Two’s monthly gross countable income = $88

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parent’s monthly gross countable income = $8,700

6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount.

   Income of each ineligible sibling that exceeds $4,075 = $0

7. Total the income amounts determined in steps 4–6.

   $88 applicant one’s monthly gross countable income + $8,700 parent’s monthly gross countable income + $0 ineligible siblings’ gross countable income = $8,788- total budget group income for applicant one

   $88 applicant two’s monthly gross countable income + $8,700 parent’s monthly gross countable income + $0 ineligible siblings’ gross countable income = $8,788 total budget group income for applicant two

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   Applicant one: $8,788 – $85 = $8,703

   Applicant two: $8,788 – $85 = $8,703

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   Applicant one: $8,703/2 = $4,351.50 ≥ $4,125

   Applicant two: $8,703/2 = $4,351.59 ≥ $4,125

Eligibility result for applicant one: Not eligible

Eligibility result for applicant two: Not eligible

Example 5

The members of the household are:

• Applicant — RSDI $88
• Applicant's parent — RSDI $699
• Applicant's ineligible 2-year-old sibling — RSDI $88
• Applicant's ineligible 5-year-old sibling — RSDI $88
   

1. Determine the family unit members.
   • Applicant
   • Applicant’s parent
   • Applicant's ineligible 2-year-old sibling
   • Applicant's ineligible 5-year-old sibling

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of four = $4,125

3. Determine the budget group members.

   Budget group is the same as the family unit.

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant’s monthly gross countable income = $88

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parent’s monthly gross countable income = $699

6. For each ineligible sibling, determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount.

   Income of each ineligible sibling that exceeds $4,075 = $0

7. Total the income amounts determined in steps 4–6.

   $88 applicant’s monthly gross countable income + $699 parent’s monthly gross countable income + $0 ineligible siblings’ gross countable income = $787 total budget group income

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   $787 – $85 = $702

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   $702/2 = $351 ≤ $4,125

Eligibility result: Eligible

Example 6

The members of the household are:

• Applicant — no income
• Applicant's parent — gross earnings $4,500 monthly
• Applicant's other parent — $850 Veterans Affairs (VA) benefits with aid and attendance monthly; gross earnings of $300 monthly
   

1. Determine the family unit members.
   • Applicant
   • Applicant’s parents

2. Determine the appropriate FPL based on the family size.

   Income limit: 150% FPL for family of three = $3,415

3. Determine the budget group members.

   Budget group is the same as the family unit.

4. Determine the monthly gross countable earned and unearned income, if any, of the MBIC applicant or recipient.

   Applicant’s monthly gross countable income = $0

5. Determine the combined monthly gross countable earned and unearned income of the applicant or recipient's parents.

   Parents' monthly gross countable income = $4,500

   VA income is needs-based, so none of the other parent's income is included in the budget.

6. Determine any monthly gross countable income that exceeds the ineligible sibling's exclusion amount for each ineligible sibling.

   Step does not apply because applicant has no ineligible siblings.

7. Total the income amounts determined in steps 4–6.

   $0 applicant’s monthly gross countable income + $4,500 parents’ monthly gross countable income = $4,500 total budget group income

8. Subtract $85 from the total in step 7 to begin applying the MBIC income exclusion.

   $4,500 – $85 = $4,415

9. Divide the amount in step 8 by two to complete the MBIC income exclusion. Compare to the income limit determined in step 2.

   $4,415/2 = $2,207.50 ≤ $3,415

Eligibility result: Eligible

Revision 11-3; Effective September 1, 2011

Premiums are waived if an applicant/recipient is an Alaskan Native or American Indian.

Revision 11-3; Effective September 1, 2011

If there is more than one MBIC-eligible recipient in the family unit, there will be only one premium per family unit. Each eligibility determination group (EDG) will have a premium amount calculated; however, the lowest premium amount of all EDGs will be the premium charged.

Revision 11-3; Effective September 1, 2011

Premiums are due on the fifth of each month.

Premiums are not required for application month, disposition month or any month in between.

Example: Application is received in January 2011. Case is disposed in March 2011 with a medical effective date (MED) of Jan. 1, 2011. No premiums are required for January, February or March. First premium is due April 5. Premiums are required for the month following the disposition month regardless of the MED.

If premiums are required, payment of MBIC premiums is a condition of continued eligibility.

N-7310 Grace Period for Premiums

Revision 11-3; Effective September 1, 2011

An applicant/recipient is given a 60-day grace period to make a premium payment before denial occurs. If a recipient has missed making a premium payment for two consecutive months, the Texas Integrated Eligibility Redesign System (TIERS) will send Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form. If a payment is not received by two days before TIERS cutoff, two months after the first missed payment, and a valid hardship is not claimed by the due date on the Form H0065-MBIC, TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from the date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

N-7320 Premiums and Reapplication for MBIC

Revision 11-3; Effective September 1, 2011

If a person is denied MBIC, but later reapplies and is eligible for MBIC, there is no requirement to pay the missed premiums from the last eligibility period before new eligibility can be granted.

N-7330 Coordination with the Children with Special Health Care Needs (CSHCN) Program

Revision 11-3; Effective September 1, 2011

If an MBIC applicant/recipient is also eligible for the CSHCN Program through the Department of State Health Services (DSHS), the state will pay the MBIC premium. There is no coordination or verification required by Medicaid for the Elderly and People with Disabilities (MEPD) specialists. Direct payment of the person's medical insurance premiums by anyone on the person's behalf is not considered as income. See Section E-1710, Medical Care and Services That Are Not Income.

DSHS will make referrals of CSHCN persons that may be potentially eligible for MBIC. Some of these people may already be eligible for the Children's Health Insurance Program (CHIP). Based on information from DSHS, there is no requirement for a CSHCN eligible person that is also eligible for CHIP to switch to MBIC. It is the person's choice. If the person chooses to remain in CHIP, document in case comments the person's choice and deny the MBIC application as a voluntary withdrawal.

Revision 11-3; Effective September 1, 2011

Premium amounts vary based on whether the family does or does not have ESI and whether HIPP is involved or not. Premium amounts are automatically determined by TIERS.

The charts in Section N-7410, Charts for Premium Amounts, outline the premium amounts for persons with:

• no ESI;
• ESI and state-paid HIPP; or
• ESI and no state-paid HIPP.

N-7410 Charts for Premium Amounts

Revision 22-3; Effective September 1, 2022

No ESI

Note: These premium amounts are current. These amounts are subject to change when FPL limits change.

ESI with State-Paid HIPP

Note: These premium amounts are current. These amounts are subject to change when FPIL limits change.

ESI and No State-Paid HIPP

No premiums are required for families with ESI who are not eligible for HIPP. These families are paying their full share of the premium for ESI and are not expected to also pay a premium for MBIC.

Revision 11-3; Effective September 1, 2011

A hardship exemption may be granted for loss of income if the loss of income is due to:

• termination of employment because of layoff or business closing;
• involuntary reduction in work hours;
• a parent leaving the household because of divorce or separation; or
• a parent's death (the parent had to be previously residing in the same household as the MBIC applicant/recipient).

No hardship exemption is allowed to waive prior months premium(s).

Hardship exemption is only allowed once per household every 12 calendar months (regardless of how many MBIC recipients are in the household).

A hardship must be requested within 10 days from the date on Form H0065-MBIC, Hardship Form. A hardship request must be in writing; however, a verbal request is acceptable to meet the 10-day deadline. Written follow-up is required.

Example: First missed payment is May 5, 2011. On June 5, 2011, the May payment is missed a second time. On June 7, 2011, Form H0062-MBIC, Late Payment Notice, and Form H0065-MBIC, Hardship Form, are sent to the client/authorized representative. Due date for premium payment is July 6, 2011. Due date for a hardship to be claimed is June 17, 2011 (10 days from date of Form H0065-MBIC). Payment must be received by two days before cut-off in July 2011 or hardship claimed by June 17, 2011. If no payment is received or hardship claimed, denial is effective July 31, 2011. TIERS will auto terminate the MBIC EDG(s) effective the end of that month.

N-7510 Hardship Approval

Revision 11-3; Effective September 1, 2011

Approve a hardship request if one of the valid reasons is met. Do not require verification of hardship reasons. Use client's statement and signature on Form H0065-MBIC, Hardship Form, as proof of the hardship; however, if the reason is something that would potentially impact benefits (such as loss of job), verify the change for potential eligibility changes to ongoing benefits. This does not have to be done before the hardship can be approved. Notify a client/authorized representative of the hardship approval on Form TF0001-MBIC, Hardship Waiver Approved.

If approved, the hardship exemption begins on the first of the month for which a premium payment was not received and is granted for three consecutive months.

Example: Premiums were missed in May and again in June. Hardship was claimed on Form H0065-MBIC, and hardship was approved in July. Premiums are waived for May, June and July.

N-7511 Hardship Approval Reasons

Revision 11-3; Effective September 1, 2011

Form TF0001-MBIC, Hardship Waiver Approved, will be pre-populated with one of the following reasons.

• Someone living with you was laid off their job. – OR – The place where they work closed.
• Someone living with you has less income because they work fewer hours.
• A parent left the house because of a divorce or separation.
• A parent died. (This is an approval reason but this actual verbiage will not print on the TF0001.)

N-7520 Hardship Denial

Revision 11-3; Effective September 1, 2011

Deny a hardship request if:

• none of the valid reasons are met; or
• Form H0065-MBIC, Hardship Form, or a verbal request was not received by the due date; or
• a hardship has been granted within the past 12 calendar months. TIERS will track the12-month period.

Notify a client/authorized representative of the hardship denial via Form TF0001-MBIC, Hardship Waiver Denied.

N-7521 Hardship Denial Reasons

Revision 11-3; Effective September 1, 2011

Form TF0001-MBIC, Hardship Waiver Denied, will be pre-populated with one of the following reasons.

• We didn't get your "Hardship Form" (H0065-MBIC) by the due date.
• It hasn't been 12 months since we last stopped your payments. Your payments can be stopped for three months only once in 12 months.
• You didn't lose money from a job (income) for reasons that allow us to stop your payments.

Revision 11-3; Effective September 1, 2011

A presidential-declared emergency hardship exemption will automatically be granted to recipients living in the declared area and premiums will be waived for three months. Recipients do not have to request a hardship for a presidential-declared emergency. TIERS will send an "emergency special notice" to inform recipients at the start of the presidential-declared emergency period that the premiums have been waived.

For MBIC recipients, the waiver of premiums for a presidential-declared emergency is for the month of declaration and forward for a total of three months.

Hardship exemption and presidential-declared emergency periods can overlap. They do not run consecutively.

Example: A recipient has hardship exemption for January, February and March. A presidential-declared emergency is declared for March. The presidential-declared emergency hardship would normally be allowed for March, April and May. Total number of months the recipient is not required to pay premiums is five, which are January, February, March, April and May.

A presidential-declared emergency has priority over a hardship exemption if the two situations fall during the same time period. If a hardship exemption has been approved but a presidential-declared emergency is granted for the same time period, the client cannot have another hardship exemption for 12 months.

There is no limit to how many times a recipient may receive a presidential-declared emergency hardship; however, a recipient may only receive one presidential-declared emergency per disaster.

Revision 11-3; Effective September 1, 2011

MBIC correspondence refers to these as "payments for past months."

Prior months' eligibility is not granted until premiums for prior months are paid. If all prior months have a $0 premium, eligibility will be granted upon disposition. If any of the prior months have a premium, the premium is due two months after the initial premium due date.

Example: Application is filed in March, disposed on April 1.The prior months are January and February. The premiums for January and February are due on July 5 (two months after May 5, the initial premium due date).

When premiums are paid, eligibility is granted beginning with the last month of the prior month period. Months cannot be skipped, even if a month with a $0 premium falls between two months that require a premium. In the following examples, January, February and March are prior months.

Examples:

• January is $90, February is $90 and March is $90. As premiums are paid, eligibility is granted first for March, then February, and then January.
• January is $90, February is $0 and March is $90. March has to be paid before February is granted.

Reminder: No hardship is allowed to waive prior months' premium(s).

Revision 11-3; Effective September 1, 2011

If a parent gets health insurance at work, that information will be sent to the HIPP program for review. If certain standards are met, HIPP will pay the entire health insurance premium as a reimbursement to the individual.

Parents/persons who want to learn more can call 1-800-440-0493 or visit www.gethipptexas.org.

When ESI information is entered into TIERS, this information is automatically sent to HIPP. HIPP eligibility is not an MEPD specialist's responsibility; however, HIPP eligibility does impact the MBIC premium amount.

Revision 11-3; Effective September 1, 2011

Cost-sharing is the amount a person pays out of their own pocket for health care. Cost-sharing includes MBIC premiums. Recipients will receive information from the premium processing vendor regarding what expenses are included in cost-sharing.

N-7910 Cost-Share Limit

Revision 22-3; Effective September 1, 2022

Each recipient has a cost-share limit. TIERS will calculate a cost-share limit for each recipient and populate the cost-share limit on Form TF0001-MBIC, Initial Certification.

There is no cost-share limit for the prior months.

Cost-share limit is set at the eligibility determination group level. If there is more than one MBIC-eligible recipient in the family unit, there will be only one cost-share limit per family unit. Each EDG will have a cost-share limit calculated. However, the lowest cost-share limit of all EDGs will be used at a case level.

The cost-share limit for each family is set at:

• 5% of countable gross annual income for a family whose countable gross annual income is at or below 200% of the FPL.
• 7.5% of countable gross annual income for a family whose countable gross annual income is 201% to 300% of the FPL.

The amount of monthly gross countable income in the month following disposition is multiplied by 12 in order to determine the gross annual income used in calculating the cost-share limit. This is the total gross countable income prior to the MBIC exclusion of $85 + one-half.

The cost-share limit can change if there is a change in income during that initial 12-month period. Example: MBIC application is received in January and certified in March. The cost-share limit is based on income budgeted for April and begins in April. In August, a change in income is reported and case action is taken in August (cut-off is taken into consideration). A new cost share limit will begin in September.

N-7920 Cost-Share Period

Revision 11-3; Effective September 1, 2011

A cost-share period is established for each recipient. This period begins the first day of the disposition month and lasts for 12 months. This is the period during which an MBIC recipient's medical costs and MBIC premiums can be counted toward the cost-share limit.

There is no cost-share period for the prior months.

The original cost-share period is retained for MBIC eligibility determination groups when:

• an individual is denied in error and then reactivated; and
• a previously certified MBIC client enters a facility (transfer) and then returns to MBIC within the same cost-share period.

A new cost-share period will be set (based on the new disposition date) when a person reapplies if an MBIC EDG is denied or terminated for any reason except for:

• denied in error, or
• transfer between programs.

N-7930 Tracking Cost-Share Expenses

Revision 11-3; Effective September 1, 2011

A recipient is exempt from MBIC monthly premiums for the remainder of the coverage period when the cost-share expenditures for the recipient reach the cost-share limit.

For a recipient without employer-sponsored health insurance, the premium processing vendor will determine when the MBIC premium payments reach the cost-share limit.

For a recipient with employer-sponsored health insurance and the Health Insurance Premium Payment Program, the recipient must track cost-share expenses. A form will be provided by the premium processing vendor for the recipient to report when the cost-share limit is reached. This form is entitled "Medical Costs List."

The premium processing vendor will provide a refund if a monthly premium payment is received after the cost-share limit has been met. This is automatically tracked by the premium processing vendor.

Revision 11-3; Effective September 1, 2011

The medical effective date (MED) for Medicaid Buy-In for Children (MBIC) cannot be before Jan. 1, 2011. This includes any prior months' eligibility for MBIC. If an application is received in which the prior months occur before January 2011, determine eligibility for other MEPD programs in those prior months. Do not automatically disregard the prior months because an MBIC application is received and the prior months occur before January 2011.

Revision 17-2; Effective June 1, 2017

Eligibility for three prior months to the application month is available for this program. Prior months' eligibility for MBIC cannot be granted before Jan. 1, 2011.

If a premium is required, eligibility for prior months is not granted until premiums have been paid.

See Appendix XLIX, Medicaid Buy-In for Children Forms Chart. Form TF0001-MBIC, Prior Months Eligibility Notice, serves as both the eligibility notice and denial notice. If the premiums are not received by the due date, the prior months are not granted and are denied. Do not send a separate denial notice for failure to pay premium for prior months.

N-8310 Verification Checklist and Pending Reasons

Revision 11-3; Effective September 1, 2011

The following new verification checklist and pending reasons have been created for this program. These reasons will be pre-populated by TIERS on Form H1020, Request for Information or Action.

• Send proof that you signed up for your job's health insurance.
• Send proof that shows you get health insurance through your job.
• Send proof that the child applying for Medicaid Buy-In for Children can't be on your job's health insurance plan.
• Send proof that your health insurance company changed.
• Let us know the next date you can enroll in your job's health insurance plan.
• Send proof that your job pays at least half the premium of your health insurance.

N-8320 Change Action Reasons

Revision 11-3; Effective September 1, 2011

The following new change action reasons have been created for this program. These reasons will be pre-populated by TIERS on Form TF0001-MBIC, Change in Monthly Premium Amount or Cost-Share Limit.

• You reached your cost-share limit for this benefit period.
• You did not reach your cost-share limit for this benefit period.
• Your family is making more money (income).
• Your family is making less money (income).
• The number of people in your family changed.
• You have health insurance through your job
• You don't have health insurance through your job.
• The Health Insurance Premium Payment program (HIPP) is paying for your private health insurance.
• The Health Insurance Premium Payment program (HIPP) isn't paying for your private health insurance.

N-8330 Denial Reasons

Revision 11-3; Effective September 1, 2011

In addition to existing MEPD denial codes, new denial reasons have been created for this program. These reasons and references will be pre-populated by TIERS on:

• Form TF0001-MBIC, Case Action Termination;
• Form TF0001-MBIC, Case Action Denial; and
• Form TF0001-MBIC, Prior Months Eligibility.

Section N-8331 below outlines the reasons and references.

N-8331 Denial Reasons and Reference Chart

Revision 11-3; Effective September 1, 2011

N-8340 Redeterminations

Revision 11-3; Effective September 1, 2011

Redeterminations for MBIC follow regular Medicaid for the Elderly and People with Disabilities (MEPD) policy for redeterminations.

Streamlining methods and passive reviews are not allowed for an MBIC redetermination.

If a case has an MBIC eligibility determination group (EDG) and another ME EDG, the persons in the case will get both a Form H1200-MBIC and another Form H1200 for the redeterminations.

A TIERS MBIC redetermination packet will include:

• Form H1233-MBIC, Redetermination Cover Letter;
• Form H1200-MBIC-R, Application for Benefits – Medicaid Buy-In for Children;
• Form H1028-MBIC, Employment Verification (Medicaid Buy-In for Children);
• Form H0003, Agreement to Release Your Facts; and
• Form H5017-MBIC, Items We Need from You.

N-8350 Appeals

Revision 13-1; Effective March 1, 2013

HHSC is responsible for all appeals, including those concerning premiums and cost sharing. If premium and/or cost-sharing information is needed for an appeal, refer to the MBIC business process document.

If an individual is dissatisfied with HHSC's decision concerning his eligibility for medical assistance, he has the right to appeal through the appeal process established by HHSC. In certain circumstances, the individual is entitled to receive continued benefits or services until a hearing decision is issued. Whether an individual is entitled to continued assistance is based on requirements set forth in appropriate state or federal law or regulation of the affected program. See the Fair and Fraud Hearings Handbook.

Revision 22-3; Effective September 1, 2022

A recipient will only receive one Your Texas Benefits  Medicaid card, which is intended to be the recipient’s permanent card. A recipient’s Your Texas Benefits Medicaid card will only be replaced if the card is damaged, lost or stolen. 

Related Policy

Your Texas Benefits Medicaid Card, R-2300