Revision 25-3; Effective Sept. 1, 2025

Note: Incomplete MBCC applications must not be submitted to BCCS.

MBCC Application (H1034)

Verify presumptive eligibility has been met:

• Verify client is under 65.
• Verify client household income is the same as or less than 200 percent of the Federal Poverty Level (FPL).
• Client must complete Form 1065.
• Verify the client does not have creditable insurance coverage. Creditable coverage is health care coverage that covers treatment for breast and cervical cancer. This includes current enrollment in Medicaid or Medicare Part A, Part B, or Part A and B. Note: If the woman is enrolled in the Healthy Texas Women (HTW) Program when she is diagnosed, she will be disenrolled from HTW and enrolled in MBCC by Medicaid eligibility staff.
• Verify client has a valid Texas mailing address.
• Verify client is a US citizen or qualified immigrant.
• Verify the client has a final biopsy-confirmed report for the qualifying diagnosis. Preliminary or temporary reports of qualifying diagnoses are not accepted.
• Verify analysis of all biopsies was performed by a U.S. CLIA-certified laboratory. Review Appendix II, Medicaid for Breast and Cervical Cancer (MBCC) Guidelines.
• Verify the client needs active treatment for cancer. If it was more than six months since the client’s diagnosis, ensure the client has recent provider notes or treatment plan indicating the need for treatment.

Answer all questions and fill in every blank on the H1034 as follows:

• Verify the client’s legal name, date of birth and Social Security number are correct. The name on Form H1034 must match the name on the client’s Social Security card or legal identification. If the names differ, grantees must provide clarification.
• List the months the client has unpaid bills. Note: MBCC only covers unpaid medical bills for services received after the person’s breast and cervical cancer diagnosis date. The client can call 2-1-1 for help with medical assistance before their diagnosis.
• Client may list an authorized representative. This representative cannot be a person from the BCCS grantee site.
• Verify presumptive eligibility has been met and check Yes for grantee certification.
• Verify the date of diagnosis is documented. The date of diagnosis is the specimen collection date, and is typically on the pathology report, operative record or procedure note.
• The BCCS grantee representative who is helping the client complete the application, identified as the BCCS case manager on Form H1034, must sign and date the application.
• Do not mark in the HHSC Agency Use Only section.

Attach copies of the following supporting documents:

• the final pathology report with the biopsy-confirmed, qualifying diagnosis and with no highlighting;
• recent treatment plan or progress notes, if the pathology report is older than six months;
• to support a metastatic or recurrent cancer diagnosis, send:
  • final biopsy-confirmed report of the original breast or cervical cancer diagnosis; and
  • diagnostic reports such as CT scan and biopsy report which indicate the disease is compatible with or consistent with an original qualifying breast or cervical cancer diagnosis.
    • for example, a diagnosis such as metastatic adenocarcinoma consistent with the prior breast primary;
    • many metastatic or recurrent cancers may look the same. The primary does not need to be explicitly diagnosed;
• certification of identity, U.S. citizenship or legal immigrant status; or
• copy of insurance card or letter or explanation of benefits from insurance company, if the client’s insurance is expired, terminated or does not cover cancer treatment.

Do not send bills, tax forms or other financial statements or information to HHSC.

Grantees retain proof of income in the client record and document financial eligibility in Med-IT®.

Verification of Citizenship and Identity

As part of Public Law 109-171, Deficit Reduction Act of 2005, people who declare to be a U.S. citizen or nationals of the U.S. must provide evidence of citizenship when they apply for or receive, Medicaid benefits. The documented verification must establish citizenship and identity. The Medicaid citizenship and qualified immigrant rules apply to MBCC. To be eligible for Medicaid, a person must be a U.S. citizen or a qualified immigrant.

Citizenship guidelines and verification requirements are in the Texas Works Handbook: A-300, Citizenship.

If an applicant states she is a citizen or legal immigrant, the  grantee indicates on the last page of Form H1034, Medicaid for Breast and Cervical Cancer, she is presumptively eligible. If the grantee or health provider is uncertain if a woman meets citizenship and eligible immigrant requirements, the completed Form H1034 should be submitted for processing and determination. Include any citizenship or immigration documents the woman provides. If an applicant states she does not meet citizenship requirements, an MBCC application should not be submitted.

Grantee may call 2-1-1 or 877-541-7905 for help with client eligibility and citizenship determination, or email HHSC Centralized Benefit Services (CBS) for more information about citizenship and immigrant status.

Med-IT

Enter client details and patient navigation in Med-IT® as follows:

• Make sure enrollment status is correct:
  • Active — client received BCCS services before the cancer diagnosis.
  • MBCC Referred-In — client never received BCCS services, was diagnosed by a non-BCCS provider and was referred in for MBCC application only.
• Make sure the navigation module is complete.
• Bill with the appropriate patient navigation code.

Processing the H1034

Fax or securely email the H1034 to BCCS at 512-776-7203 or MBCCApps@hhs.texas.gov.

When the application is received, BCCS program staff:

• request more information if needed; and
• nurse consultants review and send the H1034 to CBS.

Note: HHSC does not help with or collect documents for MBCC applications following submission to CBS.

The status of a client’s application is documented in the client’s Med-IT® record under enrollment notes when an application has been received and when it was sent to CBS for final eligibility determination. If there are no notes in the client’s enrollment record after three business days, you may send an email to MBCCApps@hhs.texas.gov. Use only the last four digits of the client Med-IT® identification number in the subject line. Exclude protected health information.

MBCC Application Status and Medicaid Number

Clients may call 211 for their application status and Medicaid number.

Revision 25-3; Effective Sept. 1, 2025

Guidelines for Determination of Qualifying Diagnosis

Texas Breast and Cervical Cancer Services (BCCS) provides the following guidance to health care providers and grantees to facilitate their determination of qualifying diagnoses for Medicaid for Breast and Cervical Cancer (MBCC). Analysis of all biopsies must be performed by a Clinical Laboratory Improvement Amendments (CLIA)-certified laboratory.

Cervical Cancer Qualifying Diagnoses

Qualifying precancerous cervical diagnoses must be biopsy-confirmed*:

• High-grade dysplasia
• High-grade squamous intraepithelial lesion (HSIL)
• Cervical intraepithelial Neoplasia (CIN) 2/3 or (CIN) 3
• Carcinoma in situ
• Adenocarcinoma in situ

Qualifying malignancies of the cervix must be biopsy-confirmed*:

• Adenocarcinoma
• Adenoid cystic carcinoma
• Adenosquamous carcinoma
• Glassy cell carcinoma
• Invasive cervical cancer
• Invasive endocervical adenocarcinoma
• Invasive neoplasm
• Malignant neoplasia
• Melanoma
• Sarcoma
• Small cell carcinoma
• Squamous cell carcinoma

*Cervical biopsy or endocervical sampling that have a qualifying pre- cancerous diagnosis or cervical malignancy qualify as biopsy confirmed.

Breast Cancer Qualifying Diagnoses

Qualifying breast cancer diagnoses must be biopsy-confirmed. On the pathology report, the diagnosis or the description of the specimen or both, may include at least one of the following phrases: breast cancer, breast carcinoma or breast malignancy.

Examples of most of breast cancer types are:

Ductal Carcinomas

• Comedo
• Cribriform
• Ductal carcinoma in situ (DCIS)
• Infiltrating
• Inflammatory
• Invasive
• Medullary
• Mucinous (colloid)
• Papillary or Micropapillary
• Scirrhous
• Tubular

Lobular Carcinoma*

• Invasive
• Infiltrating

Nipple Carcinoma

• Paget’s disease

Other Carcinomas

• Adenoid cystic carcinoma
• All Phyllodes tumors
• Any biopsy-proven malignancy identified in a biopsy of either breast
• Apocrine
• Carcinoma, NOS (not otherwise specified)
• Carcinoma with endocrine differentiation
• Metaplastic
• Primary lymphoma
• Sarcoma
• Secretory
• Undifferentiated carcinoma

*A diagnosis of lobular carcinoma in situ (LCIS) is not considered a qualifying pre-cancerous or breast cancer diagnosis for referral to MBCC.
 
For a medical condition to qualify as a breast cancer, the medical record documentation, such as the operative report or procedure note, must state:

• that a biopsy was taken from at least one breast; and
• a pathology report for that biopsy must confirm the diagnosis of a qualifying malignant lesion.

The pathology report does not need to describe the malignancy as definitively representing a breast primary. A malignancy identified on at least one biopsy of the breast must be clear from the medical record documentation.

Metastatic Breast and Cervical Cancers

Consider a Medicaid application for clients with cancers believed to be metastatic from the breast or cervix, if a diagnosis is made based only on the metastatic tumor and if:

• no more diagnostic workup is planned before treatment is initiated; and
• treatment will proceed on the assumption that the primary source is breast or cervix, whether or not a primary tumor has been identified.

The medical record documentation must clearly state that the primary source is believed to be breast or cervix and that treatment will start based on that assumption. Terms such as compatible with and consistent with a breast or cervical cancer are acceptable. For example, a diagnosis such as metastatic adenocarcinoma consistent with a breast primary is acceptable.

For clients who present with cancers metastatic to the breast or cervix, malignancy diagnosed in a biopsy taken from a breast or from the cervix constitutes a qualifying diagnosis.

In cases where a grantee or subrecipient is unsure about a cancer diagnosis, follow these first steps:

• Review the guidelines for determination of qualifying diagnosis.
• If the diagnosis is unclear, consult with their medical director or physician and provider staff about the diagnosis.  

Grantees should not submit a diagnosis to HHSC for evaluation before submitting an MBCC application.

Pathology Specimens

Pathology specimens, original slides, collected and evaluated outside the U.S must be reviewed by a U.S. CLIA-certified lab to determine a qualifying diagnosis. The BCCS program and the client cannot be billed for the reading and interpretation of the specimen submitted to a U.S. CLIA lab.

A specimen may be transported either by the client or by a lab to another lab.

Need Treatment

A person is considered to need treatment for breast or cervical cancer if after the initial screen under BCCS or the initial period of eligibility, their treating health professional determines that:

• Definitive treatment for breast or cervical cancer is needed, including treatment of a precancerous condition or an early-stage cancer, and including diagnostic services as necessary to determine the extent and proper course of treatment.
• More than routine diagnostic services or monitoring services for a precancerous breast or cervical condition are needed.

Clients receiving hormonal treatment or breast reconstruction are considered to be receiving treatment and may remain eligible for MBCC benefits if Medicaid paid for the client’s initial treatment. Clients with triple negative receptor breast cancer (TNRBC) receiving active disease surveillance are also considered to be receiving treatment and may remain eligible for MBCC benefits if MBCC paid for active treatment.

Active disease surveillance, for the purposes of determining eligibility for MBCC, periodically monitors disease progression to quickly treat cancerous and precancerous conditions that arise from the presence of a previously diagnosed breast or cervical cancer. Disease surveillance is not considered an active treatment for new applicants.

Revision 25-3; Effective Sept. 1, 2025

Patient Education and Support

Clinic Information

Evidenced-Based Interventions and Strategies

Revision 25-3; Effective Sept. 1, 2025

BCCS Program Information

Medicaid for Breast and Cervical Cancer (MBCC) Information

Revision 26-2; Effective March 1, 2026

Breast and Cervical Cancer Services Policy Manual, Monthly Income Standard Based on 2026 Federal Poverty Level (FPL) - (PDF)

Revision 25-3; Effective Sept. 1, 2025

• BCCS Billing Guideline (PDF)

Revision 24-2; Effective Sep. 20, 2024

• Med-IT® Learned of Program and Cycle Referral Reminder (PDF)