How to Fill Out Form H1113: Texas Application for Prior Medicaid Coverage

Texas Form H1113 is the one-page application you file with the Texas Health and Human Services Commission (HHSC) to request Medicaid coverage for up to three calendar months before the month you applied.¹ If you had unpaid medical bills during that window and would have qualified for Medicaid at the time, an approval shifts those bills from you to the program. You can download the form from HHSC, pick one up at a benefits office, or submit it through YourTexasBenefits.com.

Who Can Use Form H1113

Each of the three prior months is evaluated on its own. For any month you want covered, you must have met all Medicaid eligibility rules that month and have unpaid medical bills for Medicaid-covered services from that month.² HHSC checks your household’s income, residency, and citizenship or immigration status as they stood during that specific month, using the same MAGI rules it uses for a regular application. If you were under the income limit in two months but over it in the third, only the two qualifying months get approved.

A few points worth knowing before you file:

You can receive prior coverage even if your household is not currently eligible for Medicaid.²
You can request retroactive coverage for a family member who has died, as long as unpaid bills exist and that person would have qualified.²
Form H1113 is not required for Medicaid for Breast and Cervical Cancer (MBCC); HHSC does not ask for the form or for unpaid-bill verification when processing a retroactive MBCC request.¹

How to Fill Out the Form

The form is short, but each answer feeds a separate eligibility decision for each of the three prior months. If you need help, an HHSC advisor can walk you through it.¹

Agency Use Only Block

The top block lists your application date and the three prior months under review. You leave this blank. An HHSC worker fills it in when your form arrives, and the months entered there are the months your later answers must speak to.

Items 1, 2, and 3

Each of these items asks a yes-or-no question about the three prior months. Item 1 also asks you to list the other people who belong in your household based on how you file your taxes. For Items 2 and 3, complete the details box only when your answer is yes.¹ Answer for the three prior months, not for how things look today.

Item 4: Unpaid Medical Bills

This is the section the whole application turns on. List every unpaid bill for anyone named on page 1 for services received during the three prior months. For each bill, give the provider name, the date of service, and the amount owed.¹ If care spanned more than one month, group the bills by month so the worker can match each bill to the right eligibility decision.

Signature

You or your authorized representative must sign and date the form. HHSC will not process an unsigned form.¹

What to Send With the Form

HHSC has to verify both income and bills for each month you claim, so your documents need to cover those specific months.

Income proof: at least one pay stub for every working household member for each prior month you’re requesting, or an employer statement showing gross earnings for those months. For Children’s Medicaid, HHSC uses the same income verification it requires for a regular application.¹
Unpaid medical bills: statements or invoices from each provider showing the service date, the amount owed, and the patient name. The services have to be covered under Title XIX.²
Residency proof: a utility bill, rent receipt, landlord statement, mortgage receipt, Texas driver’s license, or DPS ID card.³
Citizenship or immigration status: a U.S. passport, birth certificate, certificate of naturalization, Medicare card, or USCIS immigration documents.³

If you already have an active Medicaid case or a pending application, HHSC may already have your residency and citizenship documents. Ask your caseworker before you resend anything.

Where to Send Form H1113

HHSC accepts the form three ways:¹

Online: upload the completed form and documents through your YourTexasBenefits.com account.
Fax: 877-477-2839.
Mail: Texas Health and Human Services Commission, P.O. Box 149025, Austin, TX 78714-9025.

You can also drop the form off at a local HHSC benefits office. Faxing or uploading is generally faster and gives you an immediate record that HHSC received it.

Processing and Decision

The standard Medicaid processing window in Texas is 45 days.⁴ The worker checks each of the three prior months on its own, and a month with incomplete documentation is likely to be denied even when the other months are approved. HHSC then mails a written notice showing which months were approved, which were denied, and why. Denials most often come from income being over the limit for that month or from unpaid Medicaid-covered bills that couldn’t be verified.

After You’re Approved

Once HHSC approves a prior month, the eligibility date starts on the first day of that month, and your retroactive coverage is added to the state’s eligibility system. Providers who treated you during that period can then bill Texas Medicaid directly instead of billing you.

Call each provider on your Form H1113 once your approval notice arrives and give them the retroactive coverage dates so they can file their claims. If a bill has already gone to collections, the Medicaid claim should resolve the debt once the provider submits it, but you’ll want to follow up to confirm the collection activity stops. Keep the HHSC approval notice with you for those calls.

1
Texas Health and Human Services. Form H1113, Application for Prior Medicaid Coverage
2
Texas Health and Human Services. A-830, Medicaid Coverage for the Months Prior to the Month of Application
3
Your Texas Benefits. Documents To Send With Your Application
4
Texas Health and Human Services. Medicaid for the Elderly and People with Disabilities Handbook – R-3100, Establish Processing Deadlines