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Effective Date: 



Updated: 1/2011


To notify the client/authorized representative:

  • that premium payments for Medicaid Buy-In for Children (MBIC) have not been received.
  • of the amount of the premium owed.
  • of Form H0065-MBIC, Hardship Form.
  • that if they do not meet the hardship criteria and do not pay the amount due by the due date, benefits will end.
  • of the right to appeal.


When to Prepare

The system will send Form H0062-MBIC and Form H0065-MBIC when one premium has been missed for two consecutive months. 

Number of Copies

The system prepares one copy.


The form is sent to the client at the client's address or that of the authorized representative. A prepaid return envelope is enclosed.

Form Retention

The system retains a copy for the electronic case record. If the form needs to be completed manually, the form will need to be imaged and will then be available in the electronic case record.

Detailed Instructions

This form is pre-populated by the system. If the form is completed manually, follow these instructions.

Date – Self-explanatory.

MBIC EDG number – Enter the MBIC eligibility determination group (EDG) number for each eligible child.

Case number – Enter the case number in the system.

Case name and address – Enter the case name and the address including city, state and ZIP code.

List the indicated information requested below separately for each eligible child.

Benefit period – Enter the begin date and end date of the month that payment was not received.

Child's name – Enter the name of the child whose payment was not received.

Amount you owe – Enter the amount owed.

We must get this form back from you by . . .  – Enter the date 10 days from the date of this notice. If the 10th day falls on a weekend, enter the next workday.

If you don't have a hardship

We must get your payment by . . . – Enter the date, which is the 6th day of the month following the date of this notice.

Example: The first payment is missed May 5. On June 5, the May payment is missed for the second time. This notice is sent on June 7, and the due date is July 6.

If we don't get your payment, your benefits will end on . . . – Enter the last calendar day of the month following the second missed payment month.

Example: The first missed payment is May 5. On June 5, the May payment is missed for the second time. The end date is July 31.