Downloading a Form to Your Computer

Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.

  1. Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
  2. Select the folder you want to save the file in and then click "Save."
  3. Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.

Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.

If still having trouble viewing or downloading a form, click here.

Effective Date: 
7/2015

Documents

Instructions

Updated: 1/2011

Purpose

To notify the client/authorized representative of the:

  • termination of ongoing Medicaid Buy-In for Children (MBIC) benefits.
  • reason for termination.
  • right to appeal.

Procedure

When to Prepare

The system sends Form H5024-MBIC when a client has been determined no longer eligible for MBIC.

Number of Copies

The system prepares one copy.

Transmittal

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 address including city, state and ZIP code.

Starting [insert date], [insert name] — Enter the date the child/children is no longer eligible for ongoing benefits. The date is the 1st day of the month after benefits end. If benefits end March 31, the starting date would be April 1. Enter the name of the child/children who have been determined not eligible for benefits.

The reason — Enter one of the following reasons and references.

Denial/Termination Reasons for MBIC with applicable Texas Administrative Code (TAC) provisions:

Reason

Reference

[Insert child's name] is married.

1 TAC §361.107

You didn’t send proof that shows you get health insurance through your job.

1 TAC §361.113 

You didn’t send proof that shows when your job’s health insurance benefits began.

1 TAC §361.113 

You didn’t send proof that shows your child can't be on your job’s health insurance plan.

1 TAC §361.113 

You didn’t send proof that shows you signed up for your job’s health insurance.

1 TAC §361.113 

Your payment couldn’t be processed.

1 TAC §361.115(a) 

[Insert child's name] is age 19 or older.

1 TAC §361.107

You chose to leave your job's health insurance plan.

1 TAC §361.113