Form H5023-MBIC, Prior Months Eligibility (Medicaid Buy-In for Children)

Instructions

Updated: 1/2011

Purpose

To notify the client/authorized representative of the:

• prior months eligibility for Medicaid Buy-In for Children (MBIC).
• amount of the premium for these months.
• right to appeal.

Procedure

When to Prepare

The system sends Form H5023-MBIC when the client has been determined financially eligible for prior months 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.

You have until [Insert] to pay. — Enter the 5th day of the month two calendar months after the initial premium due date.

Example: If the initial premium due date is May 5, the premium due date for the prior months premium would be July 5.

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

Benefit period — Enter the begin date and end date of the prior month(s).

Child's name — Enter individually the name of the child eligible for prior month(s).

Your payment — Enter the prior month payment amount.