Form H0053, Medicaid Buy-In Potential Eligibility Notice

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Effective Date: 7/2015


Updated: 7/2009


To notify an applicant of the:

  • potential eligibility for the Medicaid Buy-In (MBI) program;
  • months of potential eligibility;
  • premium amount(s) due for each month of potential eligibility;
  • total premium amount due for all months of potential eligibility; and
  • date the premium amount(s) are due.

To notify an applicant that:

  • premium payment coupons will be sent to the applicant for each month of potential eligibility along with a postage-paid envelope;
  • the applicant may pay the premium amount(s) for all, some or only the last month of potential eligibility;
  • the coverage start date is determined by the premium amount(s) paid and when the Medicaid coverage may begin;
  • the applicant will not be able to purchase coverage for any of the months in which the applicant does not pay a premium for again;
  • premium amounts must be paid in full;
  • partial premium amounts are not accepted and will be refunded within 60 days; and
  • this is not a payment notice.


Form H0053 is the MBI potential eligibility notice. Prepare Form H0053 when an application for MBI is potentially approved.

Number of Copies

Complete an original and two copies.


For the MBI program, send the original and first copy to the applicant at the applicant's address or that of the applicant's authorized representative/responsible party. File one copy in the case record.

Form Retention

Keep the case record copy according to the retention requirements of the case record.


Date— Self-explanatory.

Header— Self-explanatory.

MBI EDG Number— Enter the MBI eligibility determination group number.

Benefit Month — Enter all month(s) of potential eligibility beginning with the month after the notice month.

Who Is Included— Enter the applicant's name.

Monthly Premium Amount — Enter the premium amount due for each month of potential eligibility.

Due Date— Enter date premiums are due.

Total for all Benefit Periods— Enter the total amount of premiums due for all months of potential eligibility.

If you only pay one month's premium amount ...— Enter the month after the notice month.

To receive coverage for all the months ... — Enter the total amount of premium due for all months of potential eligibility.