Form H0054, Medicaid Buy-In Eligibility Notice

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.


Effective Date: 7/2015


Updated: 7/2009


To notify an applicant of the:

  • eligibility for the Medicaid Buy-In (MBI) program;
  • months of eligibility;
  • premium amount(s) paid for each month of eligibility;
  • requirement to pay the monthly premium amount and the premium amount for eligibility to continue;
  • monthly premium amount and that it must be paid in one payment every month;
  • monthly payment notice with a payment coupon and postage-paid envelope that will be mailed on the first of every month;
  • requirement that the premium payment must be postmarked no later than the 20th of every month;
  • requirement to pay only the amount listed on the monthly payment notice;
  • requirement that partial premium amounts are not accepted and will be refunded within 60 days; and
  • reminder that this is not a payment notice.


Form H0054 is the MBI eligibility notice. Prepare Form H0054 when notified that a premium payment has been received and the correct amount received.

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 most recent month.

Action — Enter "Granted."

Who Is Included — Enter the applicant's name.

Premium Amount Paid — Enter the premium amount paid for each month of eligibility.

For your eligibility to continue ... — Enter the monthly premium amount.