Form H0065-MBIC, Hardship Form (Medicaid Buy-In for Children)

Instructions for Opening a Form

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Effective Date: 7/2015


Updated: 1/2011


To notify the client/authorized representative of the opportunity to claim a hardship for Medicaid Buy-In for Children (MBIC) benefits due to a qualifying change in the client or client's household life.


When to Prepare

The system sends Form H0065-MBIC when it sends Form H0062-MBIC, Late Payment Notice.

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.

Detailed Instructions

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

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

Case number — Enter the case number in the system.

Due date — Enter the date 10 days from date of this letter.

Client name and address — Enter the client's name and the address including city, state and ZIP code.

Answer these 4 questions — The client/authorized representative must answer yes or no for all four questions.

Signature, Date and Phone Number — The client/authorized representative must sign and date the form, and provide a phone number (or telephone number of a contact) for the form to be complete.