Form H1233-MBIC, Redetermination Cover Letter (Medicaid Buy-In for Children)

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Effective Date: 11/2018


Updated: 1/2011


To notify the client/authorized representative that it is time to review the case for continued Medicaid Buy-In for Children (MBIC) benefits.


When to Prepare

The system sends Form H1233-MBIC with Form H1200-MBIC, Application for Benefits – Medicaid Buy-In for Children, when a redetermination is needed.

Number of Copies

The system prepares one copy.


Form H1233-MBIC and Form H1200-MBIC are 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.