Form H5018-MBIC, Denial Notice (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:

  • denial of eligibility for Medicaid Buy-In for Children (MBIC).
  • reason for the denial.
  • right to appeal.


When to Prepare

The system sends Form H5018-MBIC when a client does not meet the eligibility criteria for MBIC.

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. 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.

[Insert] can't get benefits — Enter the name of the child/children who does not meet eligibility criteria.

Reason and Reference — Enter one reason and one reference from the following.

Denial/Termination Reasons for MBIC with applicable Texas Administrative Code (TAC) provisions.



It is too late to ask for benefits for these months. 

1 TAC §361.115(g)

[Child's name] is married.

1 TAC §361.107

You didn't send proof that shows you get health insurance through your job.

1 TAC §361.113 

You didn't send proof that shows when your job's health insurance benefits began.

1 TAC §361.113 

You didn't send proof that shows your child can't be on your job's health insurance plan.

1 TAC §361.113 

You didn't send proof that shows you signed up for your job's health insurance.

1 TAC §361.113 

Your payment couldn't be processed.

1 TAC §361.115(a) 

[Child's name] is age 19 or older.

1 TAC §361.107

You chose to leave your job's health insurance plan.

1 TAC §361.113