Form H5019-MBIC, Hardship Waiver Approved (Medicaid Buy-In for Children)

Instructions for Opening a Form

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Updated: 1/2011


To notify the client/authorized representative the:

  • hardship request for payment of premiums for Medicaid Buy-In for Children (MBIC) has been approved.
  • reason for this action.
  • right to appeal.


When to Prepare

The system sends Form H5019-MBIC when a request for hardship for premium payments for MBIC has been approved.

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.

List the indicated information requested below separately for each eligible child.

Benefit period — Enter the begin date and end date of the month(s) the hardship is granted.

Action — This field is populated by the system. If this form is done manually, this section is not applicable (N/A).

Child's name — Enter the name of the individual child for whom the change is being made.

Your monthly payment — Enter the term "waived."

The reason — Enter one of the following reasons.

  • You live in an emergency disaster area.
  • Someone living with you was laid off their job, or the place where they worked closed.
  • Someone living with you has less income because they work fewer hours.
  • A parent left the house because of a divorce or separation.
  • A parent died.