Form H5020-MBIC, Hardship Waiver Denied (Medicaid Buy-In for Children)

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Effective Date: 7/2015


Updated: 1/2011


To notify the client/authorized representative of the:

  • denial of the hardship request for payment of premiums for Medicaid Buy-In for Children (MBIC).
  • reason for the denial.
  • right to appeal.


When to Prepare

The system sends Form H5020-MBIC when a request for a hardship waiver for premium payments for MBIC has been denied.

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.

The reason — Enter one of the following reasons.

  • We didn't get your "Hardship Form" (Form H0065-MBIC) by the due date.
  • It hasn't been 12 months since we last stopped your payments. Your payments can be stopped for 3 months only once in 12 months.
  • You didn't lose money from a job (income) for reasons that allow us to stop your payments.