Form H5021-MBIC, Initial Certification (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:

  • eligibility for Medicaid Buy-In for Children (MBIC) benefits.
  • amount of monthly premium payment for MBIC.
  • cost-share limit.  
  • right to appeal.


When to Prepare

The system sends Form H5021-MBIC when a client is eligible 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 get benefits starting [insert] — List the name(s) of each child eligible for benefits and the medical effective date.

How the program works [date inserts] — The "From" date is the medical effective date. The "to" date is the last day of the disposition (sign off) month. The "Starting" date is the 1st day of the month following the disposition (sign off) month.

Some people need to track medical bills

After you spend $_______ — Enter the cost-share limit amount.

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

Benefit period — Enter the begin date and end date of the covered period.

Child's name — Enter the name of each child eligible for MBIC.

Your monthly payment — Enter the monthly payment amount.