Form H5022-MBIC, Notice of Change in Monthly Payment or Cost Share Limit (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:

  • a change in the amount of premium for Medicaid Buy-In for Children (MBIC).
  • a change in the amount of cost share limit.
  • the reason for this action.
  • the right to appeal.


When to Prepare

The system sends Form H5022-MBIC when there is a change in the client's premium or cost share limit 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] — Enter either:

  • Your monthly payment is changing; OR
  • Your cost-share limit is changing. Cost-share is what you pay out of your own pocket for health care. If you reach the cost-share limit for a benefit period, you won't have a monthly payment for the rest of that period.

The reason — Enter one of the following reasons:

  • You reached your cost-share limit for this benefit period.
  • You did not reach your cost share limit for the benefit period.
  • Your family is making more money (income).
  • Your family is making less money (income).
  • The number of people in your family changed.
  • You have health insurance through your job.
  • You don't have health insurance through your job.
  • The Health Insurance Premium Payment (HIPP) program is paying for your private health insurance.
  • The Health Insurance Premium Payment (HIPP) program isn't paying for your private health insurance.

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 individually the name of the child for whom the change is being made.

Your monthly payment — Enter the new monthly payment amount.

Cost-share limit — Enter the new monthly cost-share limit.