To notify the client/authorized representative of the opportunity to claim a hardship for Medicaid Buy-In for Children (MBIC) benefits due to a qualifying change in the client or client's household life.
When to Prepare
The system sends Form H0065-MBIC when it sends Form H0062-MBIC, Late Payment Notice.
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.
The system retains a copy for the electronic case record.
This form is pre-populated by the system. If the form is completed manually, follow these instructions.
MBIC EDG number — Enter the MBIC eligibility determination group (EDG) number for each eligible child.
Case number — Enter the case number in the system.
Due date — Enter the date 10 days from date of this letter.
Client name and address — Enter the client's name and the address including city, state and ZIP code.
Answer these 4 questions — The client/authorized representative must answer yes or no for all four questions.
Signature, Date and Phone Number — The client/authorized representative must sign and date the form, and provide a phone number (or telephone number of a contact) for the form to be complete.