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Effective Date:
11/2018Documents
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Document
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Document
Instructions
Updated: 1/2011
Purpose
To notify the client/authorized representative that it is time to review the case for continued Medicaid Buy-In for Children (MBIC) benefits.
Procedure
When to Prepare
The system sends Form H1233-MBIC with Form H1200-MBIC, Application for Benefits – Medicaid Buy-In for Children, when a redetermination is needed.
Number of Copies
The system prepares one copy.
Transmittal
Form H1233-MBIC and Form H1200-MBIC are 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.