TX HHS Form H0053. Medicaid Buy-In Potential Eligibility Notice

The Medicaid Buy-In Potential Eligibility Notice (Form H0053) is a crucial document that helps individuals determine their eligibility for Medicaid coverage. This form is typically filled out by individuals who are considering purchasing Medicaid coverage through the Medicaid Buy-In program.

This notice provides important information about the premium payment process, including the required payment amounts and deadlines. Key features of this form include the need to make a decision on whether to pay the premium amount(s) for all, some or only the first month listed above. The form also highlights the importance of paying premiums in full, with partial payments not being accepted.

It's essential to note that this is a one-time opportunity to purchase coverage for the specified months, and failure to make timely payments may result in missed opportunities. To receive coverage for all the months, individuals must pay the total premium amount. The form also outlines the process for receiving refunds, which may take up to 60 days.

• This form is used by individuals considering purchasing Medicaid coverage through the Medicaid Buy-In program.
• The form requires payment of premiums in full, with partial payments not being accepted.
• This is a one-time opportunity to purchase coverage for specified months.