TX HHS Form H0062-MBIC. Late Payment Notice

The TX HHS Form H0062-MBIC, Late Payment Notice, is a crucial document that helps individuals who are receiving Medicaid Buy-In for Children (MBIC) benefits to address payment issues. This form is typically used in situations where the beneficiary has missed a payment or is experiencing financial difficulties, and it provides a framework for resolving these issues.

The form requires the beneficiary to provide specific information about their payment status, including the benefit period and the amount owed. It also outlines conditions under which the beneficiary may not have to pay 3 months of benefits, such as if someone in their household has lost income due to job loss, divorce or separation, or a parent's death. The form emphasizes the importance of timely payments and specifies follow-up actions that must be taken if payment is not received.

If you are struggling to make payments, this form provides a way to request assistance. To qualify for hardship, you must answer "no" to all four questions on the "Hardship Form" (HOO65-MBIC), which was sent with this letter. You must return the completed form by [date] and make payment by [date]. Failure to comply may result in benefits being terminated.

• This form is used for individuals receiving Medicaid Buy-In for Children (MBIC) benefits who are experiencing financial difficulties or missed payments.
• The form requires the beneficiary to provide specific information about their payment status and outlines conditions under which they may not have to pay 3 months of benefits.
• The form emphasizes the importance of timely payments and specifies follow-up actions that must be taken if payment is not received.