TX HHS Form H5019-MBIC. Hardship Waiver Approved (Medicaid Buy-In for Children)

The TX HHS Form H5019-MBIC, Hardship Waiver Approved, is a crucial document that helps individuals navigate the Medicaid Buy-In for Children program. This form is used in situations where a beneficiary's financial situation has changed, making it difficult to continue making payments. The form allows them to request a hardship waiver, which can provide relief from payment obligations.

The form requires specific information, including the beneficiary's case number, name, and contact details. It also outlines the reasons for requesting a hardship waiver, such as changes in income or expenses. Once approved, the beneficiary does not need to make payments for the specified benefit periods. Additionally, the form provides information on filing a complaint if the individual believes they have been treated unfairly due to discrimination.

Key features of this form include the requirement to provide supporting documentation and the possibility of requesting a hardship waiver. The form also outlines the procedures for filing a complaint with the HHSC Office of Civil Rights. By filling out this form, individuals can take advantage of the Medicaid Buy-In for Children program while experiencing financial difficulties.

• This form is used to request a hardship waiver in situations where a beneficiary's financial situation has changed.
• The form requires specific information, including the beneficiary's case number and contact details.
• Approved hardship waivers do not require payments for specified benefit periods.