TX HHS Form H5022-MBIC. Notice of Change in Monthly Payment or Cost Share Limit (Medicaid Buy-In for Children)

The Notice of Change in Monthly Payment or Cost Share Limit (Form H5022-MBIC) helps individuals who participate in the Medicaid Buy-In for Children program to notify Texas Health and Human Services (HHS) of any changes to their monthly payment or cost share limit. This form is typically used by parents or guardians who need to update their child's coverage information.

This form requires the individual to provide specific information, including the reason for the change and the new monthly payment or cost share limit. The notice must be submitted in a timely manner to ensure that any necessary adjustments are made to the child's coverage. If a refund is due as a result of the change, it may take up to three months to process.

If you have concerns about your treatment or believe you have been discriminated against, you can file a complaint with the [email protected] or by mail, phone, or fax. You can also contact the U.S. Department of Health and Human Services for further assistance.

• This form is used to notify Texas HHS of changes to monthly payment or cost share limit in the Medicaid Buy-In for Children program.
• The form requires specific information, including reason for change and new monthly payment or cost share limit.
• Refunds may take up to three months to process if a change results in a refund due.