Healthy Montana Kids Plan Application

Transcription

1 Healthy Mntana Kids Plan Applicatin Healthy Mntana Kids Plan PO Bx , Helena, MT Website: FAX: This applicatin is used nly fr children s health cverage thrugh the Healthy Mntana Kids (HMK) Plan. APPLICATION INSTRUCTIONS Please cmplete the entire applicatin in black r blue ink. Please print yur answers. If yu need assistance cmpleting this applicatin, call the HMK helpline at r cntact yur cunty Office f Public Assistance. If mre space is needed t cmplete yur answers, attach an additinal sheet with apprpriate infrmatin. A persn in yur hme r an authrized representative wh knws the financial situatin f all the peple in yur hme shuld cmplete the applicatin. This persn is respnsible fr all answers prvided. The persn listed first n the applicatin is cnsidered the applicant and will receive all crrespndence fr this husehld, unless therwise requested. Yur applicatin will be prcessed within 45 days frm the date f applicatin. Send cmpleted applicatin t: Healthy Mntana Kids Plan PO Bx Helena, MT OR Any cunty Office f Public Assistance OR An HMK Enrllment Partner U.S. CITIZENSHIP AND IDENTITY VERIFICATION If child(ren) were nt brn in Mntana, an riginal r certified dcument prving U.S. citizenship is required. Infrmatin prvided n this applicatin can be used t establish identity fr children under age 16. Fr children years ld, a pht ID is required t verify identity, e.g., driver s license, schl ID, state ID card, tribal dcuments, etc. Depending n the cverage yur children may be eligible fr, yu may wish t establish a cverage request date. T d s, cmplete page ne f the applicatin, sign it, and submit a COPY t the cunty Office f Public Assistance. The cmpleted applicatin must be returned within 45 days. It can be mailed, faxed r drpped ff at the cunty Office f Public Assistance. In accrdance with federal law and U.S. Department f Health and Human Services (HHS) plicy, this institutin is prhibited frm discriminating n the basis f race, clr, natinal rigin, sex, age, marital status, plitical beliefs, religin r disability. T file a cmplaint f discriminatin, yu may cntact the Civil Rights Crdinatr - HCSD, DPHHS, P0 Bx , Helena, MT ; r Attentin: Reginal Manager, US Department f Health and Human Services, Office fr Civil Rights, 1961 Stut Street, Rm 1426, Denver, CO 80294, phne (vice), (TTY), r (tll free), r Office fr Civil Rights, U.S. Department f Health and Human Services, 200 Independence Avenue SW, Rm 509F HHH Building, Washingtn DC 20201, phne DPHHS-HMK-001 (Rev 10-09)

2 Healthy Mntana Kids Plan Applicatin Infrmatin abut the parent r guardian cmpleting this applicatin. Please PRINT clearly. Name: Mailing address: City/ZIP: Street address: City/ZIP: Hme phne: Wrk phne: Other phne: Family Infrmatin Fill in the blanks fr everyne wh lives with yu either permanently r temprarily, whether yu cnsider them a husehld member r nt. List yurself first, then yur spuse and children, then ther adults and children. Name (First Middle - Last) Relatinship t yu Scial Security Number (required fr children applying fr cverage) Age Birth date (mm/dd/yyyy) Cunty and state f birth Gender (M/F) 1 (self) Re-enter children s names ONLY frm abve (First Middle - Last) Child needs health cverage? In schl? (K-12) Attending cllege r university? U.S. citizen?* Mntana resident? Race?** (List all that apply) (Optinal) Hispanic/Latin? * If a child is nt a U.S. citizen, prf f alien status and spnsr infrmatin must be submitted with this applicatin. ** A Asian, Native Hawaiian r Pacific Islander, B Black, I American Indian r Alaskan Native, W White If yu are submitting a cpy f this page nly and plan t return the rest f the applicatin within 45 days, please sign and date belw. Signature Date 1

3 1. Infrmatin abut family members living elsewhere List all family members wh temprarily live elsewhere (fr example, live with ther parent, with relatives, away at schl, in a hspital, etc.). Name (First Middle - Last) Where are they living? Expected return date (mm/dd/yyyy) 2. Is anyne in yur hme billed fr and respnsible t pay dependent (child, disabled adult) care expenses? Yes N If yes, please cmplete the fllwing: Persn receiving care Name f persn prviding care Amunt yu pay Reasn fr care, because applicant: Wrks/lking fr wrk In training/schl Wrks/lking fr wrk In training/schl Wrks/lking fr wrk In training/schl 3. D yu share custdy f any child applying fr HMK cverage? Yes N If yes, please cmplete the fllwing: Name f child Wh shares custdy with yu? What percentage f time des this child live with yu? 4. Is anyne living in yur hme disabled r unable t wrk? Yes N If yes, please cmplete the fllwing: Name (First Middle - Last) Receive disability payments? Surce f disability payments Yes N Yes N 5. Is anyne in yur hme pregnant? Yes N If yes, please cmplete the fllwing: Name f pregnant wman Expected delivery date (mm/dd/yyyy) Number f unbrns 6. Has anyne listed n this applicatin ever used anther name (such as maiden name, frmer married name, etc.) r scial security number? Yes N If yes, please list their full name, the name previusly used and/r SSN: 2

4 Incme 7. Earned Incme List anyne wh wrks r wh will wrk any kind f jb this mnth and in the next 12 mnths. Include anyne wh will receive wages this mnth fr wrk dne in a prir mnth. List jbs that are full-time, part-time, seasnal, spt jbs, tips, cmmissins, wrk study, etc. Persn emplyed Emplyer name Emplyer address Emplyer phne Date jb started Average days wrked per week Average hurs per week Pay per hur Average tips/cmmissins per week This mnth s grss wages befre taxes Hw ften paid Dates pay received Date pay perid ends If seasnally emplyed, which mnths are wrked? If seasnally emplyed, annual grss wages befre taxes Cmplete a clumn fr each jb held by smene in yur hme. Include seasnal jbs even if yu r they are nt currently wrking. If seasnally emplyed, please include any unemplyment benefits in the Unearned Incme sectin f this applicatin (page 5). PLEASE PROVIDE PROOF OF EARNED INCOME Examples: If currently wrking, pay stubs r earnings statements fr the past tw mnths. If seasnally emplyed, pay stubs r W2s frm each emplyer fr last tw mnths. 8. Des anyne in yur hme expect a change in pay r number f hurs wrked (e.g. vacatin, seasnal emplyment) befre the end f the next calendar mnth? Yes N If yes, please explain: 9. Is anyne in yur hme wrking in exchange fr any living expense r husing cst(s)? Yes N If yes, please explain: 3

5 10. Has anyne in yur hme stpped wrking r reduced wrk hurs in the last 30 days? Yes N If yes, please cmplete the fllwing, and include any wages paid this mnth. Name Emplyer name Date left jb/reduced hurs Date & grss amunt f final check Reasn fr leaving Is it a temprary layff? Date expected t return t wrk 11. Is anyne in yur hme self-emplyed? Yes N If yes, please cmplete the fllwing: Name f business Business wner Type f business Business start date PLEASE PROVIDE PROOF OF SELF-EMPLOYMENT INCOME Examples: Mst recent tax return with Schedules C, D, E, and F r business recrds if yur tax return is nt available. 12. Des anyne in yur hme have unearned incme? Yes N If yes, please put a check mark in frnt f all unearned incme (nt frm emplyment) received by anyne in yur hme this mnth r in the next 12 mnths. Scial Security Supplemental Security Incme (SSI) Unemplyment Insurance Benefits Wrkers Cmpensatin Child Supprt/Alimny Gifts/Cntributins Cash Assistance (Tribe r Other State) General Assistance (Cunty r BIA) Interest/Dividends Veterans Benefits Trust Fund Payments Student Financial Aid Military Alltment Retirement Benefits/Pensins Lease Incme Ryalties Fster Care Payments Insurance Settlement Lans Temprary Disability Payments Adptin Subsidy Annuity Payments Other Fr all items checked abve, please cmplete the fllwing: (If additinal space is needed, submit an extra sheet f paper with the infrmatin.) Name f persn receiving incme Type f incme Hw ften paid Amunt paid PLEASE PROVIDE PROOF OF UNEARNED INCOME Examples: Current r mst recent dcuments such as Award letters fr Scial Security, Supplemental Security Incme, Unemplyment Insurance benefits, Wrker's Cmpensatin, Veterans Administratin benefits r pensins, etc. 4

6 13. Des anyne in yur hme expect t receive any incme befre the end f the next calendar mnth (such as a settlement frm a legal actin, disability, r accident insurance claim)? Yes N If yes, please cmplete the fllwing: Name f persn receiving incme Type f incme Amunt Insurance 14. Is health insurance available t any child in yur hme, including thrugh an absent parent? Yes N 15. Is any child in yur hme currently cvered by health insurance r was cvered within the last three mnths? Yes N If yes, please cmplete the fllwing and prvide prf f the health insurance infrmatin: Name f child Plicyhlder s name Plicy number Grup number Name & address f insurance cmpany What is cvered? Medical Dental Visin Medical Dental Visin Medical Dental Visin Insurance start date (mm/dd/yyyy) Hw much is the ttal mnthly premium? Hw much f the ttal mnthly premium d yu pay? Insurance end date (mm/dd/yyyy) Reasn insurance ended 16. D yu r yur spuse have health insurance? (This questin is ptinal and des nt affect yur child s eligibility.) Yu: Yes N Spuse: Yes N 5

7 17. List any child whse parent r step-parent (including parents nt living in the hme) wrks fr the State f Mntana r the Mntana University System. Name f child Name f parent Where parent wrks 18. Des any child in yur hme have medical bills fr services received during the last three mnths r is anyne making payments n unpaid medical bills fr services received at any time? Yes N If yes, in which f the last 3 mnths were the services received? If cverage is available, mre infrmatin may be requested. Other resurces fr children Children s Special Health Services (CSHS) This prgram may assist families by paying sme medical csts and ther assistance. CSHS hlds clinics fr care and treatment f children with special health needs. Examples f cvered cnditins are asthma, diabetes, cleft lip r palate, cystic fibrsis, heart cnditins, seizures, etc. If yu have a child with a special health cnditin and wuld like us t frward yur applicatin t CSHS, please cmplete the fllwing: Child s name Cnditin Children s Mental Health Services If a child in yur family qualifies fr HMK and needs r receives treatment fr a Serius Emtinal Disturbance (SED), we will send yu infrmatin abut the HMK Extended Mental Health Plan. If yur child is determined ineligible fr HMK, but meets the incme guidelines fr the Children s Mental Health Services Plan (CMHSP), we will send yu infrmatin abut that plan. Child s name Cnditin Enrllment Partners 19. Did an HMK Enrllment Partner help yu cmplete this applicatin? Yes N If yes, please cmplete the fllwing: Enrllment Partner name Enrllment Partner rganizatin Enrllment Partner phne number Enrllment Partner ID Number 6

8 I UNDERSTAND: READ CAREFULLY BEFORE SIGNING I must reprt any required changes t the HMK helpline at r cunty Office f Public Assistance within 10 days. Failure t reprt required changes may negatively impact my children s health cverage. I must prvide infrmatin and prf as requested t help determine eligibility fr children s health cverage. DPHHS may help me btain the prf r cntact ther peple r agencies t assist me. If I need help with gathering prf, I will tell the Office f Public Assistance r HMK ffice that I need assistance. Per ARM , I authrize the MT Highway Patrl & any f its agents, cntractrs r designees t release t DPHHS & any f its agents, cntractrs r designees all mtr vehicle accident reprts, supplemental reprts & infrmatin, including witness statements, filed by law enfrcement persnnel which I r any husehld members are entitled under Sectin MCA. I may request a fair hearing if I disagree with any actin regarding my child s health cverage. The request must be in writing. The infrmatin I give here is subject t verificatin by federal and state fficials. If any infrmatin is incrrect, my applicatin may be denied and I may be subject t the criminal penalties fr knwingly prviding incrrect infrmatin. Scial Security Number(s) are used by state and federal agencies t prevent duplicate participatin and t exchange infrmatin by cmputer with ther agencies (Scial Security Administratin, Internal Revenue Service, and emplyers). The infrmatin btained frm these surces may affect my children s eligibility. It will als be used fr claims cllectin purpses. By asking fr and receiving Healthy Mntana Kids Plan benefits, sme families may be required t apply fr ther benefits/prgrams t which they may be entitled. These benefits/payments include, but are nt limited t: Scial Security benefits, Child Supprt, annuity payments, Unemplyment Insurance, retirement benefits, settlements, etc. Infrmatin prvided by applicants and/r recipients f the Healthy Mntana Kids Plan may be subject t verificatin by the Scial Security Administratin. This is authrized by the Privacy Act f 1974; 5 U.S.C. 552a as amended. Alien status infrmatin may be verified with United States Citizenship and Immigratin Services (USCIS). This infrmatin may affect eligibility. Cperatin with Prgram Cmpliance reviews and Third Party Liability requirements is mandatry t remain eligible fr cntinued benefits. Federal and state laws and regulatins limit the use and disclsure f cnfidential r prtected health infrmatin abut applicants and recipients f assistance prgrams. I will be required t repay any benefits my children were nt eligible t receive because f any errr ther than agency errr. If apprved fr the Healthy Mntana Kids Plan, my rights t any health insurance r ther third party payment are autmatically assigned by law t the State f Mntana. I understand the questins n this applicatin and the penalty fr withhlding r giving false infrmatin. I understand and agree t prvide dcuments t prve what I have said. I understand and agree the Agency may cntact ther peple r rganizatins t btain necessary verificatin f any statements n this applicatin. I certify, under penalty f perjury, all my answers are crrect and cmplete t the best f my knwledge. I understand the infrmatin prvided n this applicatin can be used t establish identity fr children under age 16. Yur Signature Signature(s) f ALL ther peple age 18 r lder wh live with yu: Name Name Name Tday's Date Relatinship t Applicant Relatinship t Applicant Relatinship t Applicant Send cmpleted applicatin t: Healthy Mntana Kids Plan, P.O. Bx , Helena, MT r FAX tll-free t , r drp ff at any cunty Office f Public Assistance r with any HMK Enrllment Partner. 7