Application for for Health Coverage & Help Paying Costs

Save this PDF as:
 WORD  PNG  TXT  JPG

Size: px
Start display at page:

Download "Application for for Health Coverage & Help Paying Costs"

Transcription

1 Application for for Health Coverage & Help Paying Costs Use Use this this application to to see see what coverage choices qualify for e e coverage to to help stay well. A new tax credit that can immediately help pay r premiums for for coverage. Free or or low-cost insurance from Medicaid or the Children s Health Insurance Program (CHIP). Who can use this application? Use this application to apply for anyone in r family. Apply even if if or r child already has coverage. You could be be eligible for lower-cost or free coverage. If If re single, may be able to use a short form. Visit Visit HealthCare.gov. Families that include immigrants can apply. You can apply for for r r child child even even if if aren t eligible for coverage. Applying won t immigration status status or or chances of becoming a permanent resident resident or or citizen. citizen. d d to to complete Appendix C. complete Appendix C. THINGS TO KNOW THINGS TO KNOW Apply Apply faster faster online online What may What may need to apply need to apply Apply faster online at. Apply faster online at. Social Security numbers (or document numbers for any legal immigrants Social who need Security insurance). numbers (or document numbers for any legal immigrants who need insurance). Employer and income information for everyone in r family (for Employer example, and from income pay stubs, information W-2 forms, for or everyone wage and in tax r statements). family (for example, from pay stubs, W-2 forms, or wage and tax statements). Policy numbers for any current insurance. Policy numbers for any current insurance. Information any job-related insurance available to r family. Information any job-related insurance available to r family. Why do we ask for Why this do information? we ask for this information? We ask income and other information to let know what coverage We ask qualify for income and if and can other get information any help paying to let for it. know We ll keep what all coverage the information qualify and provide if can private get any and help secure, paying as for required it. We ll by keep law. all the information provide private and secure, as required by law. What happens next? us (See Step 7 What happens next? on Page 9). If don t have all the information we ask for, sign us (See and Step send 7 on r Page application 9). If anyway. don t have We ll all follow the information up with we within ask for, 2 weeks. sign and You ll send get r instructions application the anyway. next steps We ll to follow complete up with r within coverage. 2 weeks. If You ll don t get instructions hear from us, on call the next or steps to complete (after r pick coverage. a language, If press don t hear 2). Filling from out us, this call application or doesn t mean (after have to pick buy a language, coverage. press 2). Filling out this application doesn t mean have to buy coverage. Get help with this Get application help with this application Online: Online: Phone: Call us at or Phone: Call After us at pick a or language, press 2. In person: After pick a language, press 2. or call (after pick a language, press 1). In person: or call (after pick a language, press 1). Page 1 of 13 Page 1 of 13

2 STEP 1 Tell Tell us us rself (We (We need need one one adult adult in in the the family family to to be be the the contact contact person person for for r application.) 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix 2. Home 2. Home address address (Leave (Leave blank blank if if don t don t have have one.) Apartment or or suite suite number 4. City 4. City State 6. ZIP code County 8. Do 8. Do live live in in Texas? 9. Do plan to stay in Texas? Mailing address (if (if different from home address) 11. Apartment or or suite number City City 13. State 14. ZIP code 15. County Phone Phone number number ( ( ) ) Do Do want want to to get get information information this this application application by by ? ? address: address: 17. phone number 19. Preferred spoken or written language (if not English) 19. Preferred spoken or written language (if not English) STEP 2 Tell Tell us us r r family family Who do need to include on this application? Who do need to include on this application? : We need to know everyone on r tax return. : We need to know everyone on r tax return. taxes to get coverage). taxes to get coverage). DO Include: You DON T have to include: DO Include: You DON T have to include: Yourself Your unmarried partner who doesn t need Yourself Your spouse Your coverage unmarried partner who doesn t need Your Your spouse children under 21 who live with coverage Your unmarried partner s children Your Anyone children under include 21 on who r live tax with return, even if they Your unmarried partner s children Anyone don t live with include on r tax return, even if they tax return (if re over 21) don t Anyone live with else under 21 who take care of and lives tax return (if re over 21) Anyone with else under 21 who take care of and lives with The amount of assistance or type of program qualify for depends on the number of people in r family and The their amount incomes. of assistance This information type helps of program us make sure qualify everyone for depends gets the on best the coverage number they of people can. in r family and their Complete incomes. Step This 2 information each person helps in us r make family. sure everyone Start with gets rself, the best then coverage add other they adults can. and children. If Complete have more Step than 2 for two each people person in r in family, r family. ll need Start to with make rself, a copy of then add pages other and adults attach and them. children. You don t If have need more to provide than two immigration people in status r family, or a Social ll Security need to number make a (SSN) copy for of the family pages members and attach who don t them. need You don t need coverage. to provide We ll immigration keep all the information status a Social provide Security private number and (SSN) secure for as family required members by law. who We ll don t use personal need coverage. information We ll only keep to all check the if information re eligible for provide private coverage. and secure as required by law. We ll use personal information only to check if re eligible for coverage. Page 2 of 13 Page 2 of 13

3 STEP STEP 2: 2: PERSON 1 (Start with rself) Complete Complete Step Step 2 for 2 for rself, rself, r r spouse/partner spouse/partner and and children children who who live live with with and/or and/or anyone anyone on on r r same same federal federal income income tax tax return return if if with with.. 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix Relationship to to?? SELF 3. Date 3. Date of of birth birth (mm/dd/yyyy) Sex Male Female 5. Social 5. Social Security number (SSN) (SSN) We We need need this this if if want coverage and have an SSN. Providing r SSN can be helpful if don t want coverage too too since since it can it can speed up up the the application process. We use SSNs to to check income and other information to see who s eligible for help with coverage costs. If someone If wants help getting an an SSN, call or visit socialsecurity.gov. TTY users should call Do 6. Do plan plan to to file file a federal a income tax tax return NEXT YEAR? (You (You can can still still apply apply for for insurance even if if don t file a federal income tax return.) YES. YES. If yes, If yes, please please answer questions a c. a c. NO. If no, skip to question c. a. a. If yes, If yes, name name of of spouse: spouse: b. Will b. Will claim claim any any dependents dependents on on r r tax tax return? return? If yes, If yes, list list name(s) name(s) of of dependents: dependents: c. Will c. Will be be claimed claimed as as a dependent a dependent on on someone s someone s tax tax return? return? If yes, If yes, 7. Are pregnant? a. If yes, how many babies are expected during this pregnancy? 7. Are pregnant? a. If yes, how many babies are expected during this pregnancy? b. If yes, due date (mm/dd/yyyy) b. If yes, due date (mm/dd/yyyy) 8. Do need coverage? 8. Do (Even need if have insurance, coverage? there might be a program with better coverage or lower costs.) (Even if have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 4. YES. If yes, answer all the questions below. NO. Leave If the no, rest SKIP of to this the page income blank. questions on page 4. Leave the rest of this page blank. 9. Do have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily 9. Do have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? chores, etc.) or live in a medical facility or nursing home? 10. Are a U.S. citizen or U.S. national? 10. Are a U.S. citizen or U.S. national? 11. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? 11. If If yes, aren t answer a U.S. these citizen questions: or U.S. a. national, Immigration do document have eligible type immigration status? If yes, answer these questions: a. b. Immigration Document ID document number type b. c. Document Have lived ID number in the U.S. since 1996? c. Have lived in the U.S. since 1996? 12. Are, or r spouse or parent, an active-duty member of the U.S. military? 12. Are, or r spouse or parent, an active-duty member of the U.S. military? 13. Are, or r spouse or parent, a veteran of the U.S. military? 13. Are, or r spouse or parent, a veteran of the U.S. military? 14. Do want help paying for medical bills from the past 3 months? 14. Do want help paying for medical bills from the past 3 months? 15. Do live with at least one child under the age of 19, and are the main person taking care of this child? 15. Do live with at least one child under the age of 19, and are 17. Were the main in foster person care taking at age care 18 or of this older? child? 16. Are a full-time student? 17. Were If yes, in which in foster state? care at age 18 or older? 16. Are a full-time student? 18. Were in an approved Unaccompanied Refugee Minor s Resettlement If yes, in which Program state? age 18 or older? 18. Were If yes, in in which an approved state? Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? Please If yes, answer in which the state? following questions if PERSON 1 is age 22 or nger: Please 19. Did answer PERSON the 1 following have insurance questions through if PERSON a job and 1 lose is age it within 22 or the nger: past 3 months? a. If yes, end date: b. Reason the insurance ended: 19. Did PERSON 1 have insurance through a job and lose it within the past 3 months? a. If yes, end date: b. Reason the insurance ended: business closing. Change in parent s marital status. business Parent s closing. COBRA coverage ended. Private Change in parent s coverage marital ended. status. Parent s COBRA coverage ended. state ended. Private coverage ended. state ended. Page 3 of 13 Page 3 of 13

4 STEP 2: 2: PERSON 1 Current Job & Income Information Employed If re If currently employed, tell tell us us r r income. Start with with question 22.. CURRENT JOB JOB 1: 1: Employer name name and and address 23. Employer phone number ( )) Wages/tips Wages/tips (before (before taxes) taxes) Hourly Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Average Average hours hours worked worked each each WEEK WEEK CURRENT JOB 2: (If have more jobs and need more space, attach another sheet of paper.) CURRENT JOB 2: (If have more jobs and need more space, attach another sheet of paper.) 26. Employer name and address 27. Employer phone number 26. Employer name and address 27. Employer phone number ( )) 28. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice month Monthly Yearly 28. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 29. Average hours worked each WEEK 29. Average hours worked each WEEK (Continue with rself) If Hispanic/Latino, If Hispanic/Latino, ethnicity ethnicity (OPTIONAL check (OPTIONAL check all all that that apply.) apply.) Mexican Mexican Mexican Mexican American American Chicano/a Chicano/a Puerto Puerto Rican Rican Cuban Race Race (OPTIONAL check all all that that apply.) apply.) White White Black Black or or African African American American Indian or or Alaska Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Asian Native Hawaiian Self-employed Skip to question In the past year, did : Change jobs Stop working Start working fewer hours ne of these 30. In the past year, did : Change jobs Stop working Start working fewer hours ne of these 31. If self-employed, answer the following questions: 31. If self-employed, answer the following questions: a. Type of work b. much net income (profits once business expenses are a. Type of work b. paid) much will net get income from this (profits self-employment once business this expenses month? are paid) will get from this self-employment this month? 32. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. 32. NOTE: OTHER You INCOME don t need to THIS tell us MONTH: child Check support, all that veteran s apply, payment, and give the or Supplemental amount and how Security often Income get (SSI). it. NOTE: You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). ne ne Unemployment Net farming/fishing Unemployment Pensions Net farming/fishing rental/royalty Pensions Social Security Net rental/royalty income Social Retirement Security accounts Type: income Retirement Alimony received accounts Type: Alimony received 33. DEDUCTIONS: Check all that apply, and give the amount and how often pay it. 33. If DEDUCTIONS: pay for certain Check things all that that can apply, be deducted and give on the a federal amount income and how tax often return, telling pay it. us them could make the cost of coverage If a little pay lower. for certain things that can be deducted on a federal income tax return, telling us them could make the cost of coverage a little NOTE: lower. You shouldn t include a cost that already considered in r answer to net self-employment (question 31b). NOTE: Alimony You shouldn t paid include a cost that already considered in r answer to deductions, net self-employment such as educator (question expenses, 31b). savings Alimony Student paid loan interest Student loan interest accounts, deductions, moving expenses, such as tuition, educator and expenses, fees savings accounts, moving expenses, tuition, and Type: fees 34. YEARLY INCOME: Complete only if r income changes from month to month. Type: 34. If YEARLY don t INCOME: expect changes Complete to r only monthly if r income, skip changes to the from next month person. to month. If Your don t total income expect this changes year to r monthly income, skip to the next Your person. total income next Your total income this year Your total income next THANKS! This is all we need to know. THANKS! This is all we need to know. Guamanian or or Chamorro Samoan t employed Skip to to question Page 4 of 13 Page 4 of 13

5 STEP 2: 2: PERSON 2 Complete Complete Step Step 2 for 2 for rself, rself, r r spouse/partner, spouse/partner, and and children children who who live live with with and/or anyone on on r r same same federal federal income income tax tax return return if if with with.. 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix Relationship to to?? 3. Date 3. Date of of birth birth (mm/dd/yyyy) 4. Sex Male Female 5. Social 5. Social Security number (SSN) We need this if want coverage and have an an SSN. 6. Does 6. Does PERSON 2 live 2 live at at the the same address as as? If no, If no, list list address: 7. Does 7. Does PERSON 2 plan 2 plan to to file file a a federal income tax return NEXT YEAR? (You (You can can still still apply apply for for insurance even if if don t file a federal income tax return.) YES. YES. If If yes, yes, please answer questions a c. NO. If no, skip to question c. a. a. If yes, If yes, name name of of spouse: b. Will b. Will PERSON PERSON 2 claim 2 claim any any dependents on on his his or or her her tax tax return? If yes, If yes, list list name(s) name(s) of of dependents: c. Will c. Will PERSON PERSON 2 be 2 be claimed claimed as as a a dependent dependent on on someone s someone s tax tax return? return? If yes, If yes, 8. Is PERSON 2 pregnant? 8. Is PERSON 2 pregnant? a. If yes, how many babies are expected during this pregnancy? a. If yes, how many babies are expected during this pregnancy? b. If yes, due date (mm/dd/yyyy) b. If yes, due date (mm/dd/yyyy) 9. Does PERSON 2 need coverage? 9. Does PERSON 2 need coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) (Even if they have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 6. YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 6. Leave the rest of this page blank. Leave the rest of this page blank. 10. Does PERSON 2 have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily 10. Does PERSON 2 have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? chores, etc) or live in a medical facility or nursing home? 11. Is PERSON 2 a U.S. citizen or U.S. national? 11. Is PERSON 2 a U.S. citizen or U.S. national? 12. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? 12. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? If yes, please answer these questions: a. Immigration document type: If yes, please answer these questions: a. b. Immigration Document ID document number: type: b. c. Document Have lived ID number: in the U.S. since 1996? c. Have lived in the U.S. since 1996? 13. Are, or r spouse or parent, an active-duty member of the U.S. military? 13. Are, or r spouse or parent, an active-duty member of the U.S. military? 14. Are, or r spouse or parent, a veteran of the U.S. military? Are Does, PERSON or r 2 spouse want help or parent, paying a for veteran 16. of the Does U.S. PERSON military? 2 live with at least one child under 17. Was PERSON 2 in foster care at age 15. Does medical PERSON bills 2 from want the help past paying 3 months? for 16. Does the age PERSON of 19, 2 and live are with they at least the main one person child under Was or PERSON older? 2 in foster care at age medical bills from the past 3 months? the taking age care of 19, of and this are child? they the main person 18 or older? taking care of this child? If yes, in which state? 18. Was PERSON 2 in an approved Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? If yes, in which state? 18. Was If yes, PERSON in which 2 in state? an approved Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? Please If yes, answer in which questions state? 19 and 20 if PERSON 2 is age 22 or nger: Please 19. Did answer PERSON questions 2 have insurance 19 and 20 through if PERSON a job 2 and is age lose 22 it within or nger: the past 3 months? 19. Did a. PERSON If yes, end 2 have date: insurance through a job and b. lose Reason it within the insurance the past 3 ended: months? a. If yes, end date: b. Reason the insurance ended: business closing. Change in parent s marital status. business Parent s COBRA closing. coverage ended. Private Change in parent s coverage marital ended. status. Parent s COBRA coverage ended. Private coverage ended. state ended. 20. Is PERSON 2 a full-time student? state ended Is PERSON If Hispanic/Latino, 2 a full-time ethnicity student? (OPTIONAL check all that apply.) 21. If Mexican Hispanic/Latino, Mexican ethnicity American (OPTIONAL check Chicano/a all Puerto that Rican apply.) Cuban 22. Mexican Race (OPTIONAL check Mexican American all that Chicano/a apply.) Puerto Rican Cuban 22. Race White (OPTIONAL check all American that apply.) Indian or Alaska Filipino Vietnamese Guamanian or Chamorro Black or African Native Japanese Asian Samoan White American American Asian Indian Indian or Alaska Filipino Vietnamese Guamanian or Chamorro Korean Native Hawaiian Black or African Native Chinese Japanese Asian Samoan American Asian Indian Korean Native Hawaiian NEED HELP WITH YOUR Chinese APPLICATION? We can help at no cost to. Call us at or Page 5 of 13 Page 5 of 13

6 STEP 2: 2: PERSON 2 Current Job Job & Income Information Employed Employed Self-employed If re If re currently employed, tell tell us us Skip to question 32. r r income. Start Start with with question t t employed Skip to to question CURRENT JOB JOB 1: 1: Employer name and and address 24. Employer phone number (( )) Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Average hours hours worked each WEEK CURRENT JOB JOB 2: 2: (If (If have have more more jobs jobs and and need more space, attach another sheet of paper.) Employer Employer name name and and address address Employer phone phone number number (( )) Wages/tips Wages/tips (before (before taxes) taxes) Hourly Hourly Weekly Weekly Every Every 2 weeks weeks Twice Twice a month month Monthly Monthly Yearly Yearly 30. Average hours worked each WEEK 30. Average hours worked each WEEK 31. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours ne of these 31. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours ne of these 32. If self-employed, answer the following questions: 32. If self-employed, answer the following questions: a. Type of work b. much net income (profits once business expenses are a. Type of work b. paid) much will net get income from this (profits self-employment once business this expenses month? are paid) will get from this self-employment this month? 33. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. 33. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. NOTE: You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). NOTE: ne You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). ne Unemployment Net farming/fishing Unemployment Pensions Net Net rental/royalty farming/fishing Pensions Social Security Net rental/royalty income Social Retirement Security accounts Type: income Retirement Alimony received accounts Type: Alimony received 34. DEDUCTIONS: Check all that apply, and give the amount and how often pay it. 34. If DEDUCTIONS: PERSON 2 pays for Check certain all things that apply, that can and be give deducted the amount on a federal and how income often tax return, pay it. telling us them could make the cost of If PERSON coverage 2 a pays little for lower. certain things that can be deducted on a federal income tax return, telling us them could make the cost of coverage NOTE: You a little shouldn t lower. include a cost that already considered in r answer to net self-employment (question 32b). NOTE: Alimony You shouldn t paid include a cost that already considered in r answer to deductions, net self-employment such as educator (question expenses, 32b). savings Alimony Student paid loan interest accounts, deductions, moving expenses, such as tuition, educator and expenses, fees savings Student loan interest accounts, moving expenses, tuition, and fees 35. YEARLY INCOME: Complete only if PERSON 2 s income changes from month to month. 35. If YEARLY don t expect INCOME: changes Complete to PERSON only 2 s if monthly PERSON income, 2 s income skip to changes the next from section. month to month. If PERSON don t 2 s expect total income changes this to PERSON year 2 s monthly income, skip to the next PERSON section. 2 s total income next year PERSON 2 s total income this year PERSON 2 s total income next year THANKS! This is all we need to know PERSON 2. THANKS! This is all we need to know PERSON 2. If have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete. If have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete. Page 6 of 13 Page 6 of 13

7 STEP 3 Things Things Everyone Pays for or Owns 1. VEHICLES: 1. VEHICLES: We We need need to to know know all all vehicles vehicles everyone, everyone, including including tax tax dependents, dependents, pays pays for for or or owns, owns, such such as as a: a: car car truck truck boat boat motorcycle motorcycle other other Does Does anyone anyone pay pay for for or or own own a vehicle? a vehicle? If yes, If yes, give give the the facts: facts: Vehicle Vehicle 1: 1: Name Name of of owner: owner: Make Make / model: / model: Year: Year: Name Name of of co-owner: Money still still owed owed on on vehicle: Is the Is the vehicle used used for for a a person with a a disability? Vehicle 2: 2: Name Name of of owner: Make Make / model: / Year: Year: Name Name of of co-owner: Money Money still still owed owed on on vehicle: Is the Is the vehicle vehicle used used for for a a person person with with a a disability? Vehicle Vehicle 3: 3: Name Name of of owner: owner: Make Make / model: / model: Year: Year: Name of co-owner: Name of co-owner: Money still owed on vehicle: Money still owed on vehicle: Is the vehicle used for a person with a disability? Is the vehicle used for a person with a disability? If need to list more than 3 vehicles, add more pages with the same facts. If need to list more than 3 vehicles, add more pages with the same facts. 2. ITEMS EVERYONE PAYS FOR OR OWNS: We need to know items everyone, including tax dependents, pays 2. ITEMS EVERYONE PAYS FOR OR OWNS: We need to know items everyone, including tax dependents, pays for or owns, such as: cash bank accounts homes or other property insurance policies stocks for or owns, such as: cash bank accounts homes or other property insurance policies stocks Does anyone pay for or own these types of items? Does anyone pay for or own these types of items? If yes, give the facts: If yes, give the facts: Item 1: Item 1: Item: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names Name on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): Item 2: Item Item: 2: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): Item 3: Item Item: 3: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names Name on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): If need to list more than 3 items, add more pages with the same facts. If need to list more than 3 items, add more pages with the same facts. Page 7 of 13 Page 7 of 13

8 STEP Are Are or or is is anyone in in r family American Indian or Alaska Native? If, If, skip skip to to Step Step If If yes, yes, go go to to Appendix B. B. STEP 5 American Indian or Alaska Native (AI/AN) family member(s) Your Family s Health Coverage Answer these questions for for anyone who needs coverage. 1. Is 1. anyone Is enrolled in in coverage now from the following? YES. YES. If yes, If yes, check the the type type of of coverage and write the person(s ) name(s) next to the coverage they have. NO. Medicaid Employer insurance Which Which state? state? Name of insurance: Date Date coverage ends ends (if (if not not ending, write write t t ending ) Policy number: Coverage start date: CHIP CHIP Coverage end date: Which state? pay each month to cover r child(ren) on this Which state? Amount pay each month to cover r child(ren) on this Date coverage ends (if not ending, write t ending ) insurance? Date coverage ends (if not ending, write t ending ) insurance? Who Who pays pays the the premium? premium? Is this COBRA coverage? Medicare Is this COBRA coverage? Medicare Is this retiree plan? TRICARE (Don t check if have direct care or Line of Duty) Is this a retiree plan? TRICARE (Don t check if have direct care or Line of Duty) Name of insurance: Name of insurance: VA care programs Policy number: VA care programs Policy number: Peace Corps Peace Corps 2. Check yes even if the coverage is from someone else s job, 2. such as a parent or spouse. Check yes even if the coverage is from someone else s job, such as a parent or spouse. YES. If yes, ll need to complete and include Appendix A. Is this a state employee benefit plan? YES. If yes, ll need to complete and include Appendix A. Is this a state employee benefit plan? NO. If no, continue to Step 6. NO. If no, continue to Step 6. These questions will not be used to decide if r family can g These 1. Is questions a child in r will home not be in the used Children to decide with Special if r Health family Care can Needs g program? 1. Is a If child yes, who? in r home in the Children with Special Health Care Needs program? If 2. yes, who? 2. If yes, who? If yes, who? Signing up to vote Signing up to vote Applying to register or declining to register to vote will not s agency. Applying to register or declining to register to vote will not s agency. If are not registered to vote where live now, would like to apply to register to vote here today? If IF YOU are DO not NOT registered CHECK EITHER to vote BOX, where YOU WILL live BE now, CONSIDERED would TO HAVE like to DECIDED apply to NOT register TO REGISTER to vote TO here VOTE today? AT THIS TIME. IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED lication form, we TO will HAVE help. DECIDED The decision NOT whether TO REGISTER to seek oto VOTE AT THIS TIME. application form in private. If believe that someone has interfered with r right to register or to decline to register to vote, or r right to choose r own political lication form, we will help. The decision whether to seek o th the Elections Division, Secretary of State, PO Box 12060, Austin, TX Phone: application form in private. If believe that someone has interfered with r right to register or to decline to register to vote, or r right to choose r own political th the Elections Division, Secretary of State, PO Box 12060, Austin, TX Phone: Agency Use Only: Voter Registration Status Agency Already Use Only: registered Voter Registration Client declined StatusAgency transmitted Client to mail Mailed to client Already registered Client declined Agency transmitted Client to mail Mailed to client Agency staff signature: Agency staff signature: Page 8 of 13 Page 8 of 13

9 STEP 6 Read Read & sign this application I m I m signing signing this this application application under under penalty penalty of of perjury perjury which which means I ve provided true true answers answers to to all all the the questions questions on on this this form form to to the the best best of of my my knowledge. knowledge. I I know know that that I I may may be be subject to to penalties under federal law law if if I I provide provide false false or or untrue untrue information. information. what what I wrote I wrote on on this this application. To To report changes, I I can go to or call or or I I I know I know that that under federal law, law, discrimination isn t permitted on the basis of race, color, national origin, sex, age, sexual.. is is incarcerated. (name of of person) We We need need this this information to to check r eligibility for help paying for coverage if choose to apply. We ll check r answers using using information in in our our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the the Department of of Homeland Security, and/or a consumer reporting agency. If the information doesn t match, we we may ask ask to to send send us us proof. proof. Renewal of of coverage in in future years To To make make it easier it easier to to determine my my eligibility for for help paying for coverage in future years, I I agree to to allow the the agency to to use use income income data, data, including including information from from tax tax returns. The agency will send me a notice, let let me me make any any changes, and and I can I can opt opt out out at at any any time. time.,, renew renew my my eligibility eligibility automatically automatically for for the the next next 5 years 5 years (the (the maximum maximum number number of of years years allowed), allowed), or or for for a shorter shorter number number of of years: years: 4 years 3 years 2 years 1 year Don t use information from tax returns to renew my coverage. 4 years 3 years 2 years 1 year Don t use information from tax returns to renew my coverage. If anyone on this application is eligible for Medicaid If anyone on this application is eligible for Medicaid I am giving to HHSC the rights to pursue and get any money from other insurance, legal settlements, or other third I am giving to HHSC the rights to pursue and get any money from other insurance, legal settlements, or other third parties. I am also giving to HHSC rights to pursue and get medical support. parties. I am also giving to HHSC rights to pursue and get medical support. I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, can tell HHSC and I may not have to cooperate. cooperating to collect medical support will harm me or my children, I can tell HHSC and I may not have to cooperate. Does any child on this application have a parent living outside of the home? Does any child on this application have a parent living outside of the home? If yes, tell us the parent living outside of the home: If yes, tell us the parent living outside of the home: First and last name Birth date (mm/dd/yyyy) First and last name Birth date (mm/dd/yyyy) Social Security number Phone Social Security number Phone Mailing address Employer Mailing address Employer City, State, ZIP City, State, ZIP My right to appeal My right to appeal If I think HHSC has made a mistake, I can appeal its decision. To appeal means to tell someone at HHSC that I think the action is If I think HHSC has made a mistake, I can appeal its decision. To appeal means to tell someone at HHSC that I think or the action is (after pick a language, press 2). I know that I can be represented in the process by someone other or than myself. My eligibility (after and pick other a important language, information press 2). I know will be that explained I can be to represented me. in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application Sign this application as long as have provided the information required in Appendix C. as Signature long as have provided the information required in Appendix C. Date (mm/dd/yyyy) Signature Date (mm/dd/yyyy) STEP 7 STEP 7 Fax: Mail: HHSC Fax: If r form is 2-sided, fax both sides. Mail: HHSC PO Box If r form is 2-sided, fax both sides. PO Midland, Box Texas Midland, Texas Page 9 of 13 Page 9 of 13

10 APPENDIX A Health Coverage from Jobs You You DON T DON T need need to to answer answer these these questions questions unless unless someone in the household is is eligible eligible for for coverage coverage from from a a job. job. Attach Attach a a copy copy of of this this page page for for each each job job that that offers coverage. Tell Tell us us the the job job that that offers coverage. Take Take the the Employer Coverage Tool on on the next page to the employer who offers coverage to to help help answer these these questions. You You only only need need to to include this page when send in r application, not the Employer Coverage Tool. Tool. EMPLOYEE Information Employee name (First, Middle, Last) Employee Social Security number EMPLOYER Information Employer name Employer Identification Number (EIN) (EIN) Employer address Employer phone number City City State ZIP ZIP code code Who Who can can we we contact contact employee employee coverage coverage at at this this job? job? 11. Phone number (if different from above) 11. Phone number (if different from above) 12. address 12. address 13. A 13. A (Continue) (Continue) 13a. If re in a waiting or probationary period, when can enroll in coverage? 13a. If re in a waiting or probationary period, when can enroll in coverage? List the names of anyone else who is eligible for coverage from this job. List the names of anyone else who is eligible for coverage from this job. (mm/dd/yyyy) (mm/dd/yyyy) Name: Name: Name: Name: Name: Name: (Stop here and go to Step 5 in the application) (Stop here and go to Step 5 in the application) Tell us the plan offered by this employer. Tell us the plan offered by this employer. 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don t include family plans): 15. For If the employer lowest-cost has plan wellness that meets programs, the minimum provide the value premium standard* that the offered employee only to would the employee pay if he/ she (don t received include the family maximum plans): discount for any tobacco If cessation the employer programs, has wellness and did programs, not receive provide any other the discounts premium based that the on employee wellness programs. would pay if he/ she received the maximum discount for any tobacco cessation a. programs, much would and the did employee not receive have any to other pay in discounts premiums based for this on plan? wellness programs. a. b. much would Weekly the employee Every have 2 weeks to pay in premiums Twice a month for this plan? Once a month Quarterly Yearly b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly 16. What change will the employer make for the new plan year (if known)? 16. What Employer change will won t the offer employer coverage make for the new plan year (if known)? Employer won t will start offer offering coverage coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) Employer will start offering coverage to employees or change the premium for the lowest-cost plan available only to the a. employee much that will meets the employee the minimum have to value pay in standard.* premiums (Premium for that plan? should reflect the discount for wellness programs. See question 15.) a. b. much will the Weekly employee Every have 2 to weeks pay in premiums Twice a for month that plan? Once a month Quarterly Yearly b. Date of change (mm/dd/yyyy): Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy): * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Page 10 of 13 Page 10 of 13

11 EMPLOYER COVERAGE TOOL Use Use this this tool tool to to help help answer answer questions questions in in Appendix Appendix A any any employer employer coverage coverage that that re re eligible eligible for for (even (even if if it s it s from from another another person s person s job, job, like like a parent a parent or or spouse). spouse). The The information information in in the the numbered boxes below match the the boxes boxes on on Appendix Appendix A. A. For For example, example, the the answer answer to to question question on on this this page page should should match match question on on Appendix A. Write Write r r name name and and Social Social Security Security number in in boxes 1 and and 2 and ask the employer to fill out the rest of of the the form. form. Complete one one tool tool for for each each employer employer that that offers offers coverage. EMPLOYEE Information The The employee needs to to fill fill out this section. 1. Employee 1. name name (First, (First, Middle, Last) Last) 2. Social Security Number EMPLOYER Information Ask Ask the the employer for for this information. 3. Employer 3. name name 4. Employer Identification Number (EIN) Employer 5. Employer address address (HHSC (HHSC will will send send notices to to this this address) 6. Employer phone number 7. City 7. City State ZIP ZIP code code Who Who can can we we contact contact employee employee coverage coverage at at this this job? job? 11. Phone number (if different from above) 11. Phone number (if different from above) 12. address 12. address 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? (Continue) (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) (mm/dd/yyyy) (Continue) (STOP and return this form to employee) (STOP and return this form to employee) Tell us the plan Tell us the plan. Which people? Spouse Dependent(s). Which people? (Go to question 14) Spouse Dependent(s) (Go to question 14) employer. employer. (Go to question 15) (STOP and return form to employee) 15. (Go to question 15) (STOP and return form to employee) only to the employee (don t include family plans): If the employer has wellness 15. programs, provide the premium that the employee would pay if he/ she received only to the maximum employee discount (don t include for any family tobacco plans): cessation If the programs, employer and has didn t wellness programs, receive any provide other the discounts premium based that on the wellness employee programs. would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn t receive a. any other much discounts would the based employee on wellness have to programs. pay in premiums for this plan? a. b. much would Weekly the employee Every have 2 weeks to pay in premiums Twice a month for this plan? Once a month Quarterly Yearly b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly If the plan year will end soon and know that the plans offered will change, go to question 16. If don t know, STOP and return form to employee. If the 16. plan What year change will end will the soon employer and make know for that the the new plan year? plans offered will change, go to question 16. If don t know, STOP and return form to employee. 16. What Employer change will won t the offer employer make coverage for the new plan year? Employer Employer won t will offer start offering coverage coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) Employer will start offering coverage to employees or change the premium for the lowest-cost plan available only to the a. employee much that will meets the employee the minimum have value to pay standard.* in premiums (Premium for that should plan? reflect the discount for wellness programs. See question 15.) a. b. much will the Weekly employee Every have to 2 weeks pay in premiums Twice a for month that plan? Once a month Quarterly Yearly Date of change (mm/dd/yyyy): b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy): * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Page 11 of 13 Page 11 of 13

12 APPENDIX B American Indian or or Alaska Native Family Member (AI/AN) Complete Complete this this appendix appendix if if or or a a family family member member are are American Indian or Alaska Native. Submit this this with with r r application. application. Tell Tell us us r r American Indian or or Alaska Native family member(s). American Indians Indians and and Alaska Alaska Natives can can get get services from the Indian Health Services, tribal programs, or or urban Indian programs. They They also also may may not not have to to pay cost sharing and may get special monthly enrollment periods. Answer the the following questions to to make sure sure r family gets the most help possible. NOTE: If If have have more people to to include, make a copy of this page and attach. 1. Name 1. Name (First (First name, Middle name, Last Last name) AI/AN PERSON 1 AI/AN PERSON 22 First Middle First Middle Last Last 2. Member 2. Member of of a federally a recognized tribe? tribe? If If yes, tribe name If If yes, tribe name 3. Has this person ever gotten a service from the 3. Has this person ever gotten a service from the Indian Health Service, a tribal program, Indian Health Service, a tribal program, or urban Indian program, or through a or urban Indian program, or through a referral from one of these programs? referral from one of these programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health Service, services from the Indian Health Service, tribal programs, or urban Indian tribal programs, programs, or through or urban referral Indian from one programs, of these or programs? through a referral from one of these programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health Service, services from the Indian Health Service, tribal programs, or urban Indian tribal programs, programs, or through or urban a referral Indian from one programs, of these programs? or through a referral from one of these programs? 4. Certain money received may not be counted 4. Certain for Medicaid money or received the Children s may not Health be counted Insurance for Program Medicaid (CHIP). or the List Children s any income Health (amount Insurance and Program how often) (CHIP). reported List any on income r application (amount and that how includes often) money reported from on these r application sources: that includes Per money capita payments from these from sources: a tribe that Per come capita from payments natural from resources, a tribe usage that rights, come leases, from or natural royaltiesresources, usage rights, leases, Payments or royalties from natural resources, farming, Payments from natural resources, farming, land designated as Indian trust land by land the designated Department as of Indian Interior trust (including land by the reservations Department and of former Interior reservations) (including reservations Money from and selling former things reservations) that have Money from selling things that have Page 12 of 13 Page 12 of 13

13 APPENDIX C Assistance with Completing this Application You You can can choose an an authorized representative. You You can can give give a trusted a person permission to to talk talk this application with us, see r information, and act act for for on on matters matters related to to this this application, including getting information r application and signing r application on on r r behalf. This This person is is called an an authorized representative. If ever need to change r authorized representative, contact HHSC. If If re a a legally appointed representative for someone on this application, submit proof proof with with the the application. 1. Name 1. Name of of authorized representative (First name, middle name, last name) 2. Address Apartment or suite number 4. City 4. City State 6. ZIP code 7. Phone 7. Phone number number ( ( ) ) 8. Organization 8. Organization name name Organization Organization ID ID number number (if (if applicable) applicable) By signing, allow this person to sign r application, get official information this application, By signing, allow this person to sign r application, get official information this application, and act for on all future matters with this agency. and act for on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy) 10. Your signature 11. Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. For certified application counselors, navigators, agents, and brokers only. Complete this section if re a certified application counselor, navigator, agent, or broker filling out this application Complete for somebody this section else. if re a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 1. Application start date (mm/dd/yyyy) 2. First name, middle name, last name, & suffix 2. First name, middle name, last name, & suffix 3. Organization name 4. Organization ID number (if applicable) 3. Organization name 4. Organization ID number (if applicable) Page 13 of 13 Page 13 of 13

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer

More information

Application for Health Coverage and Help Paying Costs

Application for Health Coverage and Help Paying Costs Iowa Department of Human Services Application for Health Coverage and Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health

More information

Family-Related Medical Assistance Application

Family-Related Medical Assistance Application Family-Related Medical Assistance Application Form Approved DCF. CF-ES 2370, Dec 2013 THINGS TO KNOW Use this application to see what coverage choices you qualify for Free or low-cost insurance from Medicaid

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Form Approved OMB. 0938-1191 Use this application to see what coverage you qualify for Affordable private health insurance plans that offer comprehensive

More information

Apply faster online at Compass.ga.gov.

Apply faster online at Compass.ga.gov. GEORGIA DEPARTMENT OF HUMAN SERVICES Division of Family and Children Services Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage

More information

Application for Health Coverage & Help Paying Costs (Short Form)

Application for Health Coverage & Help Paying Costs (Short Form) Form Approved OMB No. 0938-1191 Application for Health Coverage & Help Paying Costs (Short Form) Use this application to see what coverage you qualify for Affordable private health insurance plans that

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Free or low-cost insurance from Medicaid or the Children s Health Insurance Program

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs 09/2014 Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Apply faster online Use this application to see what coverage you qualify for Who can use this application? What

More information

Medicaid and Long-Term Care Application for Medicaid and Insurance Affordability Programs (Financial Assistance)

Medicaid and Long-Term Care Application for Medicaid and Insurance Affordability Programs (Financial Assistance) Use this application to see what Medicaid and/or Children s Health Insurance Program (CHIP). coverage choices you qualify for. New tax credits that can immediately help pay your premiums for health coverage.

More information

MEDICAL ASSISTANCE FOR CHILDREN, PREGNANT WOMEN, & PARENT/CARETAKER RELATIVES INSERT

MEDICAL ASSISTANCE FOR CHILDREN, PREGNANT WOMEN, & PARENT/CARETAKER RELATIVES INSERT NH Department of Health and Human Services (DHHS) DFA Form 800 Insert Division of Family Assistance (DFA) 01/14 MEDICAL ASSISTANCE FOR CHILDREN, PREGNANT WOMEN, & PARENT/CARETAKER RELATIVES INSERT Complete

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Who can use this application? Affordable private health insurance plans that offer

More information

APPLY ON-LINE at. InsureAlabama.org. health coverage.

APPLY ON-LINE at. InsureAlabama.org. health coverage. APPLY ON-LINE at InsureAlabama.org Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer

More information

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA) 01/14 Application for Health Coverage & Help Paying Costs

NH Department of Health and Human Services (DHHS) Division of Family Assistance (DFA) 01/14 Application for Health Coverage & Help Paying Costs THINGS TO KNOW NH Department of Health and Human Services (DHHS) DFA Form 800MA Division of Family Assistance (DFA) 01/14 Application for Health Coverage & Help Paying Costs Use this application to see

More information

Apply faster online at CoverOregon.com. Use this application through September 2014 TELL US ABOUT YOURSELF (You ll be our primary contact person.

Apply faster online at CoverOregon.com. Use this application through September 2014 TELL US ABOUT YOURSELF (You ll be our primary contact person. APPLICATION FOR HEALTH COVERAGE and financial help to lower costs Apply faster online! Apply faster online at CoverOregon.com. Use this application to find out if you qualify for: Who can use this application?

More information

DRAFT. Apply faster online at www.placeholder.gov.

DRAFT. Apply faster online at www.placeholder.gov. 01.16.13 Application for Health Insurance (and to find out if you can get help with costs) THINGS TO KNOW Use this application to see what insurance choices you qualify for Who can use this application?

More information

Health Coverage & Help Paying Costs Application for One Person

Health Coverage & Help Paying Costs Application for One Person THINGS TO KNOW Health Coverage & Help Paying Costs Application for One Person Use this application to see what insurance choices you qualify for Free or low-cost insurance from Medicaid or the Kentucky

More information

Application for Medical Assistance for Families with Children

Application for Medical Assistance for Families with Children Application for Medical Assistance for Families with Children Who can use this application? Use this application to see what choices you have Apply faster online This application is for families, children,

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for Affordable private health insurance plans that offer comprehensive coverage to help

More information

Massachusetts Application for Health and Dental Coverage and Help Paying Costs

Massachusetts Application for Health and Dental Coverage and Help Paying Costs Massachusetts Application for Health and Dental Coverage and Help Paying Costs THINGS TO KNOW HOW TO APPLY Use this application to see what coverage choices you may qualify for. Who can use this application?

More information

Application for Oregon Health Plan Coverage

Application for Oregon Health Plan Coverage Application for Oregon Health Plan Coverage USE THROUGH NOVEMBER 2015 Need help with this application? Information you will need to provide on this application: Get expert help at no cost from a certified

More information

Massachusetts Application for Health and Dental Coverage and Help Paying Costs

Massachusetts Application for Health and Dental Coverage and Help Paying Costs Massachusetts Application for Health and Dental Coverage and Help Paying Costs Commonwealth of Massachusetts EOHHS HOW TO APPLY You can submit your application in any of the following ways. Sign on to

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage choices you qualify for. Affordable private health insurance plans that offer comprehensive coverage to help

More information

NEED HELP WITH YOUR APPLICATION?

NEED HELP WITH YOUR APPLICATION? 10/2014 Application for Exemption from the Shared Responsibility Payment for Individuals who are Unable to Afford Coverage and are in Certain States with a State-based Marketplace Form Approved OMB No.

More information

1. Legal name (first, middle, last and suffix) 2. Birthdate (MM/DD/YYYY)

1. Legal name (first, middle, last and suffix) 2. Birthdate (MM/DD/YYYY) IMPORTANT REQUIRED INFORMATION Please complete and return the following questions for each person in your household. We asked you some of these questions on the application, but we need more information.

More information

APPLICATION FOR HEALTH INSURANCE

APPLICATION FOR HEALTH INSURANCE APPLICATION FOR HEALTH INSURANCE and financial help to lower costs Use this application to find out if your family qualifies for: USE THROUGH SEPTEMBER 2015 No-cost health coverage from the Oregon Health

More information

Application for Health Insurance

Application for Health Insurance You can use this application to: Application for Health Insurance Apply for free or low-cost insurance from Medicaid or Nevada Check-Up. o You can apply for and receive Medicaid, even if you already have

More information

Application for Health Coverage & Help Paying Costs (Short Form)

Application for Health Coverage & Help Paying Costs (Short Form) Application for Health Coverage & Help Paying Costs (Short Form) Use this application to see what coverage you qualify for. Who can use this application? Apply faster online: Affordable private health

More information

Application for Health Coverage and Help Paying Costs

Application for Health Coverage and Help Paying Costs Application for Health Coverage and Help Paying Costs 205IFA 8/13 Apply faster online or by phone. Visit HealthConnect.Vermont.gov or call 1-855-899-9600. Applying for health coverage through Vermont Health

More information

Standard Application for Health Coverage & Help Paying Costs

Standard Application for Health Coverage & Help Paying Costs Standard Application for Health Coverage & Help Paying Costs Form Approved OMB No. 0938-1191 Use this application to see what coverage you qualify for Who can use this application? Affordable private health

More information

Application for Health Insurance

Application for Health Insurance TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal Covered California is the place where individuals and families can get affordable health insurance.

More information

Application for Health Insurance

Application for Health Insurance TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal See Inside Things to know 1 Application 2 19 Attachments A F 20 28 Frequently Asked 29 33 Questions

More information

Application for Health Care Coverage Easy, affordable protection for your family.

Application for Health Care Coverage Easy, affordable protection for your family. Application for Health Care Coverage Easy, affordable protection for your family. This is an application for health care benefits. If you need help translating it, please contact your county assistance

More information

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items.

You will need to mail or fax us copies of items that apply to your case. See the next page for a list of these items. Getting started: Health care for children CHIP and Children s Medicaid These programs offer health-care benefits for newborns and children age 18 and younger who live in Texas. With these programs, your

More information

Health and Dental Insurance Coverage

Health and Dental Insurance Coverage Application for Health and Dental Insurance Coverage Who can use this application? Apply faster online. Use this application for youself and anyone in your tax household who needs health or dental insurance

More information

Medical Assistance Application for the Elderly and Persons with Disabilities

Medical Assistance Application for the Elderly and Persons with Disabilities Medical Assistance Application for the Elderly and Persons with Disabilities Who can use this application? Apply faster online This application is for the elderly and persons with disabilities applying

More information

Use this application to apply for an exemption from the shared responsibility payment. Who can use this application?

Use this application to apply for an exemption from the shared responsibility payment. Who can use this application? Form Approved OMB No. 0938-1190 Application for Exemption for American Indians and Alaska Natives and Other Individuals who are Eligible to Receive Services from an Indian Health Care Provider Use this

More information

Application. Health Insurance. Your destination for affordable health insurance, including Medi-Cal. See Inside

Application. Health Insurance. Your destination for affordable health insurance, including Medi-Cal. See Inside Application for Health Insurance TM Your destination for affordable health insurance, including Medi-Cal See Inside Things to know Application Covered California is the place where individuals and families

More information

Application for Health Coverage Assistance

Application for Health Coverage Assistance Application for Health Coverage Assistance Health Coverage Assistance The Health Coverage Assistance Program provides health coverage assistance according to individual needs. Eligible families may qualify

More information

Small Business Health Options Program (SHOP)

Small Business Health Options Program (SHOP) Small Business Health Options Program (SHOP) Application for employees Complete this application to apply for SHOP health coverage from your employer. Go online Visit CoveredCA.com. You ll be able to see

More information

Commonwealth of Pennsylvania chipcoverspakids.com. Application for Health Care Coverage

Commonwealth of Pennsylvania chipcoverspakids.com. Application for Health Care Coverage Commonwealth of Pennsylvania chipcoverspakids.com Application for Health Care Coverage This page has been left intentionally blank. Information about health care coverage Who can use this application?

More information

Small Business Health coverage application for EMPLOYEES

Small Business Health coverage application for EMPLOYEES Small Business Health coverage application for EMPLOYEES 205EE 8/13 Use this application to see if you are eligible for Vermont Health Connect Small Business health coverage from your employer. You will

More information

Application for Services

Application for Services Application for Services State of Alaska Department of Health and Social Services Division of Public Assistance http://dhss.alaska.gov/dpa/ If you need help filling out this form or have questions, please

More information

Your Texas Benefits: Getting Started

Your Texas Benefits: Getting Started Your Texas Benefits: Getting Started SNAP Food Benefits (This used to be called Food Stamps.) Helps buy food for good health. Some people might get help the next work day. TANF Cash Help for Families TANF:

More information

Application for Health Coverage Assistance

Application for Health Coverage Assistance Application for Health Coverage Assistance Health Coverage Assistance The Health Coverage Assistance Program provides health coverage assistance according to individual needs. Eligible families may qualify

More information

Instructions to fill out this Application

Instructions to fill out this Application Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP offers health care for children, from birth to age 18, whose families

More information

Health and Dental Insurance Coverage

Health and Dental Insurance Coverage Application for Health and Dental Insurance Coverage Who can use this application? Apply faster online. Use this application for yourself and anyone in your household who needs health or dental insurance

More information

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage

Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage Application Information for Children s Health Insurance Program (CHIP), Children s Medicaid, and CHIP perinatal coverage CHIP CHIP covers children from birth through age 18 who do not qualify for Medicaid

More information

P E N N S Y L V A N I A

P E N N S Y L V A N I A P E N N S Y L V A N I A Application for Payment of Medicare Premiums, Coinsurance and Deductibles If you have a disability and need this form in large print or another format, please call our helpline

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs Application for Health Coverage & Help Paying Costs Use this application to see what coverage you qualify for You may qualify for a free or low cost program even if you earn as much as 94,000 a year (for

More information

BadgerCare Plus Application Packet

BadgerCare Plus Application Packet BadgerCare Plus Application Packet F-10182 January 2015 LICATION PACKET This is an application for BadgerCare Plus and Family Planning Only Services. You can apply: Online at ACCESS.wi.gov. Click on Apply

More information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information

Application. For Veterans Care Health Insurance. Veterans Care covers veterans who need health insurance. Other Important Information Application For Veterans Care Health Insurance There are thousands of veterans in Illinois who are living without health insurance because they can t afford it. The citizens of Illinois feel a sense of

More information

South Dakota Application for Medicare Savings Program

South Dakota Application for Medicare Savings Program DSS-EA-270 10/15 South Dakota Application for Medicare Savings Program NOTE: This application CAN be used for a single person or a couple (self and spouse). If you want more information on the following

More information

Application & Renewal Form

Application & Renewal Form Section A: I want health insurance for: (Check ( ) the category or categories that match your situation.) Myself, my spouse (or other parent of my children) and our children under age 19 who live with

More information

Health Benefits for Workers with Disabilities Application

Health Benefits for Workers with Disabilities Application Illinois Department of Public Aid Health Benefits for Workers with Disabilities Application Note: This is NOT an application for cash assistance, food stamps or enrollment in the Medicaid spenddown program.

More information

Your Texas Benefits. How to Apply. How to apply for benefits for: People age 65 and older People with disabilities. Medicare Savings Programs

Your Texas Benefits. How to Apply. How to apply for benefits for: People age 65 and older People with disabilities. Medicare Savings Programs Your Texas Benefits How to apply for benefits for: People age 65 and older People with disabilities Medicaid for the Elderly and People with Disabilities Helps people who: Lost Supplemental Security Income

More information

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof.

9. WILL THE INFORMATION I GIVE BE CHECKED? Yes and we may also ask you to send written proof. Dear Parent/Guardian: Children need healthy meals to learn. Your child s school offers healthy meals every school day. Your childr en may qualify for free meals or for reduced price meals. 1. DO I NEED

More information

South Carolina Medicaid Program Annual Review Form

South Carolina Medicaid Program Annual Review Form Date: BG #: HH #: Case Name: South Carolina Medicaid Program Annual Review Form This form is used to review your Medicaid coverage. You must return this form to us by: Return to: Healthy Connections, PO

More information

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS Capital Advantage Insurance Company Commonwealth of Pennsylvania Edward G. Rendell, Governor APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS Application Information The information

More information

Application for Medicaid

Application for Medicaid Application for Medicaid N.C. Department of Health and Human Services This application is intended for medical assistance for the Aged, Blind and Disabled or those who want Family Planning services. A

More information

Application for Health Care Coverage

Application for Health Care Coverage Application for Health Care Coverage www.upmchealthplan.com/members/forkids Information About Health Care Coverage Who can use this application? You can use this application to apply for anyone in your

More information

Health Care Reform: Health Insurance Marketplace FAQs

Health Care Reform: Health Insurance Marketplace FAQs From Filice Insurance Health Care Reform: Health Insurance Marketplace FAQs What is a Health Insurance Marketplace? The Health Insurance Marketplace (Marketplace) is a way to find health coverage that

More information

www.chipcoverspakids.com Application for Health Care Coverage

www.chipcoverspakids.com Application for Health Care Coverage www.chipcoverspakids.com Application for Health Care Coverage Information About Health Care Coverage Who can use this application? You can use this application to apply for anyone in your family. You can

More information

What is your racial origin? (check all that apply) White Black or African Descent

What is your racial origin? (check all that apply) White Black or African Descent W-1QMB (Rev. 4/10) State of Connecticut Department of Social Services Medicare Savings Programs Application/Redetermination (QMB, SLMB, ALMB) Do you need a reasonable accommodation or special help to complete

More information

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS

APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS 1. Please read the enclosed brochure for important information. 2. You may use this application to apply for Special Care for adults

More information

WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?

WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN? HEALTH CHECK (MEDICAID) NC HEALTH CHOICE FOR CHILDREN APPLICATION Free or Low-Cost Health Coverage This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs CMS Product No. 11708 October 2014 Instructions to Help You Complete the Application for Health Coverage & Help Paying Costs Starting November 15, 2014, you can apply for health coverage through the new

More information

If more space is needed for your responses, please use a separate sheet of paper and attach it to this supplemental form.

If more space is needed for your responses, please use a separate sheet of paper and attach it to this supplemental form. State of Hawaii Department of Human Services Med-QUEST Division Application Date: Date Sent: Due Date: Supplemental Form for Individuals Applying for Coverage On a Basis Other Than MAGI and/or for Their

More information

Instructions for Completing a Medicare Savings Program (MSP) Application

Instructions for Completing a Medicare Savings Program (MSP) Application Instructions for Completing a Medicare Savings Program (MSP) Application The attached Department of Human Services (DHS) Health Services Application is used to apply for Medicare Savings Programs (MSP)

More information

COLORADO HEALTH CARE COVERAGE

COLORADO HEALTH CARE COVERAGE COLORADO HEALTH CARE COVERAGE Colorado Department of Health Care Policy and Financing administers a variety of Medical Assistance Programs for qualifying persons who live in Colorado and meet eligibility

More information

L E T T E R T O H O U S E H O L D

L E T T E R T O H O U S E H O L D Free and Reduced Price School Meals Letter to Households Page 1 of 1 L E T T E R T O H O U S E H O L D Dear Parent/Guardian: School Year 2014 2015 * * * * * * * * * * * * * * * NEW THIS SCHOOL YEAR!!!

More information

Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs CMS Product No. 11708 October 2013 Instructions to Help You Complete the Application for Health Coverage & Help Paying Costs Starting October 1, 2013, you can apply for health coverage through the new

More information

Iowa Department of Human Services Application for Food Assistance

Iowa Department of Human Services Application for Food Assistance What is Food Assistance? Iowa Department of Human Services Application for Food Assistance Food Assistance is a program to help buy food for good health. How Do I Get Food Assistance? Step 1. Fill out

More information

Health Care Coverage. Application for. (and to find out if you can get help with costs)

Health Care Coverage. Application for. (and to find out if you can get help with costs) Application for Health Care Coverage (and to find out if you can get help with costs) Use this to see what health care coverage you qualify for: Apply faster online Information you will need to apply:

More information

Application for Medicaid

Application for Medicaid Application for Medicaid N.C. Department of Health and Human Services This application is intended for medical assistance for the Aged, Blind and Disabled or those who want Family Planning services. A

More information

There are other Medicaid programs that require a different application from this one.

There are other Medicaid programs that require a different application from this one. MEDICAID APPLICATION FOR Qualified Medicare Beneficiaries (QMB) Specified Low Income Medicare Beneficiaries (SLIMB) Qualified Individuals 1 (QI) Working Disabled Individuals (WDI) INFORMATION FOR THE APPLICANT

More information

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR PARTICIPATION IN THE ADDP AND/OR HICP PROGRAM

INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR PARTICIPATION IN THE ADDP AND/OR HICP PROGRAM New Jersey Department of Health AIDS Drug Distribution Program (ADDP) and Health Insurance Continuation Program (HICP) PO Box 722 Trenton, NJ 08625-0722 INSTRUCTIONS FOR COMPLETING THE APPLICATION FOR

More information

Application for Legal Assistance

Application for Legal Assistance Application for Legal Assistance 1. What kind of problem do you need help with? Divorce Child Custody Guardianship Bankruptcy Tax Landlord/Tenant Will / Estate Planning Other 2. Applicant Information Your

More information

Application for Employment Related Day Care (ERDC) Program

Application for Employment Related Day Care (ERDC) Program Application for Employment Related Day Care (ERDC) Program Please read these instructions before filling out this application. Answer all questions. Do not write in the shaded areas. To contact our office

More information

PERSONAL INFORMATION: You may have someone help you complete this application. E-Mail Address. Birthdate Sex Race U.S. Citizen (Yes or No)

PERSONAL INFORMATION: You may have someone help you complete this application. E-Mail Address. Birthdate Sex Race U.S. Citizen (Yes or No) Georgia Application for Medicaid & Medicare Savings for Qualified Beneficiaries (QMB - payment of premiums, coinsurance, and deductibles; SLMB - payment of Part B premium; and QI-1 - payment of Part B

More information

Application for Benefits

Application for Benefits Application for Benefits If you need help reading or completing this form, please ask us for help. Keep this page for your records. How do I apply for benefits? To complete your application fill out pages

More information

CHIP Health Insurance Renewal Form

CHIP Health Insurance Renewal Form CHIP Health Insurance Renewal Form 1. Household Information. First: MI: Last: Suffix: Head of Household : Street: Apt #: Address: Phone: City: State: Zip: Email: Primary: Alternate: Best time to call:

More information

Supplement Healthcare Coverage Application

Supplement Healthcare Coverage Application Page 1 Supplement Healthcare Coverage Application About the Healthcare Coverage Application Starting October 1, 2013, you can apply for health coverage through the new Health Insurance Marketplace. Coverage

More information

Application for Health Insurance

Application for Health Insurance TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal See Inside Application 2 19 Attachments A F 20 27 Frequently Asked 28 32 Questions The state of

More information

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN

MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Si necesita ayuda para llenar el formulario favor de llamar al 1-800-456-8900 Please PRINT in blue or black ink. MEDICAL ASSISTANCE (MA)/MCHP APPLICATION FOR FAMILIES, PREGNANT WOMEN, AND CHILDREN Date

More information

Renewal Form. www.upmchealthplan.com/upmcforkids

Renewal Form. www.upmchealthplan.com/upmcforkids Renewal Form www.upmchealthplan.com/upmcforkids There are three easy ways to renew CHIP coverage! To keep CHIP coverage, you can: 1. RENEW ONLINE USING COMPASS: (If you apply online, most of your information

More information

Health Insurance for Illinois Families. Rod R. Blagojevich, Governor

Health Insurance for Illinois Families. Rod R. Blagojevich, Governor Health Insurance for Illinois Families Rod R. Blagojevich, Governor KC 2378KC (R-3-04) IL478-2437 KidCare and FamilyCare Plans KidCare and FamilyCare are health insurance plans for Illinois residents.

More information

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email:

Public Health Management Corporation. Address: Street City Zip Code. Medical Case Manager /Housing Counselor. Email: APPLICATION COVER PAGE Agency: Address: Street City Zip Code Medical Case Manager /Housing Counselor Phone: (Print Name) Email: I attest the information and documentation submitted is accurate and verified

More information

Healthcare Coverage (and to find out if you can get help with costs)

Healthcare Coverage (and to find out if you can get help with costs) APPLICATION FOR Healthcare Coverage (and to find out if you can get help with costs) Use this application to see what healthcare coverage you qualify for: Free healthcare coverage from Rhode Island Medicaid

More information

Application for Benefits

Application for Benefits Application for Benefits If you need help reading or completing this form, please ask us for help. Keep this page for your records. How do I apply for benefits? To complete your application fill out pages

More information

C A L H O U N COUNTY SCHOO LS

C A L H O U N COUNTY SCHOO LS C A L H O U N COUNTY SCHOO LS Dear Parent/Guardian: Children need healthy meals to learn. Calhoun County Schools offers healthy meals every school day. Breakfast costs $1.50; lunch costs $1.75. Your children

More information

Health Care Coverage. Application for. (and to find out if you can get help with costs)

Health Care Coverage. Application for. (and to find out if you can get help with costs) Application for Health Care Coverage (and to find out if you can get help with costs) Use this application to see what health care coverage you qualify for: Apply faster online Information you will need

More information

T.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Application

T.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Application T.E.A.C.H. Early Childhood VERMONT Associate Degree Family Child Care Provider Scholarship Name Phone Number Home: Work: Cell: Email Address City, State, Zip County SSN Date of Birth (mm/dd/yyyy) Gender

More information

New Employees of the University of South Carolina (USC) USC Division of Human Resources New Health Insurance Marketplace Coverage Options

New Employees of the University of South Carolina (USC) USC Division of Human Resources New Health Insurance Marketplace Coverage Options MEMORANDUM To: From: Re: New Employees of the University of South Carolina (USC) USC Division of Human Resources New Health Insurance Marketplace Coverage Options As a new employee, the University of South

More information

FINANCIAL ASSISTANCE APPLICATION: COVER LETTER

FINANCIAL ASSISTANCE APPLICATION: COVER LETTER FINANCIAL ASSISTANCE APPLICATION: COVER LETTER Thank you for choosing Children s of Alabama to provide for the healthcare needs of your child. Please find attached the forms you must complete in order

More information

Our Mission. Promoting Independence by Providing Car Care

Our Mission. Promoting Independence by Providing Car Care Check List Douglas County Residents Only Our Mission Promoting Independence by Providing Car Care Please Submit the Following: FOR ALL APPLICANTS Fill out application completely and sign Sign the attached

More information

Start Application: This section is in reference to the primary applicant. Just the fields unique to the primary applicant are included here.

Start Application: This section is in reference to the primary applicant. Just the fields unique to the primary applicant are included here. KDHE Medical Policy 1 Online s Eligibility Processing Job Aid June 23, 2015 This Job Aid is intended to provide instruction on the required elements of the online application. The system requires an answer

More information