To apply for the Colorado HIBI program, fill out the attached application and either fax or mail it with a:

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1 Dear Applicant, The Colorado Health Insurance Buy-In (HIBI) program may reimburse health insurance premiums, copays, deductibles and coinsurance for a Medicaid client if the health insurance plan is cost-effective to Medicaid. The purpose of this program is to provide for the medical needs of Medicaid clients and to save taxpayer dollars. HIBI is a service Medicaid offers in addition to your regular Medicaid benefits. To be eligible for HIBI, your application must show that you are eligible for Medicaid during the time period for which payments are requested and must be covered by, or have access to, a cost-effective group or individual health insurance plan. To apply for the Colorado HIBI program, fill out the attached application and either fax or mail it with a: - Copy of the front and back of your insurance card - Premium rate sheet from your employer or insurance representative - Summary of benefits - Recent paystub or other verification to show proof of your health insurance premium payment Fax or mail your application and documents within 10 days to the address listed below. program within 10 days. FORM TWO may be completed by the health insurance member's EMPLOYER, such as a Human Resource representative or Benefits Coordinator. Include both the EMPLOYER and EMPLOYEE contributions for ALL premium tiers. Fax: Mailing Address: (855) Colorado HIBI Program Sincerely, The HIBI Team Phone: (855) MyCOHIBI or (855) Monday to Friday, 8 a.m. to 5 p.m. Mountain Standard Time Fax: (855) Website: [email protected] Colorado Department of Health Care Policy and Financing

2 FORM ONE: Colorado Health Insurance Buy-In (HIBI) Application program. FORM TWO may be completed by the commercial health care plan member's EMPLOYER, such as a Human Resource representative or Benefits Coordinator. You must answer all questions. Incomplete requests will be returned to you. 1. Do you or anyone in your family receive Medicaid Benefits? Yes No 2. Do you or anyone in your family have health insurance? Yes No IF YES, which type: EMPLOYER COBRA OTHER What is the premium for this policy? $ These premiums are paid/ deducted: Weekly Every other week Twice a month Monthly Quarterly Other Type of Coverage: and child(ren) and Spouse Family IF NO, do you have access to health insurance, such as insurance benefits through your job? Yes No 3. Is your health insurance coverage court-ordered (part of a divorce/separation decree)? Yes No 4. List any medical conditions for which you are being treated: 5. Are the health care providers you use able to bill both your insurance and Medicaid? Yes No 6. Are all the health care providers you use IN-NETWORK (for plans that have a network)? Yes No If you do not have access to health insurance, you are not eligible for CO HIBI. Please safely discard your application forms. If you are not sure you are eligible, please call our toll-free number to speak with Colorado HIBI eligibility advisor at (855) MyCOHIBI or (855) Please complete this section with the commercial health insurance member s information and signature. Name of Member: SSN: DOB: Address: City/ State/ Zip: Home Phone: Cell Phone: SSN: DOB: (Check box to sign up for notifications.) Yes, HIBI can send information about the program and my payments to my address provided above.

3 Insurance Company: Policy/Subscriber/Member Number: Group Number: FORM ONE (continued): Colorado Health Insurance Buy-In (HIBI) Application Effective Date of Policy: End Date: Other: 7. List everyone in your household covered by your policy, including Medicaid recipients. (Use extra paper if necessary.) Name Social Security Number Birth Date Medicaid ID Number Relationship to Member Gender Medical Condition (e.g. Diabetes, HIV, etc.) (Last 4 digits) 8. Check box to sign up for Direct Deposit: If accepted into the Colorado HIBI program, I would like to participate in Direct Deposit. By doing so, Colorado HIBI will deposit my payments into my checking account and I will not receive a paper check. If I am not accepted into the program, Colorado HIBI will properly discard my banking information. Bank Name: Routing #: Account #: (Please provide a copy of your voided check with this application.) 9. How did you first hear about Colorado HIBI (Choose an option below)? Mail County Caseworker Hospital Health related support group Online Search Engine (ex. Google) Other I authorize any person, medical provider, insurance company, or other organization to provide any information about me or my dependent s health insurance, medical treatment and employment to the Department of Health Care Policy and Financing and its Business Associates upon request. Signature: Date: To process your application, the Colorado HIBI program must receive a copy of the front and back of your insurance card, the premium rate sheet, summary of benefits, and a recent paystub or other verification to show proof of your premium payment.

4 FORM TWO: Colorado Health Insurance Buy-In (HIBI) Application program. FORM TWO may be completed by the commercial health care plan member's EMPLOYER, such as a Human Resource representative or Benefits Coordinator. 1. Has employment terminated for the commercial health care plan member listed above? YES, Date: NO 2. Employer Information: Employer Name: Employer Federal Tax ID: Address: City: State: Zip: Phone Number: Fax Number: 3. Employer-sponsored health insurance information: Do you offer insurance to your employees? YES NO If YES, please complete the rate table below. Please complete the table below for each health insurance plan offered OR attach your company rate sheet showing all rates offered. Also, please provide a Summary of Benefits for the health insurance plan accessible to the applicant. + Spouse + Child Family Carrier Name Plan Persons Covered Monthly Employer Contribution Monthly Employee Contribution Group #

5 FORM TWO (continued): Colorado Health Insurance Buy-In (HIBI) Application 4. Does this individual have access to purchasing dependent coverage? YES NO 5. When does your company's open enrollment period start and end? Start: End: 6. Employee's History: Has the individual listed above dropped or reduced health plan coverage within the last six months? YES NO If YES, which plan? s for whom coverage terminated: Termination Date: 7. Your Information: Name (Print): Your Title: Signature: Date Signed: Phone: Ext: You can either fax or mail a copy of this form back to the Colorado HIBI program. Fax: Mailing Address: (855) Colorado HIBI If you have any questions about this application, contact our office at our toll free number: (855) Phone: (855) MyCOHIBI or (855) Monday to Friday, 8 a.m. to 5 p.m. Mountain Standard Time Fax: (855) Website: [email protected] Colorado Department of Health Care Policy and Financing