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. There are plans for: Children 18 or younger KidCare Rebate, KidCare Share, KidCare Premium, KidCare Assist, FamilyCare Assist Pregnant women and their babies KidCare Moms & Babies Parents living with their children or other relatives who are caring for children in place of their parents FamilyCare Assist. The plan you get depends on your situation and income. Children KidCare Rebate If your children already have health insurance through your employer or a private policy or can get it, the KidCare Rebate Plan may be for you. KidCare Rebate can pay you back for some or all of the premiums you pay for your children=s health insurance. With KidCare Rebate, your children could enroll in the same health plan, receive the same benefits and use the same doctors as you do. Families who would get KidCare Assist cannot get KidCare Rebate. To apply for KidCare Rebate, fill out the application and Section A of the Rebate Form on page 5. Have your employer or insurance agent fill out Section B of the Rebate Form. Return the application and Rebate Form to us. KidCare Share and KidCare Premium Under KidCare Share and KidCare Premium, you will get a card each month that you can use when your children need medical care. With both Share and Premium you will go to a doctor who takes KidCare. These plans cover most medical care. Under KidCare Share, you will usually pay a $2.00 co-payment each time your child visits a doctor, clinic or hospital or gets a prescription filled. Well-child visits and shots are offered at no cost to your family. Under KidCare Premium, you will usually pay a $3.00 or $5.00 co-payment for medical visits and prescriptions and $25.00 for non-emergency care received in an emergency room. Well-child visits and shots are offered at no cost to your family. You will also pay a low premium each month of $15.00 for one child, $25.00 for two children or $30.00 for three or more children. If you don t pay your monthly premium, your children s coverage will be cancelled. If this happens, you will have to reapply and your coverage cannot begin again for at least three months. KidCare Assist and FamilyCare Assist KidCare Assist and FamilyCare Assist are for children with lower income. You will get a card each month that you can use when your children need medical care. You will go to a doctor who takes KidCare and FamilyCare. These plans cover most medical care at no cost to your family. Pregnant Moms KidCare Moms & Babies KidCare Moms & Babies is for pregnant women and their babies. You will get a card each month that you can use when you need medical care. You will go to a doctor who takes KidCare. This plan covers most medical care including prenatal visits and delivery services for pregnant women and well-baby care for their babies up to one year of age. Parents and Caretaker Relatives FamilyCare Assist FamilyCare Assist covers most medical care for you and your spouse. You will get a card each month that you can use when you need medical care. You will go to a doctor who takes FamilyCare. You will pay small co-payments for medical care. To apply for any of these plans, fill out the application and return it to us. For KidCare Rebate, see instructions above. It may be better for you to apply at your Department of Human Services (DHS) Local Office if your family has one of the following: Child Support or Social Security Income A stepparent in the home High medical bills A family member applying for benefits who is disabled or is 65 or older For more information, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter).

KidCare and FamilyCare Application Please print in ink or type. If more space is needed to answer any question, please attach an extra sheet. Applicant=s Last Name First Name (The applicant is usually the person filling out this form; a child s parent, guardian, or relative or a pregnant woman.) Birth Date (month, day, year) Social Security Number (optional) Address Apt # City State Zip Code County Home Phone ( ) Work Phone ( ) If no phone, name a contact person: Name Phone ( ) Language Preference of Applicant: English Spanish Other (Specify) Race or Ethnic Group: (This information is optional. It will not affect your eligibility.) White Black Hispanic American Indian or Alaska Native Asian or Pacific Islander Other Complete questions #1 through #11 for family members who want health benefits. This includes pregnant women, children 18 or younger, parents living with their children, or other relatives who are caring for children in place of their parents. (If you need more space, attach an extra sheet.) 1. Name (last, first) Person #1 Person #2 Person #3 2. Sex Male Female Male Female Male Female 3. Birth Date (month/date/year) 4. Social Security Number (optional for pregnant women) 5. Relationship to Applicant (son, daughter, self, spouse, etc.) 6. Is this person an American Indian or Alaska Native? 7. U.S. Citizen? If no, and the person has an alien registration number, write the number here and attach proof. 8. For anyone 18 or younger, write: Mother=s full name b. Father s full name For all others, write N/A 9. Has this person received medical care in the past three months that you want the State to pay for? If yes, which months? 10.Is this person pregnant or has this person been pregnant in the last three months? b. Yes No Yes No Yes No Yes No Yes No Yes No b. Yes No Yes No Yes No Yes No Yes No Yes No b. For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). Page 1

Person #1 Person #2 Person #3 11.Is this person covered by health or hospital insurance (including Medicare) now or in the last three months? If yes, complete the following. Date Coverage Began (month/year) b. Has insurance ended? If yes, why? Date Coverage Ended (month/year) c. Insurance Company d. Name of Policyholder e. Policyholder s SSN (optional) f. Employer Name and Phone Number g. Policy Number and Group Number Yes No b. Yes No c. d. e. f. g. Yes No b. Yes No c. d. e. f. g. Yes No b. Yes No c. d. e. f. g. 12.How many people live with you? Only include you and your spouse, any children either of you have, their brothers and sisters 18 or younger and any other children applying for KidCare. For anyone 18 or younger who is applying for KidCare, include their parents if they live in the home. 13.Complete the information below for the people you counted in #12 above who are not applying for KidCare or FamilyCare. Do not complete the information for yourself if you are the Applicant on page 1 (Attach an extra sheet if necessary). Name Social Security Number (optional) Birth Date (month/day/year) Relationship to Applicant Name Social Security Number (optional) Birth Date (month/day/year) Relationship to Applicant 14.Is any adult, parent, stepparent, spouse or pregnant woman named on this form currently employed? Yes No If yes, complete the following and attach one pay stub received in the last 30 days from each job (see page 4). Is anyone selfemployed? Yes No If yes, attach 30 days of detailed self-employment records including income and expenses. Name of Person Employer Employer Address Employer Phone Number of Hours Worked Weekly Amount Paid (including tips) before taxes $ How Often Paid Name of Person Employer Employer Address Employer Phone Number of Hours Worked Weekly Amount Paid (including tips) before taxes $ How Often Paid 15. Does anyone named on this form GET money from any source other than employment (such as Social Security, child support, spousal support, rental property, unemployment benefits, pensions, trusts)? Yes No If yes, complete the following and attach proof of one payment received in the last 30 days for each source of income listed (see page 4). Name of Person Source Payment Amount $ How Often Paid Name of Person Source Payment Amount $ How Often Paid If income is from rental property, is the person receiving the income also the property manager? Yes No 16. Does anyone named on this form PAY child support or spousal support? Yes No If yes, complete the following and attach proof of one payment made within the last 30 days (see page 4). Name of Person Payment Amount $ How Often Paid Name of Person Payment Amount $ How Often Paid 17. Does anyone named on this form PAY for day care so they can work? Yes No If yes, complete the following for payment made in the last month. Name of Child(ren) in Day Care Name of Care Giver Person Paying Day Care Payment Amount $ Relationship of Care Giver to Child (if any) How Often Paid For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). Page 2

Read and Sign! I understand that if the children for whom I am applying are approved for KidCare Share or KidCare Premium, I am responsible for paying the appropriate premiums and co-payments.! I understand that if the children for whom I am applying are approved for KidCare Rebate, the State of Illinois is not responsible for additional premiums, deductibles or co-payments required by the employer or private health insurance policy.! If I am approved for KidCare Assist, KidCare Moms & Babies or certain income levels of FamilyCare Assist also called Medical Assistance, I give my right to collect medical support payments to the State of Illinois. I also must cooperate with the State of Illinois to establish paternity of (if necessary) and obtain medical support payments for members of my family receiving KidCare Assist, KidCare Moms & Babies or FamilyCare Assist unless I am declared exempt for a good cause. I understand that failure to cooperate will not affect any child=s eligibility for KidCare but may affect the eligibility of adults.! If my application is approved, I give the State of Illinois the right to recover, under the terms of any private or public health care coverage, any amount for which I or a member of my household approved for benefits may be eligible.! I understand that all information I give is confidential and federal and state laws limit disclosure of information about me.! Officials with responsibilities for the health benefits program for which I or the members of my household have applied may verify all information on this form. I understand that I must cooperate in these efforts to verify information. I understand that verification may occur through electronic means.! I understand that the immigration status of each person applying for medical benefits who is not a citizen of the United States will be verified with the Bureau of Citizenship and Immigration Services (BCIS). This will require the disclosure to BCIS of certain identifying information which I have provided. The information received from BCIS may affect eligibility for medical benefits.! I agree to inform KidCare within 10 days if my income or household size changes, if I move or if anyone who gets KidCare or FamilyCare moves out of Illinois, dies, or goes to jail or prison.! I understand that anyone who knowingly misuses the health benefits card issued by the State of Illinois may be committing a crime. I declare under penalty of perjury that I have read all statements on this form and the information I give is true, correct and complete to the best of my knowledge. I understand that I could be penalized if I knowingly give false information. Applicant=s Signature Date (If unable to sign, make a mark and have a witness sign next to your mark.) If someone completed this application on behalf of the Applicant, they must sign and complete the information below. Signature Date Name (print) Relationship to Applicant Address City State Zip Code Phone Where did you hear about KidCare? Check all boxes that apply. Radio Ad Doctor's Office School Employer TV Ad Clinic Government Office/Agency Labor Union Newspaper Ad or Story Hospital Mail Sent to My Home Internet/Website Billboard or Bus Poster WIC site Friend or Relative Other C-------------------------------------------------------------------------------------------------------------------------------------------------------------- Please keep for your records. If your family has CHILD SUPPORT OR SOCIAL SECURITY INCOME, A STEPPARENT IN THE HOME, HIGH MEDICAL BILLS, OR YOU ARE APPLYING FOR A DISABLED FAMILY MEMBER OR ONE WHO IS 65 OR OLDER, it may be better for you to apply at your Department of Human Services (DHS) Local Office. For more information, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). If you are not satisfied with the actions taken on this application, you have the right to a fair hearing. You can ask for a fair hearing by writing your local office, or by writing DPA Fair Hearings, 401 South Clinton Street, 6 th Floor, Chicago, IL 60607 or by calling 1-800-435-0774 (TTY: 1-877-734-7429 for persons using a teletypewriter). Use these numbers only to file an appeal. All other calls and inquiries should be directed to the numbers at the bottom of this page. KidCare is open and accessible without regard to sex, race, disability, national origin, religion or age. The State of Illinois is an equal opportunity employer that practices affirmative action. The State of Illinois provides reasonable accommodations according to Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990. For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). Page 3

Important Stuff to Include with Your KidCare and FamilyCare Application To get health insurance coverage under KidCare or FamilyCare, you must provide proof for some of the information you give. Below are descriptions of the proof to send in with your application. You must send all that apply to you. PROOF OF INCOME: Send proof of each type of income you list on the application. This may include: C Copy of one pay stub (including tips) received in the last 30 days from each job. If anyone is self-employed, provide 30 days of detailed business records that include income and expenses.. C Copy of one check or award letter for unemployment benefits, Social Security benefits and veteran s benefits received in the last 30 days. C Proof of one payment for child support or spousal support received in the last 30 days. C Proof of payment received from other income including income from trusts, pensions, rental property, etc. Send one payment received in the last 30 days for each source of income listed. Send proof of expenses tied to rental income for the last 30 days. C Proof of income for each month you listed in question 9. C If your employment ended in the last 3 months, give the date of the last day worked and the date of the last pay received. If you list more than one type of income on the application, send proof of each type. PROOF OF PAYMENT for child support or spousal support you paid: To get credit for child support or spousal support payments listed on the application, you must send proof of one payment for the last 30 days. IMMIGRATION DOCUMENTS for non-citizens: NON-CITIZENS WHO ARE PREGNANT ARE NOT REQUIRED TO PROVIDE PROOF OF IMMIGRATION STATUS FOR THEMSELVES, but if this is not provided their coverage may be affected 60 days after pregnancy. If you are applying for anyone who is not a citizen, the State of Illinois will contact the Bureau of Citizenship and Immigration Services (BCIS) to verify their legal immigration status if you write an alien registration number on the application. KidCare or FamilyCare health benefits will not affect your immigration status, unless you receive services in a nursing home or mental health facility. Proof of legal immigration status is not needed for anyone who is not requesting health benefits. Providing an alien registration number for anyone in question #7 means you will need to supply proof of their status, such as copies of any of the following: $ Alien Registration Receipt Card/Permanent Resident Card/Green Card Passport with the following stamps or attachments: Arrival-Departure Record including the stamp showing status (I-94), or Resident Alien Form (I-551) or Temporary Resident Card (I-688) A court-ordered notice for Asylees Other proof of lawful immigration status Non-citizens who are related to active or honorably discharged members of the U.S. armed services may qualify to receive KidCare by sending proof of such status. This includes spouses and unmarried dependent children. PROOF OF PREGNANCY: If anyone you list on the application is pregnant, send a signed statement from her doctor or health clinic which includes the date she is expected to deliver and the number of babies expected. PROOF OF APPLICATION for a Social Security Number: If anyone you are applying for does not have a Social Security Number, you must send a signed statement from the Social Security Administration that application has been made. Note: Pregnant women are not required to send proof of a Social Security Number. Mail your completed application with copies of Important Stuff (see above) to: KIDCARE UNIT P.O. BOX 19122 SPRINGFIELD, IL 62794-9122 *REMEMBER: If your address or other information changes, please notify the KidCare Unit by calling toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter). Page 4

KidCare Rebate Form Complete this form if you are interested in KidCare Rebate for your children. If your income qualifies your children for KidCare Share, KidCare Premium or KidCare Rebate and you choose to receive a rebate for their insurance instead of a KidCare card, please follow the steps below: 1) Have employee/policyholder complete Part A; 2) Have the policyholder's employer or personal insurance agent complete Part B and return it to you; and 3) Attach this completed form to the completed KidCare Application prior to mailing. Part A - Employee/Policyholder Section - To be completed by the employee/policyholder. Employee/Policyholder=s Last Name First Name Address Apt # City State Zip Social Security Number Phone ( (SSN is required in order for the State to make payments to the policyholder.) ) Name(s) of children for whom you are applying for KidCare Rebate: Employee/Policyholder Attestation and Signature - I agree to notify KidCare immediately at toll-free 1-877-805-5312 (TTY: 1-877-204-1012) if the insurance is terminated, if persons are added to or deleted from the policy, if premium amounts change, or if the coverage or policyholder changes. I authorize my employer, plan administrator and insurance company to provide the information requested in Part B below for the purpose of determining eligibility for KidCare. I also authorize my employer, plan administrator and insurance company to verify my coverage and any of the information below at any time during my participation in KidCare. Signature of Employee/Policyholder Part B - Employer/Insurance Agent Section - To be completed by the employer or by the policyholder's insurance agent if the policy is not provided through an employer. Note to Employer/Insurance Agent: The above named employee/policyholder is applying for a program called KidCare that may help cover the cost of their children s health insurance premiums. Please assist them by completing the information below and returning the form to the employee/policyholder as soon as possible. (As used below, employee applies to an employee or private policyholder.) For help in completing this form, call toll-free 1-877-805-5312. Employer (if employer policy) Employer Address City State Zip Person completing this form Phone ( ) Fax ( ) Insurance Company Policy Number Group Number Check which of the following benefits are covered: G Physician Services G Hospital Inpatient Services Amount of Premium Paid by Employee $ (Include amounts paid for dental, vision and prescription coverage) Premiums are paid: weekly every 2 weeks twice a month monthly every 2 months quarterly semi-annually annually Persons covered by the employee premium contribution Does the employer pay 100% of the cost of the employee's coverage? G Yes G No If NO, how much of the amount listed above is for coverage of the employee only (single rate)? $ (Include amounts for dental, vision and prescription coverage) Enrollment Period for Policy Date the Premium Listed Above Began/Begins Date of Next Scheduled Change in Premium Authorized Signature of Employer/Agent Date For help in completing this form, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543)(TTY: 1-877-204-1012 for persons using a teletypewriter). Page 5

For more information or assistance in completing this application, call toll-free 1-866-4-OUR-KIDS (1-866-468-7543) (TTY: 1-877-204-1012 for persons using a teletypewriter) Rod R. Blagojevich Governor KidCare Web site: http://www.kidcareillinois.com/