Fillable MISSISSIPPI APPLICATION FOR HEALTH BENEFITS (MEDICAID, CHIP, HELP (Mississippi)

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MISSISSIPPI APPLICATION FOR HEALTH BENEFITS (MEDICAID, CHIP, HELP (Mississippi)

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  • 124 check-boxes
  • 1318 other fields

Country of origin: US
File type: PDF

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MISSISSIPPI APPLICATION FOR HEALTH BENEFITS
(MEDICAID, CHIP, HELP PAYING COSTS FOR HEALTH INSURANCE
COVERAGE)
This application is used to apply for health coverage for:
•
Medicaid
•
CHIP (Children’s Health Insurance Program)
•
The new tax credit that can help pay your health insurance premiums
•
Private health insurance plans through a federal Health Insurance
Marketplace
Use this application to apply for children, pregnant women, low-income parents of children
under age 18 and anyone in your family that needs to apply for health coverage. If you need
assistance in completing this application, need this application in a language other than
English, or if you are hearing or visually impaired and need special assistance, contact 1-800-
421-2408.
You do not have to fill out this application on paper. If you choose, you can apply on-line at
www.medicaid.ms.gov or www.HealthCare.gov.
What you will need to apply:
•
Social Security Numbers or document numbers for legal immigrants who need insurance,
•
Birth dates,
•
Employer and income information for each person in your family with income. Use
income from paystubs or W-2 forms or any document that shows exactly what each
person receives as income,
•
Policy numbers for any current health insurance,
•
Information about any job-related health insurance available to your family.
We will keep all the information you provide private, as required by law.
Complete and sign this application and send it to the address below. If you have questions,
call 1-800-421-2408 for assistance.
REGIONAL MEDICAID OFFICE ADDRESS & PHONE NUMBER
Cover Sheet – revised 01/01/2015
PART I – HEAD OF HOUSEHOLD – This is the primary adult contact for this application. We will
contact you for any additional questions we may have. You do not have to apply for health coverage to
be the primary contact.
Full Name
Home Address
City State Zip County
Mailing Address
City State Zip County
Phone Numbers – (home) (cell)
(work) (message #)
Do you want to get information about this application by email? Yes No
If yes, provide email address: ___________________________________________________________
Preferred spoken or written language (if not English)
PART 2 – AUTHORIZED REPRESENTATIVE (Optional) – You can name a person you trust to act
as your authorized representative. This means you are giving this person permission to see your
application and to act for you on matters relating to this application, including providing information
needed to complete this application. You must complete and sign this portion of the application to name
someone to act for you. If someone is legally appointed to act for you, submit proof with this application.
Name of Representative
Address (include Apt or Lot #)
City State Zip Phone #
Relationship to Head of Household
Organization Name ID# (if applicable)
By signing, you allow this person to sign your application, get official information about this
application and act for you in all future matters related to the health coverage of the ones applying:
Signature of Head of Household Date
Part 1 & Part 2 - revised 01/01/2015
click to sign
signature
click to edit
PART 3 – HOUSEHOLD MEMBERS – Include everyone who lives with you, even if not applying. If you file a
federal tax return, include everyone that you include on your federal tax return, even if they do not live with you.
Person 1 is the head of household for this application.
Name
Social Security
Number*
Date Of
Birth
Sex:
Male
Female
How is this person
related to you?
applying?
1
SELF
2
3
4
5
6
7
8
9
10
*Social Security Numbers (SSN) – We need SSNs for everyone who has one and is applying for health coverage.
You are not required to provide an SSN for household members not applying but it will speed up the application
process if you do give us SSNs of everyone. We use SSNs to check income and other information to see who is
eligible for help with health coverage. If you need help getting an SSN, contact Social Security at 1-800-772-1213.
TTY users call 1-800-325-0778. Or visit www.socialsecurity.gov.
PART 4 – RETROACTIVE MEDICAID COVERAGE (not available to children qualifying for CHIP) If
determined eligible for Medicaid, does any household member applying need Medicaid to cover services received
within the last 3 months? Yes No If yes, complete the following:
Name of household members/months needed:
PART 5 – HEALTH INSURANCE INFORMATION – If anyone applying for health coverage currently has
health insurance, tell us about it. This includes Medicaid, CHIP, Medicare, and coverage through VA health
programs, private coverage, work, a retiree health plan or any type of health insurance.
Name of Person
Type of Coverage
Name of Health Plan
Policy Number
Part 3, Part 4 & Part 5 - revised 01/01/2015
PART 6 – INFORMATION NEEDED ON HOUSEHOLD MEMBERS – please complete the following
information on all household members listed in Part 3.
Person 1 – This is the person named as Head of Household
Name
(first) (middle/maiden) (last) (suffix)
What is your marital status? ____________________________
Are you pregnant? Yes No If yes, what is the expected date of delivery?
How many babies are expected?
Do you plan to file a federal income tax return next year? Yes No If yes, select your filing status:
Married Filing Jointly Married Filing Separately Individual Head of Household Qualifying
Widow(er) If filing jointly with spouse, name of spouse
Will you claim any dependents on your tax return? Yes No If yes, name of dependents claimed:
Will you be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax filer:
How are you related to tax filer?
Do you need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
D
o you have a physical, mental or emotional health condition that limits common activities like bathing, dressing,
daily chores, etc. or do you live in a medical facility or nursing home? Yes No If you are disabled, would
you like to apply for Medicaid as a disabled person? Yes No If yes, you will be asked to complete
additional forms to determine if you qualify for Medicaid as a disabled individual.
Are you a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number _
Have you lived in the U.S. since 1996 Yes No Are you or your spouse or parent a veteran or an active-
duty member of U.S. military? Yes No
Do you live with at least one child under the age of 18 and are you the main person taking care of this child?
Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, you will be asked to
cooperate with child support services to collect medical support from the absent parent unless child support
services determines you have good cause not to cooperate.
Were you in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 1 - revised 10/01//2019
Person 1 – continued
Cu
rrent Job & Income Information: Are you currently:
Employed – How many jobs? ____ Self-employed – How many jobs? _ Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment __________
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will you get from this self-employment?
$ How often is this income received?
In the past year, did you: Change jobs Stop Working Start Working Fewer Hours Other
Explain:
Other Income – Tell us about other income that you receive that is not the result of your current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement,
Interest, Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If you are eligible for certain benefits, such as Unemployment Compensation, you must apply in order to be
eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if you get these income types to support your family.
Check here if you get any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
your reported income (unless already deducted from income shown above). If you pay alimony, student loan
interest or have other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if your income changes from month to month: What is your total income for this
calendar year? $ Next year (if different) $
Part 6 / Person 1 continued - revised 01/01/2015
Person 2 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?_______________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 2 - revised 10/01/2019
Person 2 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 2 continued - revised 01/01/2015
Person 3 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 3 - revised 10/01/2019
Person 3 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 3 continued - revised 01/01/2015
Person 4 – give us information on person #4 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ______________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No If
yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 4 - revised 10/01/2019
Person 4 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 4 continued - revised 01/01/2015
Person 5 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
Name –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 5 - revised 10/01/2019
Person 5 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 5 continued - revised 01/01/2015
Person 6 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Does this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 6 - revised 10/01/2019
Person 6 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 6 continued - revised 01/01/2015
Person 7 – give us information on person #4 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ___________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No If
yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 7 - revised 10/01/2019
Person 7 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? _ Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 7 continued - revised 01/01/2015
Person 8 – give us information on person #2 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?________________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, give names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 8 - revised 10/01/2019
Person 8 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment_
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward household income, but it helps us to know if this person gets these income types to help support the family.
Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 8 continued - revised 01/01/2015
Person 9 – give us information on person #3 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ____________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No
If yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, names of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native
Chinese Asian Indian Filipino J apanese Korean Vietnamese Other Asian Native
Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 9 - revised 10/01/2019
Person 9 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $
How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 9 continued - revised 01/01/2015
Person 10 – give us information on person #4 listed in Part 3: Household Members
Does this person live at the same address with the head of household? Yes No
N
ame –
(first) (middle/maiden) (last) (suffix)
What is this person’s marital status? ___________________________
Is this person pregnant? Yes No If yes, what is the expected date of delivery?_______________
How many babies are expected?
Does this person plan to file a federal income tax return next year? Yes No If yes, select filing
status: Married Filing Jointly Married Filing Separately Individual Head of Household
Qualifying Widow(er) If filing jointly with spouse, name of spouse
Will this person claim any dependents on their tax return? Yes No If yes, name of dependents
claimed:
Will this person be claimed as a dependent on someone’s tax return? Yes No If yes, name of tax
filer: Relationship to tax filer?
Does this person need health coverage? Yes If yes, answer all questions below.
No If no, skip to “Current Job and Income Information” on next page.
Do
es this person have a physical, mental or emotional health condition that limits common activities like
bathing, dressing, daily chores, etc. or does this person live in a medical facility or nursing home? Yes
No If disabled, would this person like to apply for Medicaid as a disabled person? Yes No If
yes, additional forms must be completed to determine if this person qualifies as a disabled individual.
Is this person a United States citizen or U.S. National? Yes No If no, complete the following:
Immigration status (such as lawful permanent resident, refugee, asylee, etc.)
Immigration document type and ID number
Has this person lived in the U.S. since 1996 Yes No Is this person or their spouse or parent a
veteran or an active-duty member of U.S. military? Yes No
Does this person live with at least one child under the age of 18 and is this person the main person taking
care of this child? Yes No If yes, name of child(ren)
Do any of the children named have a parent living outside the home? Yes No If yes, this person
will be asked to cooperate with child support services to collect medical support from the absent parent
unless child support services determines there is good cause not to cooperate.
Was this person in foster care at age 18 or older? Yes No If yes, in what state?
Race (optional) check all that apply: White Black American Indian or Alaska Native Chinese
Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian
Samoan Guamanian or Chamorro Other Pacific Islander Other
If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a
Puerto Rican Cuban Other
Part 6 / Person 10 - revised 10/01/2019
Person 10 – continued
Current Job & Income Information: Is this person currently:
Employed – How many jobs? Self-employed – How many jobs? _ Unemployed
Job #1: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week Start date of employment
Job #2: Employer Name
Employer Address & Phone:
Wages/tips (before taxes) $ Hourly Weekly Every 2 weeks Twice month
Monthly Yearly Average hours worked each week
Start date of employment
Self-employment – type of work
How much net income (profit after expenses allowed by the IRS) will this person get from this self-employment?
$ How often is this income received?
In the past year, did this person: Change jobs Stop Working Start Working Fewer Hours Other-
Explain any changes:
Other Income – Tell us about other income that this person receives that is not the result of current employment.
Include income such as Social Security benefits, Unemployment benefits, Alimony, Pensions, Retirement, Interest,
Dividends, Rental Income, Royalties.
Type of Benefit
Amount Paid (before
deductions)
How Often Received?
Start Date of Payment
If this person is eligible for certain benefits, such as Unemployment Compensation, this person must apply in
order to be eligible for Medicaid.
Child Support, SSI, TANF, Veterans’ payments and Workers’ Compensation are types of income not counted
toward your household income, but it helps us to know if this person gets these income types to help support the
family. Check here if this person gets any of these income types:
Deductions from income – certain deductions allowable on a federal tax return are allowed to be deducted from
reported income (unless already deducted from income shown above). If this person pays alimony, student loan
interest or has other allowable deductions, tell us what they are: Type
Amount Paid $ How Often?
Yearly Income – complete if income changes from month to month: What is this person’s total income for this
calendar year? $
Next year (if different) $
Part 6 / Person 10 continued - revised 01/01/2015
PART 7 – ACCESS TO HEALTH INSURANCE
Is anyone in the household offered health coverage from a job? This includes health coverage the
person could get through their job, someone else’s job (such as a parent or spouse) and includes private
employer plans, TRICARE, federal or state employee plans or any type of employer health coverage.
Yes No If yes, you will need to complete Appendix A.
Is this a state employee’s benefit plan? Yes No
PART 8 – COMPLETE ONLY IF ANY HOUSEHOLD MEMBERS ARE AMERICAN INDIAN
OR ALASKA NATIVE. If no, skip to Part 9.
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health
programs, or urban Indian health programs. You may also not have to pay cost sharing and may get
special monthly enrollment periods. Answer the following questions to make sure your family gets the
most help possible.
Name
Name
Name
Member of Federally Recognized
Tribe? Yes No
If yes, name tribe:
Member of Federally Recognized
Tribe? Yes No
If yes, name tribe:
Member of Federally Recognized
Tribe? Yes No
If yes, name tribe:
Has this person ever gotten a
service from the Indian Health
Service, a tribal health program
or through a referral from one of
these programs? Yes No
Has this person ever gotten a
service from the Indian Health
Service, a tribal health program
or through a referral from one of
these programs? Yes No
Has this person ever gotten a
service from the Indian Health
Service, a tribal health program
or through a referral from one of
these programs? Yes No
If no, is this person eligible to get
services from the Indian Health
Service, tribal health programs or
through a referral from one of
these programs? Yes No
If no, is this person eligible to get
services from the Indian Health
Service, tribal health programs or
through a referral from one of
these programs? Yes No
If no, is this person eligible to get
services from the Indian Health
Service, tribal health programs or
through a referral from one of
these programs? Yes No
If you have more people to include, make a copy of this page and attach.
Certain money received may not be counted for Medicaid or CHIP. Tell us if any of the income reported
for any American Indian or Alaska Native household member includes money from the following:
Per capita payments from a tribe
that come from natural resources,
usage rights, leases or royalties?
Yes No
Amount $
How often?
Name of Person Receiving the
Payment _____________________
Payments from natural resources,
farming, ranching, fishing, leases
or royalties from reservation land
or Indian trust land?
Yes
No
Amount $
How often?
Name of Person Receiving the
Payment _____________________
Money from selling things that
have cultural significance?
Yes
No
Amount $
How often?
Name of Person Receiving the
Payment_____________________
Part 7 & 8 - revised 01/01/2015
PART 9 - Children’s Health Insurance Program (CHIP)
A coordinated care organization (CCO) needs to be selected for children under the age of 19 who are determined
eligible for the Children’s Health Insurance Program (CHIP). If you are applying for a child under 19,
please
choose one (1) of the following Coordinated Care Plans:
M
olina Healthcare United HealthCare No preference
• Your ability to get coverage will not be affected if you do not answer this question.
• Although you do not have to answer this question now, if children under the age of 19 are
eligible for
CHIP, they will be auto enrolled into a Coordinated Care Plan. You will have
90 days to
change/select another plan.
• This CCO selection applies only if the child is determined eligible for CHIP.
PART 10– READ & SIGN THIS APPLICATION
I’m signing this application under penalty of perjury which means I’ve provided true answers to all the
questions on this form to the best of my knowledge. I know that I may be subject to civil and criminal
penalties under federal law if I provide false and/or untrue information.
I know that I must report to Medicaid or the federal health insurance marketplace if anything changes and
is different from what I wrote on this application. I understand that a change in my information could
affect the eligibility for member(s) of my household. To report changes: Call 1-800-421-2408 or report
in person or by calling your local Medicaid Regional Office.
I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin,
sex, age or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file
.
I confirm that no one applying for health insurance on this application is incarcerated (in jail).
If anyone applying is eligible for Medicaid or CHIP, you need to know and agree to the following:
If Medicaid pays for a medical expense, any money from other health insurance or legal settlements will
go to Medicaid to reimburse for these services. By accepting Medicaid, you agree to give up your rights
to any third party payments to the Division of Medicaid.
If you receive care or treatment under Medicaid or CHIP, you authorize the health care provider to release
to Medicaid or the CHIP insurer your medical records and information relating to your diagnosis,
examination and treatment.
Your case will be reviewed every year and you will be sent a notice regarding the action you must take, if
any, to renew Medicaid or CHIP coverage. Adults may be reviewed more than once per year depending
on the types of changes that are reported during the year.
Information that you give may be selected for review by state or federal auditors (reviewers). You must
cooperate with the review process if your case is selected. No additional permission is needed to get
verification or other information to review your case.
Children under age 21 who are eligible for Medicaid are eligible for a free health care prevention
program. It provides a way for children to get medical exams, check-ups, follow up treatment and special
care to make sure they maintain good health. You will be asked to select an approved screening provider
once your children are enrolled in Medicaid.
Part 9 & 10 - revised 10/01/2019
PART 10 – READ & SIGN THIS APPLICATION - continued
Adults eligible for Medicaid should get a yearly health screening (physical exam) from your local doctor
or clinic. This exam will not count against your annual doctor visit limit.
See your local health department for information on family planning services and WIC food services.
We need information on this application form to check your eligibility for help paying for health coverage
if you choose to apply. We’ll check your answers using information in our electronic databases and
databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security
and/or a consumer reporting agency. If the information does not match, we may ask you to send us proof.
Renewal of coverage in future years: Check the box of your choice
To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to
allow the federal health insurance marketplace to use income data, including information from tax returns.
The marketplace will send me a notice, let me make any changes and I can opt out at any time.
Yes, renew my eligibility automatically (if possible) for the next: 5 years (maximum) 4 years 3 years
2 years 1 year Don’t use information from tax returns to renew my coverage.
Your Right to Appeal
If
you think that the Health Insurance Marketplace or Medicaid or CHIP made a mistake, you can appeal the
decision. To appeal means to ask for a hearing or review of the action taken that you think is wrong. You can find
out how to appeal any action taken by the federal health insurance marketplace or Medicaid/CHIP by calling 1-800-
421-2408. You can be represented by someone other than yourself including an attorney (legal representative).
Your eligibility and other important information will be explained to you. A change in your information reported on
your application or review form could affect the eligibility of all household members applying or receiving benefits
through the Marketplace or Medicaid or CHIP.
Sig
n This Application
Signature of Head of Household or Authorized Representative Date (month, day, year)
Do you want to register to vote? Yes No If yes, complete the attached voter registration form and return it
with this application.
For Certified Application Counselors and Navigators Only – Complete this section if you are a certified
application counselor or navigator filling out this application for somebody else.
Cou
nselor’s Full Name -
Organization Name ID#
Application Start Date
Part 10 continued - revised 01/01/2015
Appendix A – Employer Coverage (Issue Date 10/01/2013)
APPENDIX A TO MISSISSIPPI APPLICATION FOR HEALTH COVERAGE
HEALTH COVERAGE FROM JOBS
If someone in the household is eligible for health coverage from a job, please complete this form. Complete this form for
each job that offers coverage, using separate forms for each job. Take this form to the employer to help complete the
health coverage questions if needed. Complete the form for each household member eligible for health coverage through
a job, even if it is from another person’s job, like a spouse or parent of a child under age 26.
Name of employee: ___________________________________ SSN: ____________________________
Employer Information
Employer ID # (EIN)
Name of Employer:
Address of Employer:
City State Zip
Phone #
Email
Contact Person Regarding Health Coverage:
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? __
Yes (Continue) __ No (Stop here)
If you are in a waiting period or probationary period, when can you enroll in coverage? ______________
List the names of anyone else who is eligible for coverage from this job.
Name: ___________________________________________________________________
Name: ___________________________________________________________________
Name: ___________________________________________________________________
Tell us about the health plan offered by this employer:
Does the employer offer a health plan that covers an employee’s spouse or dependent? □ No □Yes – which people?
□ Spouse □ Dependent
Does the employer offer a health plan that meets the minimum value standard? □ Yes □ No An employer-sponsored
health 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% of such costs (Sec. 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
For the lowest cost plan that meets the minimum value standard offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/she received the
maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness
programs.
Employee premiums for this plan $______________. How often? ____________________________
What change will the employer make for the new plan year (if known)?
□ Employer will not offer health coverage
□ Employer will start offering health 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). Premium amount $ __________________ How often? _________________________
Date of change:__________________________________________________________________________
Appendix A – Employer Coverage (Issue Date 10/01/2013)
APPENDIX A TO MISSISSIPPI APPLICATION FOR HEALTH COVERAGE
HEALTH COVERAGE FROM JOBS
If someone in the household is eligible for health coverage from a job, please complete this form. Complete this form for
each job that offers coverage, using separate forms for each job. Take this form to the employer to help complete the
health coverage questions if needed. Complete the form for each household member eligible for health coverage through
a job, even if it is from another person’s job, like a spouse or parent of a child under age 26.
Name of employee: ___________________________________ SSN: ____________________________
Employer Information
Employer ID # (EIN)
Name of Employer:
Address of Employer:
City State Zip
Phone #
Email
Contact Person Regarding Health Coverage:
Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months? __
Yes (Continue) __ No (Stop here)
If you are in a waiting period or probationary period, when can you enroll in coverage? ______________
List the names of anyone else who is eligible for coverage from this job.
Name: ___________________________________________________________________
Name: ___________________________________________________________________
Name: ___________________________________________________________________
Tell us about the health plan offered by this employer:
Does the employer offer a health plan that covers an employee’s spouse or dependent? □ No □Yes – which people?
□ Spouse □ Dependent
Does the employer offer a health plan that meets the minimum value standard? □ Yes □ No An employer-sponsored
health 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% of such costs (Sec. 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
For the lowest cost plan that meets the minimum value standard offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/she received the
maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness
programs.
Employee premiums for this plan $______________. How often? ____________________________
What change will the employer make for the new plan year (if known)?
□ Employer will not offer health coverage
□ Employer will start offering health 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). Premium amount $ __________________ How often? _________________________
Date of change:__________________________________________________________________________
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MISSISSIPPI APPLICATION FOR HEALTH BENEFITS (MEDICAID, CHIP, HELP (Mississippi)

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Completed 26 May 2021

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