for Low Income Families Medicaid Insurance - Alabama Department

NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].

Application for Health Coverage & Help Paying Costs

APPLY ON-LINE atInsureAlabama.org

thin

gs

to k

no

w

Use this application to see what coverage choices you qualify for

• Affordableprivatehealthinsuranceplansthatoffercomprehensivecoveragetohelpyoustaywell

• Anewtaxcreditthatcanimmediatelyhelppayyourpremiumsfor healthcoverage

• Freeorlow-costinsurancefromAlabamaMedicaidorALLKids.You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).

Who can use this application?

• Usethisapplicationtoapplyforanyoneinyourfamily.• Applyevenifyouoryourchildalreadyhashealthcoverage.Youcouldbe

eligibleforlower-costorfreecoverage.• Ifyou’resingle,youmaybeabletouseashortform.

Ifyoudonotneedhelpwithcost,gotoHealthCare.gov.• Familiesthatincludeimmigrantscanapply.Youcanapplyforyourchildeven

ifyouaren’teligibleforcoverage.Applyingwon’taffectyourimmigrationstatusorchancesofbecomingapermanentresidentorcitizen.

• Ifsomeoneishelpingyoufilloutthisapplication,youmayneedtocompleteAppendixC.

What you may need to apply

• SocialSecurityNumbers(ordocumentnumbersforanylegalimmigrantswhoneedinsurance)

• Employerandincomeinformationforeveryoneinyourfamily(forexample,frompaystubs,W-2forms,orwageandtaxstatements)

• Policynumbersforanycurrenthealthinsurance• Informationaboutanyjob-relatedhealthinsuranceavailabletoyourfamily

Why do we ask for this information?

Weaskaboutincomeandotherinformationtoletyouknowwhatcoverageyouqualifyforandifyoucangetanyhelppayingforit.We’ll keep all the information you provide private and secure, as required by law. ToviewthePrivacyActStatement,gotoHealthCare.gov/placeholder.

What happens next?

Sendyourcomplete,signedapplicationtotheaddressonpage11. If you don’t have all the information we ask for, sign and submit your application anyway.We’llfollow-upwithyou.You’llgetinstructionsonthenextstepstocompleteyourhealthcoverage.Ifyoudon’thearfromus, calltheAlabamaMedicaidAgencyat1-800-362-1504 orcallALLKidsat 1-888-373-KIDS (5437).Fillingoutthisapplicationdoesn’tmeanyouhavetobuyhealthcoverage.

of 11


STEP 1(Weneedoneadultinthefamilytobethecontactpersonforyourapplication.)

1.Firstname,Middlename,Lastname,&Suffix

2.Mailingaddress 3.Apartmentorsuitenumber

4.City 5.State 6.ZIPcode 7.County

8.Homeaddress(ifdifferentfrommailingaddress) 9.Apartmentorsuitenumber

10.City 11.State 12.ZIPcode 13.County

14.Phonenumber

()–15.Otherphonenumber

()–16. Doyouwanttogetinformationbyemail? Yes No

Emailaddress:

17.Whatisyourpreferredspokenorwrittenlanguage(ifnotEnglish)?

18.MaritalStatus:(Married,Divorced,Separated,Single,Widowed) CIRCLE ONE

STEP 2Who do you need to include on this application?Tellusaboutallthefamilymemberswholivewithyou.Ifyoufiletaxes,weneedtoknowabouteveryoneonyourtaxreturn.(Youdon’tneedtofiletaxestogethealthcoverage).

DO Include:• Yourself• Yourspouse• Yourchildrenunder21wholivewithyou• Yourunmarriedpartnerwhoneedshealthcoverage• Anyoneyouincludeonyourtaxreturn,eveniftheydon’t

livewithyou• Anyoneelseunder21whoyoutakecareofandlives

withyou

You DON’T have to include: • Yourunmarriedpartnerwhodoesn’tneedhealthcoverage• Yourunmarriedpartner’schildren• Yourparentswholivewithyou,butfiletheirowntaxreturn

(ifyou’reover21)• Otheradultrelativeswhofiletheirowntaxreturn

Theamountofassistanceortypeofprogramyouqualifyfordependsonthenumberofpeopleinyourfamilyandtheirincomes.Thisinformationhelpsusmakesureeveryonegetsthebestcoveragetheycan.

Complete Step 2 for each person in your family. Startwithyourself,thenaddotheradultsandchildren.If you have more people in your family, you’ll need to make a copy of the pages and attach them.Youdon’tneedtoprovideimmigrationstatusoraSocialSecurityNumber(SSN)forfamilymemberswhodon’tneedhealthcoverage.We’llkeepalltheinformationyouprovideprivateandsecureasrequiredbylaw.We’llusepersonalinformationonlytocheckifyou’reeligibleforhealthcoverage.

Tell us about yourself.

Tell us about your family.

of 11


STEP 2: PERSON 1CompleteStep2foryourself,yourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.

1.Firstname,Middlename,Lastname,&Suffix 2.Relationshiptoyou?

SELF3.Dateofbirth(mm/dd/yyyy) 4.Sex Male Female

5.SocialSecurityNumber(SSN) - - We need this if you want health coverage and have an SSN. ProvidingyourSSNcanbehelpfulifyoudon’twanthealthcoveragetoosinceitcanspeeduptheapplicationprocess.WeuseSSNstocheckincomeandotherinformationtoseewho’seligibleforhelpwithhealthcoveragecosts.IfsomeonewantshelpgettinganSSN,call1-800-772-1213orvisitsocialsecurity.gov. TTYusersshouldcall1-800-325-0778.

6.Do you plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)

YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.

a. Willyoufilejointlywithaspouse? Yes No

If yes,nameofspouse:

b. Willyouclaimanydependentsonyourtaxreturn? Yes No

If yes,listname(s)ofdependents:

c. Willyoubeclaimedasadependentonsomeone’staxreturn? Yes No

If yes,pleaselistthenameofthetaxfiler:

Howareyourelatedtothetaxfiler?

7. Areyoupregnant? Yes Noa.If Yes,howmanybabiesareexpectedduringthispregnancy? Due Date: _________

FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes No

IfyouareinterestedinapplyingforWIC(forpregnantorbreast-feedingwomenandchildrenunderagefive)youcanapplyatyourlocalCountyHealthDepartment.

8.Do you need health coverage? (Evenifyouhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts).

YES. If yes,answerallthequestionsbelow. NO. If no, skiptotheincomequestionsonpage3. Leavetherestofthispageblank.

9. Doyouhaveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No

10. AreyouaU.S.citizenorU.S.national? Yes NoIf No, Answer #1111. If you aren’t a U.S. citizen or U.S. national,doyouhaveeligibleimmigrationstatus?

Yes.FillinyourdocumenttypeandIDnumberbelow.

a.Immigrationdocumenttype b.DocumentIDnumberc.HaveyoulivedintheU.S.since1996? Yes No d.Areyou,oryourspouseorparentaveteranoranactive-duty memberoftheU.S.military? Yes No

12.Doyouwanthelppayingformedicalbillsfromthelastthreemonths? Yes No

13.Doyoulivewithatleastonechildundertheageof19,andareyouthemainpersontakingcareofthischild? Yes No

14.Areyouafull-timestudent? Yes No 15.Wereyouinfostercareatage18orolder? Yes No

16.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other

17.Race (OPTIONAL—check all that apply.)

White BlackorAfrican American

AmericanIndianorAlaskaNative

AsianIndian Chinese

Filipino Japanese Korean

Vietnamese OtherAsian NativeHawaiian

GuamanianorChamorro Samoan OtherPacificIslander Other

(Start with yourself)

of 11


CURRENT JOB 1:18.Employernameandaddress 19.Employerphonenumber

()–20.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly

$ 21.AveragehoursworkedeachWEEK

CURRENT JOB 2: (Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper.)22.Employernameandaddress 23.Employerphonenumber



26.In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese

27.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare

paid)willyougetfromthisself-employmentthismonth?

$

28.OTHER INCOmE THIS mONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).

None Unemployment $ Howoften?

Pensions $ Howoften?

SocialSecurity $ Howoften?

Retirementaccounts $ Howoften?

Alimonyreceived $ Howoften?

Net farming/fishing $ Howoften?

Netrental/royalty $ Howoften?

Otherincome $ Howoften? Type:

29.DEDUCTIONS:Checkallthatapply,andgivetheamountandhowoftenyougetit.

Ifyoupayforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question27b).

Alimonypaid $ Howoften?

Studentloaninterest $ Howoften? Otherdeductions $ Howoften?Type:

30.YEARLY INCOmE: Complete only if your income changes from month to month.If you don’t expect changes to your monthly income, skip to the next person.

Yourtotalincomethis year$

Yourtotalincomenext year(ifyouthinkitwillbedifferent)$

THANKS! This is all we need to know about you.

STEP 2: PERSON 1 (Continue with yourself)

Current Job & Income Information Employed Ifyou’recurrentlyemployed,tellusaboutyourincome.Startwithquestion18..

Not employed Skiptoquestion28.

Self-employed Skiptoquestion27.

of 11


STEP 2: PERSON 2CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.


3.Dateofbirth(mm/dd/yyyy) 4.Sex Male Female

5.SocialSecuritynumber(SSN) - - We need this if you want health coverage and have an SSN.

6.DoesPERSON2liveatthesameaddressasyou? Yes No

If no,listaddress:7.Does PERSON 2 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)

YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON2filejointlywithaspouse? Yes No


b. WillPERSON2claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:

c. WillPERSON2beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON2relatedtothetaxfiler?

8. IsPERSON2pregnant?YesNo(circleone)a.If yes,howmanybabiesareexpected? DueDate:FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes NoIfyouareinterestedinapplyingforWIC(forpregnantorbreast-feedingwomenandchildrenunderagefive)youcanapplyatyourlocalCountyHealthDepartment.

9.Does PERSON 2 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)

YES. If yes,answerallthequestionsbelow.

NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.

10. DoesPERSON2haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No

11. IsPERSON2aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 2 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?

Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON2livedintheU.S.since1996? Yes No d.IsPERSON2,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No

13. DoesPERSON2wanthelppayingformedicalbillsfromthelast3months?

Yes No

14. DoesPERSON2livewithatleastonechildundertheageof19,andaretheythemainpersontakingcareofthischild?

Yes No

15. WasPERSON2infostercareatage18orolder?

Yes No

Please answer the following questions if PERSON 2 is 22 or younger:

16. DidPERSON2haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:

17.IsPERSON2afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other




AsianIndian Chinese




Now, tell us about any income from PERSON 2 on the back.

of 11


STEP 2: PERSON 2




CURRENT JOB 2: (Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber



28.In the past year, did PERSON 2: Changejobs Stopworking Startworkingfewerhours Noneofthese



$











IfPERSON2paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question29b).



32.YEARLY INCOmE: Complete only if PERSON 2’s income changes from month to month.

Ifyoudon’texpectchangestoPERSON2’smonthlyincome,addanotherpersonorskiptothenextsection.

PERSON2’stotalincomethis year$

PERSON2’stotalincomenext year (ifyouthinkitwillbedifferent)$

THANKS! This is all we need to know about PERSON 2. If you have more people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.

Current Job & Income Information Employed Ifyou’recurrentlyemployed,tellusaboutyourincome.Startwithquestion20..



Continue with person 2

of 11




















Yes No


Yes No


Yes No







AsianIndian Chinese





of 11


STEP 2: PERSON 3




CURRENT JOB 2: (IfPerson3hasmorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber






$



















Current Job & Income Information Employed IfPerson3iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..




of 11




















Yes No


Yes No


Yes No







AsianIndian Chinese





of 11


STEP 2: PERSON 4




CURRENT JOB 2: (IfPerson4hasmorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber






$



















Current Job & Income Information Employed IfPerson4iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..




of 11


1. Are you or is anyone in your family American Indian or Alaska Native?

IfNo, skiptoStep4.

Yes. If yes, BesuretocompleteAppendixB.

STEP 3

Answerthesequestionsforanyonewhoneedshealthcoverage.

1. Is anyone enrolled in health coverage now from the following?

YES. If yes,checkthetypeofcoverageandwritetheperson(s)’name(s)nexttothecoveragetheyhave. NO.

Medicaid

CHIP

Medicare

TRICARE(Don’tcheckifyouhavedirectcareorLineofDuty)

VAhealthcareprograms

PeaceCorps

Employerinsurance

Nameofhealthinsurance:

Policynumber:IsthisCOBRAcoverage? Yes NoIsthisaretireehealthplan? Yes No

OtherNameofhealthinsurance:

Policynumber:

Isthisalimited-benefitplan(likeaschoolaccidentpolicy)?

Yes No

2. Is anyone listed on this application offered health coverage from a job? Checkyesevenifthecoverageisfromsomeoneelse’sjob,suchasaparentorspouse.

YES. If yes,you’llneedtocompleteandincludeAppendixA.Isthisastateemployeebenefitplan? Yes No NO. If no, continue to Step 5.

STEP 4 Your Family’s Health Coverage

American Indian or Alaska Native (AI/AN) family member(s)

PRA Disclosure Statement AccordingtothePaperworkReductionActof1995,nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysavalidOMBcontrolnumber.ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1191.Thetimerequiredtocompletethisinformationcollectionisestimatedtoaverage[InsertTime(hoursorminutes)]perresponse,includingthetimetoreviewinstructions,searchexistingdataresources,gatherthedataneeded,andcompleteandreviewtheinformationcollection.Ifyouhavecommentsconcerningtheaccuracyofthetimeestimate(s)orsuggestionsforimprovingthisform,pleasewriteto:CMS,7500SecurityBoulevard,Attn:PRAReportsClearanceOfficer,MailStopC4-26-05,Baltimore,Maryland21244-1850.

of 11


STEP 5 Read & sign this application.

Mailyoursignedapplicationto:

ALL Kids Program P.O. Box 304839 montgomery, AL 36130-4839 1-888-373-KIDS (5437) 334-206-3783 (Fax Number)

Ifyouwouldliketoregistertovote,youmaycompleteavoterregistrationformbygoingtoTheSecretaryofStatewebsite,www.alabamavotes.gov.Ifyoudonothavetheabilitytouseacomputertocompleteyourvoterregistrationformwecanmailyouaform. Pleasecheckhere____tohaveaformsenttoyou.

STEP 6 mail completed application. IfyouneedassistancefromtheHealthInsuranceMarketplaceyoucancontactthem atHealthcare.gov orbycallingthenumberslistedbelow. Available 24/7 1-800-318-2596 TTY: 1-855-889-4325

• I’msigningthisapplicationunderpenaltyofperjurywhichmeansI’veprovidedtrueanswerstoallthequestionsonthisformtothebestofmyknowledge.IknowthatImaybesubjecttopenaltiesunderfederallawifIprovidefalseandoruntrueinformation.

• IknowthatImusttelltheHealthInsuranceMarketplaceifanythingchanges(andisdifferentthan)whatIwroteonthisapplication.IcanvisitHealthCare.govorcall1-800-318-2596toreportanychanges.Iunderstandthatachangeinmyinformationcouldaffecttheeligibilityformember(s)ofmyhousehold.

• Iknowthatunderfederallaw,discriminationisn’tpermittedonthebasisofrace,color,nationalorigin,sex,age,sexualorientation,genderidentity,ordisability.Icanfileacomplaintofdiscriminationbyvisitingwww.hhs.gov/ocr/office/file.

• Iconfirmthatnooneapplyingforhealthinsuranceonthisapplicationisincarcerated(detainedorjailed).Ifnot,isincarcerated.

Weneedthisinformationtocheckyoureligibilityforhelppayingforhealthcoverageifyouchoosetoapply.We’llcheckyouranswersusinginformationinourelectronicdatabasesanddatabasesfromtheInternalRevenueService(IRS),SocialSecurity,theDepartmentofHomelandSecurity,and/oraconsumerreportingagency.Iftheinformationdoesn’tmatch,wemayaskyoutosendusproof.

If anyone on this application is eligible for medicaid• IamgivingtotheMedicaidagencyourrightstopursueandgetanymoneyfromotherhealthinsurance,legalsettlements,or

otherthirdparties.IamalsogivingtotheMedicaidagencyrightstopursueandgetmedicalsupportfromaspouseorparent.• Doesanychildonthisapplicationhaveaparentlivingoutsideofthehome?

Yes

No

• Ifyes,IknowIwillbeaskedtocooperatewiththeagencythatcollectsmedicalsupportfromanabsentparent.IfIthinkthatcooperatingtocollectmedicalsupportwillharmmeormychildren,IcantellMedicaidandImaynothavetocooperate.

my right to appealIfIthinktheHealthInsuranceMarketplaceorMedicaid/Children’sHealthInsuranceProgram(CHIP)hasmadeamistake,Icanappealitsdecision.ToappealmeanstotellsomeoneattheHealthInsuranceMarketplaceorMedicaid/CHIPthatIthinktheactioniswrong,andaskforafairreviewoftheaction.IknowthatIcanfindouthowtoappealbycontactingtheMarketplaceat1-800-318-2596.IknowthatIcanberepresentedintheprocessbysomeoneotherthanmyself.Myeligibilityandotherimportantinformationwillbeexplainedtome.

Renewal of coverage in future yearsTomakeiteasiertodeterminemyeligibilityforhelppayingforhealthcoverageinfutureyears,IagreetoallowtheMarketplacetouseincomedata,includinginformationfromtaxreturns.TheMarketplacewillsendmeanotice,letmemakeanychanges,andIcanoptoutatanytime.

Yes,renewmyeligibilityautomaticallyforthenext 5years(themaximumnumberofyearsallowed),orforashorternumberofyears: 4years

3years

2years

1year

Don’tuseinformationfromtaxreturnstorenewmycoverage.

Sign this application. ThepersonwhofilledoutStep1shouldsignthisapplication.Ifyou’reanauthorizedrepresentativeyoumaysignhere,aslongasyouhaveprovidedtheinformationrequiredinAppendixC.

Signature Date(mm/dd/yyyy)

(nameofperson)

for Low Income Families Medicaid Insurance - Alabama Department

Documents

Transcript of for Low Income Families Medicaid Insurance - Alabama Department