Model Employer CHIP Notice

Medicaid And The Children’s Health Insurance Program (CHIP)

Offer Free Or Low-Cost Health Coverage To Children And Families

If you are eligible for health coverage from your employer, but are unable to afford the premiums, some States have premium assistance programs that can help pay for coverage. These States use funds from their Medicaid or CHIP programs to help people who are eligible for employer-sponsored health coverage, but need assistance in paying their health premiums.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, you can contact your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, you can contact your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, you can ask the State if it has a program that might help you pay the premiums for an employer-sponsored plan.

Once it is determined that you or your dependents are eligible for premium assistance under Medicaid or CHIP, your employer’s health plan is required to permit you and your dependents to enroll in the plan – as long as you and your dependents are eligible, but not already enrolled in the employer’s plan. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance.

If you live in one of the following States, you may be eligible for assistance paying your employer health plan premiums. The following list of States is current as of [February 1, 2010??]. You should contact your State for further information on eligibility –

ALABAMA – Medicaid	INDIANA – Medicaid
Website: http://www.medicaid.state.al.us/ Phone: 1-800-362-1504	Website: http://www.in.gov/fssa/2408.htm Phone: 1-877-438-4479
ALASKA – Medicaid	IOWA – Medicaid
Website: http://health.hss.state.ak.us/dpa/programs/medicaid/ Phone: 1-888-804-6330	Website: www.dhs.state.ia.us/hipp/ Phone: 1-888-346-9562
ARIZONA – CHIP	KANSAS – Medicaid
Website: http://www.azahcccs.gov/applicants/default.aspx Phone: 602-417-5422	Website: https://www.khpa.ks.gov Phone: 1-800-635-2570
ARKANSAS – CHIP	KENTUCKY – Medicaid
Website: http://www.arkidsfirst.com/home.htm Phone: 1-888-474-8275	Website: http://chfs.ky.gov/dms/default.htm Phone: 1-800-635-2570
CALIFORNIA – Medicaid	LOUISIANA – Medicaid
Website: http://www.dhcs.ca.gov/services/medical/Pages/default.aspx Phone: 1-800-635-2570	Website: http://www.dhh.state.la.us/offices/?ID=92 Phone: 1-888-342-6207
COLORADO – Medicaid and CHIP	MAINE – Medicaid
Medicaid Website: http://www.colorado.gov/ Medicaid Phone: 1-800-221-3943 CHIP Website: http:// www.CHPplus.org CHIP Phone: 1-800-359-1991	Website: http://www.maine.gov/dhhs/oms/ Phone: 1-800-321-5557
FLORIDA – Medicaid	MASSACHUSETTS – Medicaid and CHIP
Website: http://www.fdhc.state.fl.us/Medicaid/index.shtml Phone: 1-866-762-2237	Medicaid Website: http://www.mass.gov/MassHealth Medicaid Phone: 1-800-462-1120 CHIP Website: http://www.mass.gov/eohhs Click on For Consumers, then Insurance (including Mass Health), then Additional Insurance and Assistance Programs, then Children’s Medical Security Plan CHIP Phone: 1-800-841-2900
GEORGIA – Medicaid
Website: http://dch.georgia.gov/ Click on Programs, then Medicaid Phone: 1-800-869-1150
IDAHO – Medicaid and CHIP	MINNESOTA – Medicaid
Medicaid Website: www.accesstohealthinsurance.idaho.gov CHIP Website: www.medicaid.idaho.gov CHIP Phone: 1-800-926-2588	Website: http://www.dhs.state.mn.us/ Click on Health Care, then Medical Assistance Phone: 800-657-3739
MISSOURI – Medicaid	NORTH CAROLINA – Medicaid
Website: http://www.dss.mo.gov/mhd/index.htm Phone: 573-751-3425	Website: http://www.nc.gov Phone: 919-855-4100
MONTANA – Medicaid	NORTH DAKOTA – Medicaid
Website: http://medicaidprovider.hhs.mt.gov/clientpages/clientindex.shtml Telephone: 1-800-362-8312	Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/ Phone: 1-800-755-2604
NEBRASKA – Medicaid	OKLAHOMA – Medicaid
Website: http://www.dhhs.ne.gov/med/medindex.htm Phone: 1-877-255-3092	Website: http://www.okhca.org/ Phone: 1-800-522-0310
NEVADA – Medicaid and CHIP	OREGON – Medicaid and CHIP
Medicaid Website: http://dwss.nv.gov/ Medicaid Phone: 1-775-684-3676 CHIP Website: http://www.nevadacheckup.state.nv.us/ CHIP Phone: 1-877-543-7669	Medicaid Website: http://www.oregon.gov/DHS/healthplan/index.shtml Medicaid Phone: 1-800-359-9517 CHIP Website: http://www.oregon.gov/DHS/healthplan/app_benefits/ ohp4u.shtml CHIP Phone: 1-800-359-9517
NEW HAMPSHIRE – Medicaid
Website: http://www.dhhs.state.nh.us/DHHS/ MEDICAIDPROGRAM/default.htm Phone: 1-800-852-3345 x 5254
NEW JERSEY – Medicaid and CHIP	PENNSYLVANIA – Medicaid
Medicaid Website: http://www.state.nj.us/humanservices/ dmahs/clients/medicaid/ Medicaid Phone: 1-800-356-1561 CHIP Website: http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710	Website: http://www.dpw.state.pa.us/ServicesPrograms/ MedicalAssistance/ Phone: 1-866-542-3015
	RHODE ISLAND – Medicaid
	Website: http://www.dhs.ri.gov/People/FamilieswithChildren/HealthCare/RIteShare/tabid/212/Default.aspx Phone: 401-462-5300
NEW MEXICO – Medicaid and CHIP	SOUTH CAROLINA – Medicaid
Medicaid Website: http://www.hsd.state.nm.us/mad/index.html Medicaid Phone: 1-888-997-2583 CHIP Website: http://www.insurenewmexico.state.nm.us/PAKHome.htm CHIP Phone: 1-888-997-2583	Website: http://www.scdhhs.gov Phone: 1-888-549-0820
	TENNESSEE – Medicaid
	Website: http://www.state.tn.us/tenncare/ Phone: 1-866-311-4287
NEW YORK – Medicaid	TEXAS – Medicaid
Website: http://www.newyorkhealth.gov/health_care/ medicaid/index.htm Phone: 718-557-1399	Website: https://www.gethipptexas.com/ Phone: 1-800-252-8263
UTAH – Medicaid	WASHINGTON – Medicaid
Website: http://health.utah.gov/medicaid/ Phone: 1-800-662-9651	Website: http://ihrsa/sites/DCS/COB/default.aspx Phone: 1-800-562-6136
VERMONT– Medicaid	WEST VIRGINIA – Medicaid
Website: http://ovha.vermont.gov/ Telephone: 1-800-250-8427	Website: http://www.wvrecovery.com/hipp.htm Phone: 304-342-1604
VIRGINIA – Medicaid and CHIP	WISCONSIN – Medicaid
Medicaid Website: http://www.dmas.virginia.gov/rcp-HIPP.htm Medicaid Phone: 1-800-432-5924 CHIP Website: http://www.famis.org/welcome.cfm CHIP Phone: 1-866-873-2647	Website: http://dhs.wisconsin.gov/medicaid/index.htm Phone: 1-800-362-3002
	WYOMING – Medicaid
	Website: http://www.health.wyo.gov/healthcarefin/index.html Telephone: 307-777-7531

To see if any more States have added a premium assistance program since [February 1, 2010??], or for more information on special enrollment rights, you can contact either:

U.S. Department of Labor U.S. Department of Health and Human Services

Employee Benefits Security Administration Centers for Medicare & Medicaid Services

www.dol.gov/ebsa www.cms.hhs.gov

1-866-444-EBSA (3272) 1-877-267-2323, Ext. 61565

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