Model Employer CHIP Notice (Private Sector Burden)

Model Employer Children's Health Insurance Program Notice

CHIP Model Notice

Model Employer CHIP Notice (Private Sector Burden)

OMB: 1210-0137

Document [doc]
Download: doc | pdf


Premium Assistance Under Medicaid and the

Children’s Health Insurance Program (CHIP)


If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, 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, 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, ask your state if it has a program that might help you pay the premiums for an employer-sponsored plan.


If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).



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 July 31, 2016. Contact your State for more information on eligibility –


ALABAMA – Medicaid

FLORIDA – Medicaid

Website: http://myalhipp.com/

Phone: 1-855-692-5447

Website: http://flmedicaidtplrecovery.com/hipp/

Phone: 1-877-357-3268

ALASKA – Medicaid

GEORGIA – Medicaid

The AK Health Insurance Premium Payment Program

Website: http://myakhipp.com/

Phone: 1-866-251-4861

Email: [email protected]

Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Website: http://dch.georgia.gov/medicaid

- Click on Health Insurance Premium Payment (HIPP)

Phone: 404-656-4507

ARKANSAS – Medicaid

INDIANA – Medicaid

Website: http://myarhipp.com/

Phone: 1-855-MyARHIPP (855-692-7447)

Healthy Indiana Plan for low-income adults 19-64

Website: http://www.hip.in.gov

Phone: 1-877-438-4479

All other Medicaid

Website: http://www.indianamedicaid.com

Phone 1-800-403-0864

COLORADO – Medicaid

IOWA – Medicaid

Medicaid Website: http://www.colorado.gov/hcpf

Medicaid Customer Contact Center: 1-800-221-3943

Website: http://www.dhs.state.ia.us/hipp/

Phone: 1-888-346-9562



KANSAS – Medicaid

NEW HAMPSHIRE – Medicaid

Website: http://www.kdheks.gov/hcf/

Phone: 1-785-296-3512

Website: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603-271-5218

KENTUCKY – Medicaid

NEW JERSEY – Medicaid and CHIP

Website: http://chfs.ky.gov/dms/default.htm

Phone: 1-800-635-2570

Medicaid Website:

http://www.state.nj.us/humanservices/

dmahs/clients/medicaid/

Medicaid Phone: 609-631-2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1-800-701-0710

LOUISIANA – Medicaid

NEW YORK – Medicaid

Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1-888-695-2447

Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1-800-541-2831

MAINE – Medicaid

NORTH CAROLINA – Medicaid

Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html

Phone: 1-800-442-6003

TTY: Maine relay 711

Website: http://www.ncdhhs.gov/dma

Phone: 919-855-4100

MASSACHUSETTS – Medicaid and CHIP

NORTH DAKOTA – Medicaid

Website: http://www.mass.gov/MassHealth

Phone: 1-800-462-1120

Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1-844-854-4825

MINNESOTA – Medicaid

OKLAHOMA – Medicaid and CHIP

Website: http://mn.gov/dhs/ma/

Phone: 1-800-657-3739

Website: http://www.insureoklahoma.org

Phone: 1-888-365-3742

MISSOURI – Medicaid

OREGON – Medicaid

Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573-751-2005

Website: http://healthcare.oregon.gov/Pages/index.aspx

http://www.oregonhealthcare.gov/index-es.html

Phone: 1-800-699-9075

MONTANA – Medicaid

PENNSYLVANIA – Medicaid

Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1-800-694-3084

Website: http://www.dhs.pa.gov/hipp

Phone: 1-800-692-7462

NEBRASKA – Medicaid

RHODE ISLAND – Medicaid

Website: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebraska_index.aspx

Phone: 1-855-632-7633

Website: http://www.eohhs.ri.gov/

Phone: 401-462-5300

NEVADA – Medicaid

SOUTH CAROLINA – Medicaid

Medicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1-800-992-0900

Website: http://www.scdhhs.gov

Phone: 1-888-549-0820



SOUTH DAKOTA - Medicaid

WASHINGTON – Medicaid

Website: http://dss.sd.gov

Phone: 1-888-828-0059

Website: http://www.hca.wa.gov/free-or-low-cost-health-care/program-administration/premium-payment-program

Phone: 1-800-562-3022 ext. 15473

TEXAS – Medicaid

WEST VIRGINIA – Medicaid

Website: http://gethipptexas.com/

Phone: 1-800-440-0493

Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

Phone: 1-877-598-5820, HMS Third Party Liability

UTAH – Medicaid and CHIP

WISCONSIN – Medicaid and CHIP

Website:

Medicaid: http://health.utah.gov/medicaid

CHIP: http://health.utah.gov/chip

Phone: 1-877-543-7669

Website:

https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1-800-362-3002

VERMONT– Medicaid

WYOMING – Medicaid

Website: http://www.greenmountaincare.org/

Phone: 1-800-250-8427

Website: https://wyequalitycare.acs-inc.com/

Phone: 307-777-7531

VIRGINIA – Medicaid and CHIP


Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924

CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1-855-242-8282



To see if any other states have added a premium assistance program since July 31, 2016, or for more information on special enrollment rights, 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, Menu Option 4, Ext. 61565


Paperwork Reduction Act Statement


According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number. The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.


The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue, N.W., Room N-5718, Washington, DC 20210 or email [email protected] and reference the OMB Control Number 1210-0137.


OMB Control Number 1210-0137 (expires 10/31/2016)

6



File Typeapplication/msword
AuthorMulhall, Tamara - EBSA
Last Modified ByMulhall, Tamara - EBSA
File Modified2016-09-01
File Created2016-09-01

© 2024 OMB.report | Privacy Policy