124i Instructions for Form DMA 124: Application For Health Insurance Premium Payment (HIPP Program) | Medicaid

Provide the name of the head of household and address and telephone number where he or she may be contacted if additional information or data verification is required.

Provide the name and address of the person completing the application. A copy of the decision on the application will be returned to the referral source.

If known, complete insurance information is helpful. Enter the complete name of the policy holder, BOTH the insurance group number, if applicable, and policy number, if applicable, address and telephone number of the insurance company. This information is usually available on the member’s insurance card.

If known, enter the maximum out-of-pocket expense per individual and for the entire family. The out-of- pocket expense should not be confused with the lifetime limit of the policy. The lifetime limit is the maximum amount of coverage offered by the policy.

If the annual deductible amount is included in the out-of-pocket expense, check “Yes”. If not, check No”.

If known, enter amount of the annual deductible. If unknown, leave blank.

If known, check “Yes” if the policy is an HMO or PPO and “NO” if not. If unknown, leave blank.

List all persons living at this address who are Medicaid eligible and eligible for coverage under this policy. Enter the full name, Social Security Number, date of birth, Medicaid identification number, relationship to the policy holder and gender for each person. If there are more than five persons, attach a second form.

If any person in Step 9 above is pregnant, check “Yes” and enter the expected delivery date. If none are pregnant, check “No”.

If any person in Step 9 above is currently diagnosed with a medically expensive condition, enter the individual’s name and the diagnosis. If no medically expensive conditions exist, enter “No”. Medical conditions include but are not limited to: Diabetes, Blood Disorder, Cancer, Mental Illness/Retardation, Heart Condition, Asthma, Scoliosis or other Back Injury, Stroke, Seizure Disorder, Kidney/Liver Disorder, Alcohol/Drug Addiction, HIV Positive/AIDS.

Enter the amount the policy holder pays for insurance coverage. Check the frequency of premium payments.

If the policy holder is eligible for COBRA benefits, check “Yes” if COBRA forms have been received, and “No” if none received. If “Yes”, enter date received. Enter the last employment date. Indications of COBRA coverage might be a recent job termination, recent layoff from a job or a new job where the benefits do not cover a pre-existing condition.

Check “Yes” if the employer and/or insurance company can be contacted for verification. If “No” is checked, the application will be denied for insufficient information to process the application.

Check “Yes” if the applicant or any of the dependents listed were involved or injured in an accident that required medical attention within the last 12 months. If an attorney or insurance company is involved, please obtain this information and note it on the application. If no accidents occurred, please check “NO”