apply on-line at insurealabama · if you don’t have all the information we ask for, sign and...
TRANSCRIPT
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
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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.
Page 1 of 11
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].
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.
Page 2 of 11
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].
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)
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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].
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
()–24.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 25.AveragehoursworkedeachWEEK
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.
Page 4 of 11
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].
STEP 2: PERSON 2CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
1.Firstname,Middlename,Lastname,&Suffix 2.Relationshiptoyou?
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
If yes,nameofspouse:
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
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 2 on the back.
Page 5 of 11
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].
STEP 2: PERSON 2
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
()–22.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 23.AveragehoursworkedeachWEEK
CURRENT JOB 2: (Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber
()–26.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 27.AveragehoursworkedeachWEEK
28.In the past year, did PERSON 2: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.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:
31.DEDUCTIONS:Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON2paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question29b).
Alimonypaid $ Howoften?
Studentloaninterest $ Howoften? Otherdeductions $ Howoften?Type:
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..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 2
Page 6 of 11
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].
STEP 2: PERSON 3CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
1.Firstname,Middlename,Lastname,&Suffix 2.Relationshiptoyou?
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.DoesPERSON3liveatthesameaddressasyou? Yes No
If no,listaddress:7.Does PERSON 3 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON3filejointlywithaspouse? Yes No
If yes,nameofspouse:
b. WillPERSON3claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:
c. WillPERSON3beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON3relatedtothetaxfiler?
8. IsPERSON3pregnant?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 3 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)
YES. If yes,answerallthequestionsbelow.
NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.
10. DoesPERSON3haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
11. IsPERSON3aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 3 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?
Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON2livedintheU.S.since1996? Yes No d.IsPERSON3,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No
13. DoesPERSON3wanthelppayingformedicalbillsfromthelast3months?
Yes No
14. DoesPERSON3livewithatleastonechildundertheageof19,andaretheythemainpersontakingcareofthischild?
Yes No
15. WasPERSON3infostercareatage18orolder?
Yes No
Please answer the following questions if PERSON 3 is 22 or younger:
16. DidPERSON3haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:
17.IsPERSON3afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 3 on the back.
Page 7 of 11
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].
STEP 2: PERSON 3
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
()–22.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 23.AveragehoursworkedeachWEEK
CURRENT JOB 2: (IfPerson3hasmorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber
()–26.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 27.AveragehoursworkedeachWEEK
28.In the past year, did PERSON 3: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.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:
31.DEDUCTIONS:Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON3paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question29b).
Alimonypaid $ Howoften?
Studentloaninterest $ Howoften? Otherdeductions $ Howoften?Type:
32.YEARLY INCOmE: Complete only if PERSON 3’s income changes from month to month.
Ifyoudon’texpectchangestoPERSON3’smonthlyincome,addanotherpersonorskiptothenextsection.
PERSON3’stotalincomethis year$
PERSON3’stotalincomenext year (ifyouthinkitwillbedifferent)$
THANKS! This is all we need to know about PERSON 3. 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 IfPerson3iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 3
Page 8 of 11
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].
STEP 2: PERSON 4CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
1.Firstname,Middlename,Lastname,&Suffix 2.Relationshiptoyou?
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.DoesPERSON4liveatthesameaddressasyou? Yes No
If no,listaddress:7.Does PERSON 4 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON4filejointlywithaspouse? Yes No
If yes,nameofspouse:
b. WillPERSON4claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:
c. WillPERSON4beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON3relatedtothetaxfiler?
8. IsPERSON4pregnant?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 4 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)
YES. If yes,answerallthequestionsbelow.
NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.
10. DoesPERSON4haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
11. IsPERSON4aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 4 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?
Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON4livedintheU.S.since1996? Yes No d.IsPERSON4,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No
13. DoesPERSON4wanthelppayingformedicalbillsfromthelast3months?
Yes No
14. DoesPERSON4livewithatleastonechildundertheageof19,andaretheythemainpersontakingcareofthischild?
Yes No
15. WasPERSON4infostercareatage18orolder?
Yes No
Please answer the following questions if PERSON 3 is 22 or younger:
16. DidPERSON4haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:
17.IsPERSON4afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 4 on the back.
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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].
STEP 2: PERSON 4
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
()–22.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 23.AveragehoursworkedeachWEEK
CURRENT JOB 2: (IfPerson4hasmorejobsandneedmorespace,attachanothersheetofpaper.)24.Employernameandaddress 25.Employerphonenumber
()–26.Wages/tips(beforetaxes) Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 27.AveragehoursworkedeachWEEK
28.In the past year, did PERSON 4: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.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:
31.DEDUCTIONS:Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON4paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question29b).
Alimonypaid $ Howoften?
Studentloaninterest $ Howoften? Otherdeductions $ Howoften?Type:
32.YEARLY INCOmE: Complete only if PERSON 2’s income changes from month to month.
Ifyoudon’texpectchangestoPERSON4’smonthlyincome,addanotherpersonorskiptothenextsection.
PERSON4’stotalincomethis year$
PERSON4’stotalincomenext year (ifyouthinkitwillbedifferent)$
THANKS! This is all we need to know about PERSON 4. 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 IfPerson4iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 4
Page 10 of 11
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].
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.
Page 11 of 11
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].
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)