Form Dmas 500 – Fill Out and Use This PDF

The DMAS-500 form serves as an application or renewal form for the Health Insurance Premium Payment Programs, managed by the Department of Medical Assistance Services. It aims to facilitate health care access by covering health insurance premiums for eligible individuals and families. This comprehensive form requests detailed personal, household, and employer/company information, essential for determining eligibility for these beneficial programs. If you or your family members are exploring options to reduce medical insurance costs, consider filling out the DMAS-500 form today by clicking the button below.

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Form Dmas 500 PDF Details

Among the myriad forms and documents pivotal to the operations of healthcare and insurance within the United States, the DMAS-500 form stands out as a cornerstone for individuals seeking to access Health Insurance Premium Payment Programs offered by the Department of Medical Assistance Services. This form serves multiple purposes, guiding applicants through the process to either apply for or renew assistance programs aimed at alleviating the financial burdens of health insurance premiums. Critical to both the policyholder and the Department of Medical Assistance Services, it meticulously gathers personal information, household composition, and employment status, alongside specific insurance plan details. Through its sections, the form not only ensures the accurate identification of eligible applicants but also facilitates a comprehensive understanding of their household's healthcare coverage needs and their insurance premium responsibilities. Additionally, it includes crucial employer verification sections, catering to the verification of the policyholder's employment status and the health insurance benefits provided by their employer or through COBRA, signifying a lifeline for those navigating the complex overlap of healthcare needs and financial constraints. The authorization segment at its conclusion underpins the applicant's commitment to truthfulness, with the implicit understanding that the information provided will directly influence the Department's decision-making process regarding their eligibility for premium assistance, underscoring the form's role as a bridge between struggling families and essential healthcare access.

Question	Answer
Form Name	Form Dmas 500
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	frm3 virginia dmas hipp verification e mail address form

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HI PP # ________________ Analyst ____________

Health Insurance Premium Payment Programs Application/Renewal Form

Department of Medical Assistance Services

(804)225-4236 / (800) 432-5924 (in Virginia only) hippcustomerservice@dmas.virginia.gov

SECTI ON 1: PERSONAL I NFORMATI ON					All Sect io n s Belo w To Be Com p let ed By Em p lo y ee
(Last, First, MI )		Policyholder/ Employee Name:

Home Phone			Cell Phone		Work Phone		Alternate Phone:
(	)		(	)	(	)	(	)

Street Address:					City		State	Zip Code

Mailing Address (if different):

City

State

Zip Code

PLEASE PROVI DE MEDI CAI D MEMBER’S ADDRESS I F DI FFERENT FROM POLI CYHOLDER’S:

Street Address:

City:

State:

Zip Code:

SECTI ON 2: HOUSEHOLD I NFORMATI ON ( PLEASE PRI NT) - STARTI NG WI TH THE POLI CYHOLDER, LI ST EVERYONE LI VI NG I N THE HOUSEHOLD

Relationship to

Does this

I s this

Does this

person

Name

Date of Birth

Policyholder/ Employee?

Social Security

person

person get

covered

(Last, First MI )

(MM/ DD/ YY)

1 - Spouse

2 - Parent/ Step

Number

get

3 – Child

4 - Step-child

Medicaid?

under your

Medicare?

5 – Guardian

Other (Specify)

insurance?

Policyholder/ Employee

Yes

Other: _____________

Yes

Other: _____________

Yes

Other: _____________

Yes

Other: _____________

Yes

Other: _____________

SECTI ON 3: EMPLOYER/ COMPANY I NFORMATI ON

Employee Status:

Full-Time

Part -Time

Human Resources Representative or

Representative’s Phone Number:

Laid-Off

Benefits Manager:

Date Hired/ Laid-off: ________________

Retired from previous employment?

Yes

(

)

Deceased?

Yes

Name of Employer/ Company and Street Address:

City

State

Zip Code

I nsurance Plan Type:

I f I ndividual Policy, is the Policyholder self employed?

Employer Plan

COBRA

I ndividual Policy

None

Yes

Not Applicable

How often do you pay the insurance premium?

W eekly:

52,

50 or 48 wks/ yr

Every Tw o

Amount Each Pay Period:

Weeks:

24 or

26/ yr

Semi- Monthly

Monthly Other: ________________

Can you enroll Medicaid family members under your employer or COBRA health plan, if not currently

enrolled?

Yes

Not Applicable I f yes, what is the earliest date?

Court Ordered Absent Parent Case?

Yes No

AUTHORI ZATI ON: I have given true & accurate information to the best of my knowledge. I understand that if I have given false information, withhold information, or fail to report a change I may be breaking the law & could be prosecuted for perjury, larceny &/ or welfare fraud. I authorize insurers or employers to release any information on myself, or other household member (s) necessary to determine eligibility for the HI PP Programs.

Applicant Signature:

Date:

HI PP Case Number:________________________ ( required)

DMAS-500 REV. 02/ 01/ 2012

HI PP # ________________ Analyst ____________

HEALTH INSURANCE PREMIUM PAYMENT PROGRAMS APPLICATION/RENEWAL

FORM INSTRUCTIONS

Instructions: Please print and answer all of the questions, then sign and date the Health Insurance Premium payment Program Application/Renewal Form. Attach a copy (front and back) of all health insurance cards (Medical, Dental & Pharmacy), copy of your most recent pay stub and a copy of the Summary of Benefits (this is a summary of what is covered under the insurance plan) to your Application/Renewal, along with a completed Employer Insurance Verification Form signed by your employer. Send all documents to the DMAS HIPP Unit (see below).

Section 1 – Personal Information

Provide the Policy Holder’s full name, telephone numbers including the area code, complete street address and mailing address (if different), city, state, zip code. If a home, work or cellular number is not available, please include an alternate number where a message can be left. If the member’s address is different from the policyholder’s, please provide complete street address, city, state and zip code.

Section 2 – Household Information

Starting with the employed person, list all individuals living in the household including, but not limited to, parents, step- parents, guardians and children. Complete the date of birth in month/day/year format for each household member. Indicate the relationship of the person to the employed person by circling the corresponding number and relationship; i.e., 1 - Spouse, 2–Parent/Step, 3–Child, 4–Step-child, 5–Guardian, Other (specify). Next, enter the nine-digit Social Security Number for each household member. Answer the remaining questions for each household member by placing a checkmark or an ‘x’ in the appropriate box.

Section 3 – Employer/Company Information

Indicate whether employment status is full or part-time and the date hired, retired or laid-off. If retired from previous employment, please indicate as well. Provide the employer or company name, street address, city, state and zip code, as well as the Human Resource Representative, or Benefits Manager’s name and work phone number. If none, please provide a work phone number.

Indicate by placing a checkmark or an ‘x’ in the appropriate box:

•if the policyholder’s health insurance is covered under an Employer Sponsored plan, COBRA, or Individual Policy;

O note if the Individual Policy box is selected, indicate if policyholder is self- employed; or

•if the coverage was court ordered to be carried by an absent/non-custodial parent.

Indicate whether the health insurance premium is deducted from the Policyholder’s paycheck weekly, every two weeks, 24 times a year, 26 times a year, semi-monthly or monthly, etcetera. If none of the choices apply, please select ’not applicable’. Indicate the amount taken from each pay period.

Indicate if the policyholder is able to enroll Medicaid eligible household members not currently enrolled under the employer or COBRA plan. Enter the earliest enrollment date in month/day/year format.

Please read the authorization section carefully and sign the Health Insurance Premium Payment Program Application/Renewal Form. Attach a copy (front and back) of all health insurance cards (Medical, Dental, Vision & Prescription Drug (Pharmacy)), copy of your most recent pay stub and a copy of the Summary of Benefits (this is a summary of what is covered under the insurance plan) to your Health Insurance Premium Programs Application/Renewal Form and completed and signed Employer Insurance Verification Form.

Both the Health Insurance Premium Payment Programs Application/Renewal Form and Employer Insurance Verification Form must be received to be considered an application. The application date will be the date the application/renewal form is received at DMAS. Mail all documents to the address listed below, Fax to (804) 225-

4393 or scan and email to HIPPcustomerservice@dmas.virginia.gov

Department of Medical Assistance Services

Health Insurance Premium Payment Programs Unit

600E. Broad Street, 12th Floor Richmond, VA 23219

(804)225-4236 / (800) 432-5924 (in Virginia only)

DMAS-500 REV. 02/ 01/ 2012

HI PP # ________________ Analyst ____________

EMPLOYER INSURANCE VERIFICATION

DEPARTMENT OF MEDICAL ASSISTANCE SERVICES Health Insurance Premium Payment Programs Unit 600 E. Broad Street, 12th Floor, Richmond, VA 23219

(804)225-4236 / (800) 432-5924 (in Virginia only) hippcustomerservice@dmas.virgnia.gov

The Commonwealth of Virginia is considering providing the health insurance premium assistance on behalf of the employee below in accordance with Section 1906/1906A of the Social Security Act. Any information provided on the form will remain confidential. Please complete, sign and return this form within 10 days to the address above. The policy holder has authorized release of information, through their signature below, for verification of all required information necessary for making a determination. If you have questions in regards to completing the form, please contact us at the phone numbers listed above.

My signature serves as permission for the release of information for verification of all required information for HIPP.

Employee Signature: _____________________________ Phone#:___________________ Date:_____________

Check box to grant permission for employer to email form to the Department of Medical Assistance Services.

INFORMATION BELOW IS TO BE COMPLETED BY THE EMPLOYER ONLY

If self-employed, policyholder must complete as the employer.

SECTI ON 1 – EMPLOYEE I NFORMATI ON

Employee Name: (Last, First, MI ):

Full SSN:

Date of Birth:

Employee Status

Full-Time

Part-Time

Laid-Off

Retiree

I s this employee eligible for coverage under your

Leave of Absence

company’s group health plan?

Yes

Date Hired/ Laid-off/ Retired: _____________

Deceased?

* Yes

I f No, reason: ____________________________________

School Employee?

* Yes

I s employee currently enrolled in the Health Plan?

* I f yes, check box:

10-Month

12-Month

* Yes

* I f yes, provide Effective Date: ___________________

SECTI ON 2 – MEMBERSHI P

( Start w ith Employee) - At t ach an ad d it io n al p ag e if m o r e t h an 7

Name

Full SSN

Date of Birth

Relationship

Currently

Eligible for

( Last, First MI )

Enrolled in Plan

Health Plan

Employee

Yes

- -

/ /

Yes

- -

/ /

Yes

- -

/ /

Yes

- -

/ /

Yes

- -

/ /

Yes

- -

/ /

Yes

SECTI ON 3 - COVERAGE			OPEN- ENROLLMENT I NFORMATI ON
I f employee currently enrolled, w hat is the type of coverage?			Open Enrollment Period
Select one of the follow ing:			Open Enrollment Period
Select one of the follow ing:
Employee Only	Employee + Child	Family	From: ____________________ To: ___________________
Employee Only	Employee + Child	Family
Employee + Spouse	Employee + Children	Other______________	Plan Year Begin Date: _____________________________
COBRA			Plan Year Begin Date: _____________________________
COBRA

I f the employee is not currently enrolled, w hen can enrollment occur?

During Open Enrollment Dates: _______________________

Anytime

After employment period is met -Date Eligible: ___________________

DMAS -502 REV. 02/ 01/ 2012

HI PP # ________________ Analyst ____________

SECTI ON 4 – PLAN BENEFI TS ( Please indicate the cost and benefits for the coverage you have selected.)

Employee Name(Last, First, MI ):

Full SSN:

Name and Address of Medical I nsurance Company:

I nsurance Company Phone: (

)

I nsurance Policy/ Group Number:

Type of Health Plan ( Check all that apply) :

Services Covered Under Health Plan ( Check all

Comprehensive Major Medical

HMO/ PPO

that apply) :

Hospital Only

Other

Medical

Pharmacy

Vision

Does policy have a health savings account (HSA)?

Yes

Dental

Name and Address of Dental I nsurance Company:

I nsurance Company Phone: (

)

I nsurance Policy/ Group Number:

Name and Address of Vision I nsurance Company:

I nsurance Company Phone: (

)

I nsurance Policy/ Group Number:

Medical, Dental and Vision I nsurance Premium I nformation. Provide Employer & Employee costs for the elected plan( s) :

Coverage

Medical

Dental

Vision

Type

Premium

Deduction

Premium

Deduction

Premium

Deduction

Frequency

Employee Only

Weekly:

Cost to Employer

52 Weeks

Cost to Employee

50 Weeks

48 Weeks

Employee + Spouse

Semi- Monthly:

Cost to Employer

24 pay pd

Cost to Employee

26 pay pd

20 pay pd

Employee + Child

Monthly:

Cost to Employer

10 Months

12-Months

Cost to Employee

Employee + Children

Cost to Employer

Cost to Employee

Family

Cost to Employer

Cost to Employee

SECTI ON 5 – EMPLOYER’S REPRESENTATI VE

HR Representative/ Benefits Manager:	Department:


Employer/ Company Name:	Work Phone:


Employer Address:	City:	State:	Zip Code:

Check the box that applies to your employer plan:

Yes, this plan meets;

No, this plan does not meet- both requirements below.

Qualifies as creditable coverage, group health plan under section 270(c)(1) of the Public Health Service Act; and

offered to all individuals (i.e. all employees) in a manner considered a nondiscriminatory eligibility classification for Code of 1986 (but determined without regard to clause (i) of subparagraph (B) of such paragraph).

I certify all information contained herein is true and accurate to the best of my know ledge.

Employer Signature:

Date:

DMAS -502 REV. 02/ 01/ 2012

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1. Start filling out the Form Dmas 500 with a number of necessary blanks. Gather all of the information you need and ensure absolutely nothing is left out!

2. The third part is to fill in the next few blank fields: Indicate whether the health, Department of Medical Assistance, Health Insurance Premium Payment, E Broad Street th Floor, Richmond VA, in Virginia only, and DMAS REV.

Learn how to complete Form Dmas 500 portion 2

3. Completing Health Insurance Premium Payment, in Virginia only, hippcustomerservicedmasvirgniagov, The Commonwealth of Virginia is, My signature serves as permission, Check box to grant permission for, INFORMATION BELOW IS TO BE, If selfemployed policyholder must, SECTI ON EMPLOYEE I NFORMATI ON, Employee Name Last First MI, Full SSN, Date of Birth, Employee Status Leave of Absence, FullTime, and PartTime is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Part number 3 for completing Form Dmas 500

Lots of people generally make some errors while filling in PartTime in this section. Make sure you read again what you enter right here.

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