Form Mo 886 3565 PDF Details

Navigating through the intricacies of health insurance can be daunting, especially when dealing with costs that seem to constantly rise. Enter the MO HealthNet Division's Application for Health Insurance Premium Payment (HIPP) Program, a form designed to provide financial relief to eligible Missouri residents. This comprehensive document, formally known as MO 886 3565, serves as a beacon of hope for policyholders struggling to keep up with their health insurance premiums. By providing detailed information about the policyholder, including social security numbers, addresses, and telephone numbers, along with the specifics of the insurance policy such as insurance name, policy number, and group number, applicants can open the door to potential assistance. The form delves deeper by asking for information about the policy’s lifetime limits, cost caps per illness, and out-of-pocket limits, ensuring a complete understanding of the financial burdens faced. Moreover, it requires listing all family members who could be covered under the policy, their MO HealthNet eligibility, and details regarding the current insurance coverage. Applicants must disclose their employment status, the nature of their policy (whether it’s through an employer, a former employer, or privately purchased), and how premiums are being paid. This detailed application process ensures that those who find themselves overwhelmed by the cost of health insurance have a potential path to reduce their financial load, underscoring the commitment of the Missouri Department of Social Services to support its residents’ healthcare needs.

QuestionAnswer
Form NameForm Mo 886 3565
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmissouri hipp program, caretakers, HEALTHNET, Biweekly

Form Preview Example

MISSOURI DEPARTMENT OF SOCIAL SERVICES

MO HEALTHNET DIVISION

APPLICATION FOR HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM

1. POLICYHOLDER INFORMATION

 

 

 

 

 

 

2. INSURANCE INFORMATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICYHOLDER NAME

 

 

 

 

 

 

 

INSURANCE NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

POLICYHOLDER SOC. SEC. #

 

 

 

 

 

 

 

CLAIM MAILING ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

INS. CITY, STATE, ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

INS. TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE, ZIP

 

 

 

 

 

 

 

POLICY NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE

 

 

 

 

 

 

 

POLICY GROUP NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Policy’s lifetime dollar limit: ____________________________

4. Policy’s cost cap per illness: ______________________________

5. Amount of lifetime limit used to date: ____________________

6. Policyholder’s annual out-of-pocket limit: ____________________

7. LIST ALL PERSONS THAT CAN BE COVERED UNDER THE POLICY INCLUDING POLICYHOLDER

 

 

 

 

 

 

 

 

 

 

 

NAME

BIRTHDATE

MO HEALTHNET ELIGIBLE

MO HEALTHNET ID #

 

SOC. SEC. #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

YES

 

NO

APP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

YES

 

NO

APP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

/

/

YES

 

NO

APP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Are you currently enrolled in this policy?

Yes

No

 

 

 

 

 

 

 

 

9. Are your dependents currently enrolled in this policy?

Yes

 

No

 

 

 

 

 

 

10. Are you currently:

Employed

Unemployed

On family or medical leave

 

 

 

 

11. Is this policy:

Through an employer

Through a former employer

Privately purchased

 

12. Are your premiums:

Payroll deducted

Paid directly to the insurance company

Paid directly to the employer

13. How much is your share of the premiums? _______________________________________

 

 

 

 

14. Premiums are paid:

Monthly

Biweekly

 

Semimonthly

Weekly

Quarterly

 

15. Next premium due date: ________________________________

 

 

 

 

 

 

 

 

16. List employer or former employer’s name, address and telephone number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER NAME

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER TELEPHONE

 

 

 

 

 

 

 

 

 

 

 

 

EMPLOYER ADDRESS

 

CITY

 

 

 

 

 

STATE

 

ZIP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IMPORTANT

 

 

 

 

 

 

YOU MUST PROVIDE A COPY OF THE INSURANCE POLICY BOOKLET, SUMMARY PLAN DESCRIPTION, EMPLOYEE HANDBOOK,

ENROLLMENT MATERIALS, SCHEDULE OF BENEFITS OR SUMMARY OF COVERAGE THAT DESCRIBES THE POLICY. ELIGIBILITY

FOR THE HIPP PROGRAM CANNOT BE ESTABLISHED WITHOUT THIS INFORMATION.

 

 

 

 

My signature below guarantees that my answers on this form are correct, true and complete to the best of my knowledge. I authorize

insurers or employers to release any information on myself or my dependent(s) needed to determine eligibility for the HIPP program.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF POLICYHOLDER

 

 

 

 

 

 

 

 

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SIGNATURE OF CARE COORDINATOR

 

 

 

 

 

 

 

 

 

 

TITLE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AGENCY/AFFILIATION

 

 

 

 

 

 

TELEPHONE

 

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Completed application with a copy of your

 

MO HealthNet Division

 

 

 

 

 

policy information can be mailed to this

 

ATTN: HIPP Program

 

 

 

 

 

address or given to your Division of Family

 

P.O. Box 6500

 

 

 

 

 

Services caseworker to forward.

 

 

 

 

Jefferson City, MO 65102-6500

 

 

 

 

 

 

 

 

 

 

 

 

MO 886-3565 (4-08)

DISTRIBUTION: WHITE - DIVISION OF MEDICAL SERVICES CANARY - DIVISION OF FAMILY SERVICES PINK - RECIPIENT

HIPP-A

INSTRUCTIONS FOR COMPLETING THE APPLICATION

The Health Insurance Premium Payment (HIPP) Program pays for the cost of health insurance plans when the Department of Social Services decides it would cost less to buy health insurance to cover medical care than to pay for the care only with MO HealthNet funds. To be eligible for the Health Insurance Premium Payment (HIPP) program, some or all of the persons covered under an insurance policy must be eligible for MO HealthNet.

WHO MUST APPLY?

You must apply to the HIPP program if all of the following are true:

You or a member of your household is applying for MO HealthNet or are MO HealthNet-eligible (excluding spend-down)

You or a member of your household is employed or lost employment within the last thirty days, and

The employer or former employer offers group health insurance coverage.

If the Department of Social Services decides the health insurance plan is cost-effective, you must participate in the HIPP Program.

Applicants’, participants’, parents’, guardians’ or caretakers’ MO HealthNet benefits may be denied or canceled if the applicant, participant, parent, guardian or caretaker does not provide information necessary to establish cost effectiveness or does not enroll in a group health insurance plan that the Department determines is cost effective.

WHO CAN CHOOSE TO APPLY?

You can choose to apply to the HIPP program if you or a member of your household is applying for MO HealthNet or are MO HealthNet- eligible (excluding spend-down) and have health insurance available from sources other than employers (personal policies, credit unions, church affiliations, labor unions, memberships in organizations, etc.) If the Department determines the health insurance plan is cost effective, MO HealthNet will pay the premium.

Section 1. List the following information about the policyholder. Name, social security number, address, and telephone number. If you do not have a telephone, list a number where you can be reached or a message left.

Section 2. List the name, claim mailing address and telephone number of the insurance company, the policy number and the policy group number for any insurance you currently have or any insurance offered by your employer or some other source. If your employer or former employer does not offer group health insurance, write “no insurance available” across section 2, then sign and date the application.

Questions Please try to provide as much information as you can obtain regarding the out-of-pocket cost, lifetime limits and caps per illness.

3 - 6.

Section 7. List the name and birth date of everyone in your family who can be covered under this policy, including the policyholder. Check one box (Yes or No) to indicate whether the person is currently on MO HealthNet. If a box is marked yes, write the person’s MO HealthNet identification number (DCN) listed on their MO HealthNet card. If they have applied for MO HealthNet and do not know if they are eligible, the APP (for Applied) box should be checked. List the social security number for each individual.

Question 8. Indicate whether you are currently covered by this insurance policy.

Question 9. Indicate whether your spouse or children are currently covered by this policy.

Question 10. Indicate your current employment status.

Question 11. Indicate if this insurance is through your current employer, a former employer (such as a COBRA plan), or an insurance plan you have purchased on your own.

Question 12. Indicate if your premiums are currently paid through payroll deduction, direct payment to the insurance company or direct payment to the employer.

Question 13. List how much the premium amount is each time a payment is due. If the insurance is through an employer and the employer pays for part of the cost, list only your share of the cost.

Question 14. List how often a premium payment is due. For example: monthly (once a month), biweekly (every two weeks), semimonthly (twice a month), weekly (once a week), quarterly (every three months).

Question 15. List the date your next premium is due.

Section 16. List your employer or former employer’s name, address and telephone number. Employers are contacted to verify payroll deductions, rates, etc.

Signature: Sign and date the application form at the bottom.

MO 886-3565 (4-08)

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Stage # 1 of filling in HealthNeteligible

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HealthNeteligible writing process detailed (part 2)

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