Health Insurance Renewal Form PDF Details

Ensuring the continued health and well-being of children is paramount for any guardian or parent, making the process of renewing child health insurance coverage through Child Health Plus (CHPlus) a critical task that must be carried out with diligent attention to detail. As it is now the time for renewal, guardians are urged to fully review the comprehensive Health Insurance Renewal Form, which serves as a lifeline to maintain necessary healthcare coverage for children under the age of 19. This form not only facilitates the assessment of Medicaid eligibility but also emphasizes the importance of prompt and accurate completion to prevent the lapse of coverage. Guardians should be prepared to accurately provide contact information, detailed household composition, income verification, and expenses, all of which play a vital role in determining the premium and eligibility for continued enrollment in CHPlus or potential eligibility for Medicaid programs. Of significance is the stipulation that this form cannot be utilized to add new children to CHPlus, underscoring the form’s specific purpose for renewal only. Additionally, the document outlines the possible requirement of a monthly premium, necessitating guardians to refer to the later section for a calculation based on household income and size. Moreover, the form provides essential contact information for assistance and emphasizes key rights, such as the option to change health plans and the availability of special programs for children with disabilities or chronic illnesses. Completing this form is not merely an administrative task but a crucial step in safeguarding the health and future well-being of children under the guardianship.

QuestionAnswer
Form NameHealth Insurance Renewal Form
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other nameshealthfirst renew online, renew health first, renew healthfirst, renew healthfirst insurance

Form Preview Example

CHILD HEALTH PLUS B

HEALTH INSURANCE RENEWAL FORM

SM

Child Health Plus

 

HEALTH INSURANCE RENEWAL FORM

Page 1 of 6 (04/2012)

It is time to renew your child(ren)'s Child Health Plus (CHPlus) coverage!

Please read this entire renewal form before you begin filling out the form.

If you do not complete this form on time, your child(ren)'s health care coverage will end. Please make sure you answer all the questions on this form or your child(ren) may lose coverage.

If you have questions about what is needed to renew your child(ren)'s coverage or need help completing this form, contact us at:

Healthfirst

1-877-869-1156

Do not use this renewal form to add a new child to CHPlus. This form can only be used to renew coverage for children already enrolled in CHPlus who are under the age of 19 and to evaluate existing CHPlus members for Medicaid eligibility. If you would like to add a new child to CHPlus, please contact your health plan or a facilitated enroller to complete a new Access NY Health Care application for that child.

*Child Health Plus Premium - There may be a monthly premium for Child Health Plus. If you are required to pay a premium, one month's payment must be submitted with this form. Please refer to the information on page 6 about family premium contributions to determine the amount of your monthly premium based upon your family's income and household size. If you have any questions or need to know where to mail your premium, please call Healthfirst, 1-877-869-1156.

Important Information About Your Rights - You have the option of changing your CHPlus health plan at anytime, but you will have to obtain and complete a new Access NY Health Care application. You cannot use this renewal form to switch your CHPlus health plan. If your child is disabled or has a chronic illness, he/she may be eligible for Medicaid programs and services. To receive information about changing health plans or to learn about programs for special needs families, call 1-800-698-4543.

SECTION A: CONTACT INFORMATION

This section should be completed by a parent, guardian, or person renewing coverage on behalf of the child(ren). Tell us who you are and how to contact you.

Legal First Name of Person Completing this Form

Middle Initial

Legal Last Name

What Language Do You

 

 

 

 

Speak?

Read?

 

 

 

 

 

Primary Phone Number

Another Phone Number

E-Mail Address

 

What type of number is this? Home Cell Work Other

What type of number is this? Home Cell Work Other

Do you want to receive information from your health plan via email? Yes No

If known, please provide your child(ren)’s health plan identification number(s): _______________

______________ _______________ _______________

Home Address of the Children Renewing Health Insurance

 

Did your address change in the past 12 months? Yes No

Street Address

 

 

 

 

Apartment Number

 

 

 

 

 

 

City

State

 

Zip Code

 

County

 

 

 

 

 

 

Mailing Address if Different from the Home Address

 

 

 

 

 

Street Address

 

 

 

 

Apartment Number

City

State

Zip Code

County

 

SECTION B: ABOUT YOUR HOUSEHOLD

 

Page 2 of 6 (04/2012)

 

 

 

 

 

 

 

You must answer all of the questions and check all appropriate boxes for each person listed.

DO NOT LEAVE A BOX IN THE ROW BLANK.

List information about yourself in the first row of boxes. In the other rows, list the name of all the children in the household, spouses, parents, step-parents, and any other children under 21 living with them. You may also list other household members at your option; however, they may not be added to your family size. This information helps us determine the size of your family and which program your child is eligible for.

1.Enter the full legal name of each person living in your household. List yourself in row 01.

2.Indicate how each person listed in this section is related to you (example: spouse, child, step-child, niece, etc).

3.Give the date of birth for each person listed.

4.Write yes or no to indicate if this person is renewing CHPlus coverage. You must write no for all family members who are not renewing CHPlus coverage.

5.Write yes or no if this person is a Public Employee who can get health insurance coverage through a State Health Benefits Plan or the New York State Health Insurance Program (NYSHIP). NYSHIP is offered to employees/retirees of NYS government, the State Legislature and the Unified Court System. Some local government agencies and school districts also elect to participate with NYSHIP. If you are not sure, check with your employer or benefit administrator. If your child has access to a State Health Benefits Plan through NYSHIP, he/she will be ineligible for Child Health Plus coverage.

6.Indicate if this person is male or female.

7.Answer if anyone is pregnant in the household by writing yes or no. You will need to provide proof of pregnancy for anyone that is pregnant (see page 6).

8.Identify whether or not this person is a full time student by writing yes or no.

9.A Social Security Number (SSN) should be provided for any child renewing coverage or household member if they have one. Write Not Applicable (N/A) if this person does not have a Social Security Number.

10.Almost all children are eligible for either CHPlus or Medicaid, regardless of citizenship or immigration status, if they are New York State residents and do not have other health insurance. Please list every child's citizenship and immigration status to help us determine their program eligibility. If your child’s immigration status has changed since the last application, you must provide proof of the change for each child (see page 6 for examples of acceptable proof) and give the date the child’s immigration status changed. No proof is needed if your child’s status has not changed in the last year.

 

1

 

2

 

3

 

4

 

5

 

6

 

7

 

8

 

9

 

 

 

 

10

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Public

 

 

 

 

 

Is this

 

 

 

 

 

 

 

 

Citizenship or Immigration Category

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Relationship

 

 

 

 

Renewing

 

 

Employee with

 

 

 

 

 

Person

 

 

Full

 

 

Social

 

 

 

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Check a Box)

 

 

 

 

 

to Person

 

 

 

 

CHPlus

 

 

State Health

 

 

Sex

 

 

Time

 

 

Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pregnant?

 

 

 

 

 

 

Only enter a date of status if you check the

 

 

Legal Name

 

 

in Box 01

 

 

of Birth

 

Coverage?

 

Benefits?

 

 

(Male or

 

 

(Yes/No)

 

S

tudent

?

 

(If you have one)

 

 

 

immigrant box (DOS: mm/dd/yy)

 

 

(First, Middle Initial, Last)

 

(

Spouse, Child

)

(

mm/dd/yy

)

 

(Yes/No)

 

 

(Yes/No)

 

 

Female)

 

 

SEND PROOF

 

 

(Yes/No)

 

 

(XXX-XX-XXXX)

 

 

 

ONLY SEND PROOF OF A CHANGE

 

 

01

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

Self

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

02

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

04

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

05

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

06

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

07

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/_______

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

08

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

None of these apply

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Non-immigrant (Visa Holder)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Immigrant

DOS:_____/_____/____ ___

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION C: HOUSEHOLD INCOME

 

Page 3 of 6 (04/2012)

 

 

 

 

Complete all of the following boxes for all adults living in the household as well as anyone else in the household (including children) who receive income. For each person, indicate what type(s) of income they receive, how much before taxes, and how often (weekly, every 2 weeks, monthly, or annually). If the person is not regularly employed throughout the year, or if the person's income goes up and down every month, write the amount the person expects to receive this calendar year. Do not use an income range or approximations. If there is “No Income” coming into the household, check the box below each person’s name and indicate below how the renewing child(ren) are financially supported.

Here is a list of different types of income that you may be receiving and we need to know about:

*Earnings from Work: Gross Wages, Salaries, Commissions, Tips, Overtime, and Self- Employment before taxes

*Unearned Income: Social Security Benefits (SSB), Disability Payments (SSD), Unemployment Payments, Interest and Dividends, Veteran's Benefits, Workers’ Compensation, Child Support/Alimony, Rental Income, and Pension

*Contributions/Other: Income (money) from Relatives, Friends, Roomers and Boarders (include money that anyone gives to help meet living expenses), Temporary (Cash) Assistance, Supplemental Security Income (SSI), Student Grants, or Loans

You have two options to give proof of your income.

1.You can provide a Social Security Number for each individual who receives income for us to check (verify). If you provide a Social Security Number, you do NOT have to provide any income documents with this form. You must

still complete all of the questions in this section. -OR-

2.You can provide proof of your income for each type of income listed. See page 6 for a list of documents you will need to provide as proof of your income. The proof submitted must be dated within one month prior to the date you sign this form and include the name of the person who gets the income.

 

 

Name of ALL Adult(s) in Section B

 

 

 

 

 

 

 

 

 

 

 

 

How

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

and Other Household Members,

 

 

Social Security Numbe

r

 

 

Type of Income

 

 

How Much?

 

 

Often?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Including Children, Who Receive Income

 

 

(XXX-XX-XXXX)

 

 

(Either write your Social Security Number or You Must Send Proof of Your Household Income)

 

(Before Taxes)

 

(Ex: Monthly)

 

 

 

 

 

 

 

 

 

Earnings from Work

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Unearned Income

List Type :

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive Child Support?

Yes No

$

 

 

 

 

 

 

Check if this person does not receive income.

 

Contributions/Other

List Type:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earnings from Work

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Unearned Income

List Type :

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive Child Support?

Yes No

$

 

 

 

 

 

 

Check if this person does not receive income.

 

Contributions/Other

List Type:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earnings from Work

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Unearned Income

List Type :

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive Child Support?

Yes No

$

 

 

 

 

 

 

Check if this person does not receive income.

 

Contributions/Other

List Type:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Earnings from Work

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Employer:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

Unearned Income

List Type :

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you receive Child Support?

Yes No

$

 

 

 

 

 

 

Check if this person does not receive income.

 

Contributions/Other

List Type:

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO INCOME: If there is no money coming into the household, explain below how the children renewing coverage are being supported. For example, the children are living with a friend/relative who is paying for their living expenses (room and/or board). If someone is paying your living expenses, you must supply a letter from the person providing support that they have signed and dated. The letter must include their name, address, telephone number and the amount they give you or the children for living expenses as well as how often.

Explanation:

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Part no. 1 in filling in healthfirst renewal form

2. Given that the previous array of fields is finished, you need to add the required details in Veterans Benefits, Award letter or Benefit check stub, Private PensionAnnuities, Statement from pensionannuity, Workers Compensation Award letter, returns for other, than self employed, must be for, applications prior to, April of the, following year, and Family Premium Contribution There so you're able to move on further.

healthfirst renewal form completion process outlined (portion 2)

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