Private Health Insurance Premium (PHIP) Application at a glance
What it is: Private Health Insurance Premium Benefit.
Where and when to file: Office of MaineCare Services Private Health Insurance Premium (PHIP) 11 State House Station Augusta, Maine 04333-0011
PHIP pays private health insurance premiums for members who qualify. You must already have health insurance, or you must be able to get it. The program will not find health insurance for you. The program will pay part or all of the monthly cost of your health insurance plan. If your child is enrolled in the Katie Beckett Program and you become eligible for the PHIP Program, your Katie Beckett premium may increase. The PHIP Benefit Program will pay you (the policyholder) every month. Even if you have private health insurance, you can qualify. PHIP is only for people who have MaineCare and private health insurance. The following information is needed to see if you are eligible for PHIP:
What to bring and attach to Private Health Insurance Premium (PHIP) Application
Proof of the cost of your premium on a current pay stub or a current bill.
The rates for the insurance to include the breakdown of cost for Employee, Employee/Spouse, Employee/Child, and Family.
The annual open enrollment period dates and the effective date of the benefit period.
The section of your benefit summary that includes your individual deductible amount.
A copy of your medical and pharmacy insurance card, front and back.
Employer and Insurance Information form, enclosed with this application.
W-9 form, completed by the policyholder in order to reimburse you your monthly premiums.
A completed Direct Deposit Form.
A voided check or letter from your bank on their letterhead providing their routing number, your name, address, account number and must indicate if it is a savings or checking account.
A deposit slip or a starter check is not accepted.
A filled-in Private Health Insurance Premium (PHIP) Application example: an employee completes the employer and insurance page
How to fill out Private Health Insurance Premium (PHIP) Application, box by box
Employee and employer information
Enter the Employee Name, the Employee Social Security Number, the Employee Address and the Telephone Number.
Enter the Employer Name, the Contact Person, the Employer Address, the Telephone Number and the Date of open enrollment.
Employer and Insurance Information Form: Please fill in all requested information on the form.
Medical Ins. Carrier
Enter the Medical Ins. Carrier Name and the Carrier Address.
Employee Cost and How Often Deducted
Only show how much is actually being deducted from paycheck as Employee Cost, on the Single - Medical, Employee w/Chrn - Medical, Employee & Spouse - Medical or Family - Medical row. Under Coverage, put an X on the covered services. For Weekly, circle 50 or 52 times/yr.; for Bi-Weekly, circle 24 or 26 times/yr.
Be sure you list the amount you pay for your policy and, if it is an employer plan, how often money is deducted from your paycheck.
Please also note when open enrollment is, to know when to expect your costs to change. Dental is not covered.
Medical Deductibles, Enrolled, Group # and Certificate #
Enter the Medical Deductibles for Single and for Family.
Under Enrolled, mark Medical Y or N.
Enter the Group # and the Certificate #.
MaineCare Member Information
Participants Form: Please list the names, relationship to the policy holder; and MaineCare ID number and date of birth for each person.
This form tells who in the family is covered or will be covered by the private health insurance.
Enter the Policyholder, the MaineCare ID# or DOB and the Email Address.
For each MaineCare Member, enter the ID# or DOB and the Relationship to Policyholder.
More rules for Private Health Insurance Premium (PHIP) Application
You are not qualified for prior months.
Other forms you send
W-9 Form
W-9 Form: The policyholder of the health insurance should complete this form.
Please fill in ONLY the policyholder's name, address, social security number and date, and sign the signature line.
This form is not used for tax reporting services.
The Accounting department needs it in order to send you checks.
Direct Deposit Form
Direct Deposit Form: The policyholder must be on the checking or savings account.
If you have a savings account that you want the check to go into, attach a letter from the bank with the account number, routing number, and name of account holder.
Common questions about Private Health Insurance Premium (PHIP) Application
Where do I file it?
Office of MaineCare Services Private Health Insurance Premium (PHIP) 11 State House Station Augusta, Maine 04333-0011 Send the information by mail, email, or fax.
Where to get help with Private Health Insurance Premium (PHIP) Application
If you have questions, please feel free to contact the office.
Toll Free: (800) 977-6740; Fax: (207) 287-9385
Sources
[1] Private Health Insurance Premium (PHIP) Application, Maine Department of Health and Human Services, Office of MaineCare Services (the Official source link on this page).