Renewal Form Husky PDF Details

In Connecticut, ensuring that low-income adults and families have access to essential health insurance coverage is a high priority, which is addressed through the application and renewal process for Medicaid under the HUSKY Health Program. The comprehensive Renewal Husky Form is specifically designed for individuals seeking to renew their health coverage, catering principally to adults, pregnant individuals, children under 19, and anyone under a court order to provide medical support. This form underscores the commitment to accessibility by offering assistance through designated contact numbers for general inquiries, the deaf, and hearing-impaired individuals, along with a promise of support for those requiring information in alternative formats. It comprehensively gathers applicant information, including personal details, household composition, income, and other critical aspects like employment income, other household income, and daycare expenses, ensuring a complete understanding of the applicant's situation. Additionally, it accommodates immigration status and tribal membership, reflecting a meticulous approach to inclusivity and fairness. The form also emphasizes the importance of cooperation with child support enforcement for certain applicants, underscoring the state’s dual focus on child welfare and health coverage. Notably, the form includes guidance on addressing pre-existing conditions and stipulates the implications of providing false information, highlighting the state’s diligence in maintaining program integrity while ensuring the delivery of health benefits. By signing the form, applicants agree to a set of responsibilities and authorize the state to use their information for administering health programs, showcasing a balanced partnership between the state and beneficiaries aimed at fostering a healthier Connecticut.

QuestionAnswer
Form NameRenewal Form Husky
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesHUSKY Application English renewal form huskypdffillercom 2012

Form Preview Example

Application AND

MEDICAID FOR

LOW-INCOME

Renewal Form

ADULTS

Connecticut Pre-Existing Condition Insurance Plan

This application is for individuals and families who only need health insurance.

If you need other types of assistance for your family, call INFOLINE at 2-1-1. Deaf and hearing-impaired individuals may use a TDD/TTY by calling 1-800-410-1681. Questions, concerns, complaints, or requests for information in alternative formats must be directed to 1-800-842-1508.

If you have any questions about this application or need help completing it, call 1-800-656-6684.

If the information you have does not fit on this form, please attach separate sheets of paper as needed.

Section A: I want health insurance for: (Check (√) the category or categories that match your situation.)

Myself because I am age 19 or older.

My spouse (or other parent of my children who lives with me). My children under age 19 who live with me.

Children in my care who live with me and are under the age of 19.

Myself because I am pregnant. My due date is: ______________________.

My children under age 19 who do not live with me. I am under a court order to provide medical support. This is the address of my children: ________________________.

I would like to apply for Family Planning coverage (e.g. birth control, sterilization and treatment for sexually transmitted diseases).

Section B: Applicant Information - Tell us about yourself.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Last Name

 

 

First Name

 

MI

Maiden Name

 

Day Phone Number

 

Evening Phone Number

 

Client ID

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address (If different)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

 

Gender

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you Hispanic

Race–(Check all that apply)

 

 

 

 

 

 

 

 

 

Social Security Number (Optional

 

Are You a US Citizen?

 

What Language Do You

 

 

or Latino?

 

 

Alaskan Native/Eskimo

 

Asian

 

 

Black or African descent

 

 

if not applying for yourself)

 

(Optional if not applying for

 

Speak Best?

 

 

 

 

 

Yes

 

No

 

Native American

 

Pacific

 

 

 

White

 

 

 

 

 

yourself)

Yes

No

 

 

 

 

 

 

 

 

 

 

 

Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section C: Tell us about the people who need health coverage. Include information about yourself if you want health coverage.

 

First Name

Relation-

Is this person a

Social

 

 

 

Race (select

US Citizen?

Has Earnings

 

parent of at

Date of

Gender

Hispanic or

from the

Last Name

and

ship to the

Security

If No, fill out

or other

least one of the

Birth

M/F

Latino?

above

 

Middle Initial

applicant

Number

Section J

Income?

 

children?

 

 

 

categories)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

Yes

 

No

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

Yes

 

No

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

Yes

 

No

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

Yes

 

No

Yes

No

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If anyone listed in Section C is pregnant

Please list the person’s name and the date that the baby is due:

 

 

 

 

 

 

 

 

Does anyone listed receive SSI or have a disability? Yes

No

If yes, list name of person:

 

 

 

 

 

 

 

 

Is anyone listed legally blind?

Yes

No If yes, list name of person:

 

 

 

 

 

 

 

 

Does anyone listed here have a pre-existing medical condition?

Yes No If yes, list name of person(s):

 

 

 

 

 

 

 

W-1HUS (Revised 10/2012)

If you have any questions about this application or need help completing it, call 1-800-656-6684.

 

 

1

Section D: Other Household Members - We need information about others who live in the household and who are the parents, stepparents and spouses of the people who want health insurance. Include information about yourself if you are a parent in the home but did not list your name in section C because you do not want health coverage for yourself. Also, please list any other children in the household under age 19 who are not applying for health insurance. Do not include anyone listed in Section B or C of page one.

 

 

 

 

Social Security

 

 

 

 

 

Receives

 

 

 

Receives

 

 

 

 

 

 

Show who this person is related to and how they

 

 

 

Name

 

 

Date of Birth

 

 

 

 

Earned

 

 

 

 

Other

 

 

 

Number (Optional)

 

are related (Example, father of Billy Smith)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Income?

 

 

 

Income?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

Yes

 

 

No

 

 

 

Yes

 

 

No

Section E: Parents Who Do Not Live in the Household – If you are a parent or a caretaker relative living with a child and you want health coverage for yourself, you must agree to cooperate with child support. This means that you will give us information about parents who do not live in the home and help us pursue medical support. If you do not agree to cooperate, you cannot get HUSKY or Charter Oak coverage for yourself, however, your children can still qualify for HUSKY. You may ask for an exemption from this requirement if you feel there is a threat of domestic violence. Even if you do not want health coverage for yourself, we can help you obtain child support.

Do you agree to cooperate with the Child Support Division to seek medical support for your children from a parent who does not live in the home? Yes No If you do not want to cooperate, is the reason a fear of abuse by the parent who is not in the home? Yes No

Do you want us to help you obtain child support? Yes No If you agree to help us pursue support, please provide the following information. Also, if you are applying for your children who do not live with you, please provide the following information.

Name of Parent

Name of Child

 

 

 

 

Parent’s Address

Name, Address, and Phone Number of Parent's Employer

 

 

 

Section F: Employment Income - Complete the following for anyone in Sections C and D who receives earned income. Include your earnings if you are a spouse or parent of a child listed in section C. Also, include your income if you are a caretaker relative and you want health coverage for yourself. If a person has more than one job, list each job separately. If you are self-employed, please send us proof of business income and expenses. This may be last year’s income tax return including all Schedules. If the tax return is more than 3 months old, provide a Profit and Loss Statement detailing the income and expenses since the last time taxes were filed and a copy of the business records for the same time period. If neither are available, send us a sworn notarized statement or DSS form W-38 showing income and expenses for us to review.

 

Name of

 

 

Full-time or part-time

 

 

 

 

 

 

 

 

Hours

 

 

 

Pay Before

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Government

 

 

 

Date

 

 

Employed

 

 

student?

 

 

Employer Name, Address and Phone Number

 

 

 

Worked

 

 

 

Deductions

 

 

 

 

 

 

 

 

 

Employee?

 

 

 

 

 

 

 

Started

 

 

Person

 

 

If yes, name of school?

 

 

 

 

 

 

per Week

 

 

(including tips)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

$

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City/Town

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

$

per

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Federal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section G: Other Income - Please complete the following for anyone in Sections C and D who receives other income such as child support, Social Security, or Unemployment Compensation. Include your unearned income if you are a parent of a child listed in Section C. Also include your unearned income if you are a caretaker relative and you want health coverage for yourself.

Name of Person

Type of Income

How Much?

How Often?

W-1HUS (Revised 10/2012)

If you have any questions about this application or need help completing it, call 1-800-656-6684.

2

Section J: Immigration -

Section H: Day Care Expenses - If you or anyone in the household pay for day care for a child or a disabled adult complete the following. Also, include any day care payments made by a state agency such as the Care4Kids Program.

Name of Person who

Receives Care

 

Amount Paid

 

 

Amount Paid by

 

 

 

 

 

 

 

 

By You

 

 

the State

 

 

 

 

 

 

 

How Often?

Day Care Provider Name, Address

And Phone Number

Section I: Health Insurance - Does anyone for whom you are applying currently have other health insurance or Medicare?

Yes

 

No If yes, please complete the

 

following.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name(s) of Insured

 

Insurance Company Name,

 

 

 

 

Type

 

 

Policy or Member

 

 

 

Begin

 

 

Source

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, and Phone Number

 

 

 

 

 

 

Number

 

 

 

Date

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

 

 

 

Employer-Sponsored

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

State Employee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy

 

 

 

 

 

 

 

 

 

 

Private (self-pay)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did any child have employer-sponsored health insurance terminated or canceled in the last two months?

Yes

No Did any adult have any other

 

health insurance terminated or canceled in the last six months? Yes No

If yes to one or both, complete the following:

 

 

Name of Insured

 

Insurance Company Name,

 

 

 

 

 

Type

 

 

Policy or Member

 

 

 

Date

 

 

 

Why is this Insurance No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address, and Phone Number

 

 

 

 

 

 

 

Number

 

 

Ended

 

 

 

Longer Available?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Vision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dental

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

How much do you pay, or did you pay, for this insurance? $______________ How often? ___________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If anyone on the household has unpaid medical bills, paid bills for medical services received in the past 3 months, or is currently paying on a loan

 

that was taken to pay for medical bills, please provide the following information. We may need more information about your medical bills later.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Medical

 

 

 

 

 

Amount Still

 

 

 

Amount Paid

 

 

If you took a loan to pay for medical care, give the Name of the Lender,

 

 

 

 

 

Total Charge

 

 

 

 

 

 

 

Service

 

 

 

 

Owed

 

 

 

 

Each Month

 

 

Amount of the Loan, and the Date the Loan was Taken.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provide immigration information for those who are not citizens and who are applying for health insurance.

Name

 

 

Date of US

 

INS Number

 

 

INS Status

 

Date Status

 

 

Blind or

 

 

Receives

 

Member of US Armed Forces or

 

 

 

 

 

 

 

 

Entry

 

 

 

 

Received

 

 

Disabled?

 

 

SSI?

 

 

Veteran or Child or Spouse?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section K: Tribal Membership - Members of federally recognized American Indian tribes and Alaskan Natives who qualify for subsidized HUSKY coverage do not have to pay premiums or co-payments. Are any of the people listed in Section B or C members of a federally recognized American Indian tribe or Alaskan Natives? Yes No

If yes, list the person’s name and tribe and provide a tribal card or letter as verification_________________________________________________________________________

 

W-1HUS (Revised 10/2012)

If you have any questions about this application or need help completing it, call 1-800-656-6684.

3

Section L: Read Carefully and Sign Below

I UNDERSTAND THAT

There is a grievance process if I disagree with an action taken on my case;

All information given on this form is subject to verification by federal, state and local officials;

All information given on this form is confidential and the Department of Social Services (DSS) or its agent will use this information only to administer DSS programs or as required by law or a court order;

By receiving medical assistance, I allow the state to recover the cost of my medical bills, which may have been covered by other insurance, directly from the insuring company;

The state may recover the cost of accident-related medical services paid by the state from the proceeds of a lawsuit;

Any payment made by the state on behalf of an enrollee as a result of a false statement, misrepresentation or concealment of or failure to disclose income or health insurance coverage by an applicant responsible for maintaining insurance may be recovered by the state; and

If I have knowingly given incorrect information I may be subject to penalties for false statements and larceny as specified in the Connecticut General Statutes sections 53a-122, 53a-123, 53a-157b, and 17b-97, as well as penalties under Federal Law.

I AGREE TO

Notify DSS or its agent within 10 days of all changes in family circumstances, for example, income, medical insurance, address, residence of child, or household size;

Cooperate with federal, state, and local officials by providing authorizations, documents and other proof regarding the information that I have provided on this form;

Cooperate with federal and state personnel in a Quality Control Review;

Not alter, trade, lend, or sell my medical services card and/or the medical services card of any individual for whom I applied for health insurance, and to have the Department or its agent file Medicare claims and pursue appeals.

Allow DSS or any health insurer, provider, or other entity providing services to me or my family under Medicaid, the HUSKY program, Charter Oak Health Plan or Connecticut Pre-existing Condition Insurance Plan (CT PCIP) to release information about me or my family as necessary for the delivery of Medicaid, HUSKY program, Charter Oak Health Plan or CT PCIP services and for the administration of the Medicaid, HUSKY program, Charter Oak Health Plan or CT PCIP, as permissible by federal or state law.

Pay the health plan premium (if required) and applicable co-payments in accordance with the plan’s payment rules. I understand that if I do not pay the required premium, the health care coverage for myself or my family members will be canceled.

I certify that I have read this form or have had it read to me in a language that I understand and the information given on this form is true and complete to the best of my knowledge.

SIGNATURE

Date

 

 

Witness' Signature (if signed with an X)

Date

OFFICIAL USE ONLY

Reviewed By

Date

Interpreter's Signature

Date

If someone helped the applicant complete this form, this person must sign also.

Helper's Signature

Date

If someone completed this form on the applicant’s behalf, this person must sign also.

_______

Representative’s Signature

Date

Return this form in the self-addressed envelope provided. If no envelope was provided, mail the completed forms to:

HUSKY/Charter Oak/CT PCIP, P.O. BOX 280747, EAST HARTFORD CT 06128

You may also send it to your local DSS office.

 

 

How did you hear about the HUSKY, Charter Oak, or CT Pre-existing Condition Insurance Plan?

 

TV

Radio

Newspaper

Doctor's Office

211 InfoLine

Presentation

Other____________________________________

 

 

 

 

 

 

 

 

 

 

Medical assistance coverage will not be denied due to a pre-existing medical condition.

 

W-1HUS (Revised 10/2012)

If you have any questions about this application or need help completing it, call 1-800-656-6684.

4

This application will be considered without regard to race, color, gender, age, physical or mental disability, religious creed, national origin, sexual orientation, ancestry, language barriers, or political beliefs.

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It's straightforward to complete the pdf following our helpful guide! This is what you have to do:

1. The Renewal Form Husky necessitates specific details to be typed in. Ensure the following fields are complete:

Writing segment 1 of Renewal Form Husky

2. Now that this segment is finished, you'll want to put in the needed particulars in Middle Initial, If anyone listed in Section C is, Yes No Yes No Yes No Yes No, Yes No Yes No Yes No Yes No, Yes No Yes No Yes No Yes No, Yes No Yes No Yes No Yes No, WHUS Revised, and If you have any questions about allowing you to progress further.

Filling out segment 2 of Renewal Form Husky

3. This 3rd part should be rather easy, Number Optional, are related Example father of, Receives Earned Income, Yes No Yes No, Income, Yes No Yes No, Section E Parents Who Do Not Live, yourself you must agree to, Name of Parent, Name of Child, Parents Address, Name Address and Phone Number of, Section F Employment Income, parent of a child listed in, and Employer Name Address and Phone - these form fields will have to be filled in here.

Renewal Form Husky writing process described (part 3)

4. This next section requires some additional information. Ensure you complete all the necessary fields - Government Employee CityTown State, per, Section G Other Income Please, Name of Person, Type of Income, How Much, How Often, WHUS Revised, and If you have any questions about - to proceed further in your process!

Tips to complete Renewal Form Husky part 4

Lots of people frequently make errors when filling in Section G Other Income Please in this area. You need to go over whatever you enter right here.

5. This form should be finalized by going through this section. Further there is a full set of form fields that require accurate details for your form usage to be complete: Receives Care, By You, the State, How Often, And Phone Number, Section I Health Insurance Does, following, Names of Insured, Insurance Company Name Address and, Type Medical Vision Dental, Policy or Member, Number, Begin Date, Source, and EmployerSponsored State Employee.

Stage number 5 for filling out Renewal Form Husky

Step 3: Go through all the information you've typed into the form fields and then click the "Done" button. Make a free trial subscription with us and gain instant access to Renewal Form Husky - download or modify from your personal cabinet. When you use FormsPal, you can complete forms without needing to get worried about data leaks or entries being shared. Our protected platform ensures that your personal details are maintained safely.