Renewal Form Husky – Fill Out and Use This PDF

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.)

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.

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.

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 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.

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.

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.