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Instructions:

  • Fill out the Health Insurance Premium Payment (HIPP) application. Directions for each individual section are at the beginning of that section.
  • Click "Submit" as bottom of page. (Information will be forwarded to our HIPP Supervisor or case worker)
  • Receive response within 5 business days from submittal.

APPLICATION FOR HEALTH INSURANCE PREMIUM PAYMENT (HIPP Program)

Please fill in all available information below and click the submit button at the bottom of this page.

Important Notice: This is a optional program which the State of West Virginia has decided to provide qualified Medicaid recipients.

Instructions
Head of Household:
Provide the name of the head of household and address and telephone number where he or she may be contacted if additional information or data verification is required.


Referral Source:
Provide the name and address of the person completing the application. A copy of the decision on the application will be returned to the referral source.

Head of Household:

Referral Source:

Address:                   

Address:            

City: State:

City: State:

Zip:   Tele:   

Zip:   Tele:   

1. Complete the following regarding your health insurance policy. If known, complete insurance information is helpful. Enter the complete name of the policy holder, BOTH the insurance group number, if applicable , address and telephone number of the insurance company. This information is usually available on the member's insurance card.

Policy Holder Name:

Insurance Co Name:       

Policy Number:         

Insurance Co. Address: 

Group Number:         

City / State / Zip:            

Policy Holder's SSN:

Telephone Number:        

2. What is the Maximum OUT OF POCKET EXPENSE. If known, enter the maximum out-of-pocket expense per individual or for the entire family. The out-of-pocket expense should not be confused with the lifetime limit of the policy. The lifetime limit is the maximum amount of coverage offered by the policy.

Individual    Family  

3. Is the annual deductible included in the out of pocket expense? Check yes or no.

Yes:     No:  

4. If no, what is the annual deductible:? If unknown, leave blank.

Individual   Family  

5. Is this policy an HMO (Health Maintenance Organization) or a PPO (Preferred Provider Organization)? If unknown, leave blank.

HMO:     PPO:  

6. Complete the following information regarding the employer offering this policy.

Employer Name:          Employer Address:
Employer Telephone: City / State / Zip:     

7. List all Medicaid eligible persons covered under this policy. List all persons living at this address who are Medicaid eligible and eligible for coverage under this policy. Enter the full name, Social Security Number, date of birth, Medicaid identification number, relationship to the policy holder and gender for each person. If more than five persons, attach a second form.
NAME SSN DOB MEDICAID ID RELATIONSHIP M / F

8. Are any of these persons pregnant?

Yes:     No:  

9. Have any of the Medicaid eligible persons listed in #7 above been diagnosed with a medically expensive condition including but not limited to the following:  Diabetes, Blood Disorder, Cancer, Mental Illness/Retardation, Heart Condition, Asthma, Scoliosis or other Back Injury, Stroke, Seizure Disorder, Kidney/Liver Disorder, Alcohol/Drug Addiction, HIV Positive/AIDS?          
Yes:      No:  
If yes, please enter the individual's name and the diagnosis/condition.

              Name:                               

            Condition:        

10. If known, how much are the premiums for this policy?   

Paid:    Weekly    Biweekly        Semimonthly        Monthly        Quarterly        Other   

11. If known, check the services covered under this policy?

Hospital       Physician       Dental       Drug       Home Health       Long Term Care   

Hospital:                Medical inclusive of room and board charges
Physician:              Professional services offered by physcicians
Pharmacy:             Drugs and pharmaceuticals
Dental:                   Oral care - both routine and emergency
Home Health:       Care and services provided in the insured person's home
Long Term Care: Care provided in a non acute setting (i.e.Nursing Facility)

12. Complete the following information if COBRA benefits might be available from a former employer.  Indications of COBRA coverage might be a recent job termination, recent layoff from a job or a new job where the benefits do not cover a pre-existing condition.

                   Have you received COBRA forms?      If Yes, enter date received

                    Date COBRA received:                       

                    Last Date of Employment:                  

13.  Can we contact your employer and/or insurance carrier to verify this information?

Yes:     No:  
If "No" is checked, the application will be denied for insufficient information to process the application.

14. Was applicant or any dependent injured at work or in an accident that required medical attention in the last 12 months?

Yes:     No:        

If an attorney or insurance company is involved, please provide the following information:

                                Attorney Name:              

                                Insurance Company:     

I acknowledge that I have read and completed this application, or that it was read to me, and that I understand it's purpose and effect, and that it is a true and correct statement to the best of my knowledge and belief.         

Check Here

Your Name:
Date:

Send mail to wvrecovery@pcgus.com with questions or comments about this web site.                            
Copyright © 2001 Public Consulting Group, Inc.
Last modified: January 30, 2003