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Applications


Applying for health insurance

Application for Health Coverage & Help Paying Costs
[PDF] English | Spanish | Order online

Acknowledgment of Receipt of Verbal Consent
[PDF]  English | Spanish | Arabic | Amharic | Urdu | Vietnamese

 

Applying for more than two people

You may need to print more pages if you are applying for Medicaid, FAMIS or Plan First for more than two people in your household. Use the Additional Person Single Page Supplement. You cannot use this application by itself. You must also complete the Application for Health Coverage & Help Paying Costs. Then submit the Additional Person Single Page Supplement with your application. 

Additional Person Single Page Supplement
[PDF] English | Spanish | Order online

 

Applying for Medicaid for adults over age 19 with disabilities, or who are 65 or older, or for anyone who needs long-term care

You must complete the ABD-LTC Application – Appendix D and the Application for Health Coverage & Help Paying Costs. 

ABD-LTC Application – Appendix D
[PDF] English | Spanish | Order online

 

Applying for the medically needy

Complete Medically Needy Spenddown – Appendix E if you applied for health care coverage for someone who is medically needy, but has income greater than the Medicaid limit and wants to be evaluated for a spenddown based on income, resources, and medical expenses. Spenddown works like an insurance policy deductible. The amount of the “deductible” is called the “spenddown liability.” Once medical bills are equal to or greater than the spenddown liability, the application will be re-evaluated for Medicaid eligibility. 

Medically Needy Spenddown – Appendix E
[PDF] English | Spanish | Order online

 

Applying for persons with special needs

Complete Nursing or Community Based Care – Appendix F if you applied for health care coverage for someone who needs help with everyday things like bathing, dressing, walking or using the bathroom to live safely in the home. Also complete Appendix F if a doctor or nurse has told the person applying that they have a physical disability, chronic (long-term) disease, mental or emotional illness, or addiction disorder.

Nursing or Community Based Care – Appendix F
[PDF] English | Spanish | Order online                                                                                        

To learn more about how to appeal a decision, go to Appeals.

 

Applying for premium assistance

Complete FAMIS Select application if your family is enrolled in FAMIS and needs premium assistance. FAMIS Select helps families pay for employer-sponsored health insurance. The FAMIS Select program allows families to choose between covering their children through an employer-sponsored health plan or through FAMIS.

FAMIS Select Application
[PDF] English | Spanish

 

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