/depts/,/depts/uwhealth/,/depts/uwhealth/benefits/,/depts/uwhealth/benefits/open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/,/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/resources/,

/depts/uwhealth/benefits/open-enrollment/uwmf-open-enrollment/health-insurance/resources/CHIP-model-notice.pdf

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UWHC,UWMF,

Departments & Programs,UW Health,Benefits,UW Health Open Enrollment,UWMF Open Enrollment,Health Insurance,Resources

CHIP Model Notice

CHIP Model Notice - Departments & Programs, UW Health, Benefits, UW Health Open Enrollment, UWMF Open Enrollment, Health Insurance, Resources


Premium Assistance Under Medicaid and the
Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your
employer, your state may have a premium assistance program that can help pay for coverage, using funds from
their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact
your State Medicaid or CHIP office to find out if premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these programs, contact your State Medicaid or CHIP office or dial 1-
877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under
your employer plan, your employer must allow you to enroll in your employer plan if you aren’t already enrolled.
This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being
determined eligible for premium assistance. If you have questions about enrolling in your employer plan,
contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-EBSA (3272).


If you live in one of the following states, you may be eligible for assistance paying your employer health
plan premiums. The following list of states is current as of August 10, 2017. Contact your State for more
information on eligibility –

ALABAMA – Medicaid FLORIDA – Medicaid
Website: http://myalhipp.com/
Phone: 1-855-692-5447
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-877-357-3268
ALASKA – Medicaid GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://myakhipp.com/
Phone: 1-866-251-4861
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility:
http://dhss.alaska.gov/dpa/Pages/medicaid/default.asp
x
Website: http://dch.georgia.gov/medicaid
- Click on Health Insurance Premium Payment (HIPP)
Phone: 404-656-4507
ARKANSAS – Medicaid INDIANA – Medicaid
Website: http://myarhipp.com/
Phone: 1-855-MyARHIPP (855-692-7447)
Healthy Indiana Plan for low-income adults 19-64
Website: http://www.in.gov/fssa/hip/
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO – Health First Colorado
(Colorado’s Medicaid Program) &
Child Health Plan Plus (CHP+)
IOWA – Medicaid
Health First Colorado Website:
https://www.healthfirstcolorado.com/
Health First Colorado Member Contact Center:
1-800-221-3943/ State Relay 711
CHP+: Colorado.gov/HCPF/Child-Health-Plan-Plus
CHP+ Customer Service: 1-800-359-1991/
State Relay 711
Website:
http://dhs.iowa.gov/ime/members/medicaid-a-to-
z/hipp
Phone: 1-888-346-9562




KANSAS – Medicaid NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/
Phone: 1-785-296-3512
Website:
http://www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603-271-5218
KENTUCKY – Medicaid NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm
Phone: 1-800-635-2570
Medicaid Website:
http://www.state.nj.us/humanservices/
dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website:
http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid NEW YORK – Medicaid
Website:
http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Phone: 1-888-695-2447
Website:
https://www.health.ny.gov/health_care/medicaid/
Phone: 1-800-541-2831
MAINE – Medicaid NORTH CAROLINA – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-
assistance/index.html
Phone: 1-800-442-6003
TTY: Maine relay 711
Website: https://dma.ncdhhs.gov/
Phone: 919-855-4100
MASSACHUSETTS – Medicaid and CHIP NORTH DAKOTA – Medicaid
Website:
http://www.mass.gov/eohhs/gov/departments/masshe
alth/
Phone: 1-800-862-4840
Website:
http://www.nd.gov/dhs/services/medicalserv/medicaid
/
Phone: 1-844-854-4825
MINNESOTA – Medicaid OKLAHOMA – Medicaid and CHIP
Website: http://mn.gov/dhs/people-we-
serve/seniors/health-care/health-care-
programs/programs-and-services/medical-
assistance.jsp
Phone: 1-800-657-3739
Website: http://www.insureoklahoma.org
Phone: 1-888-365-3742
MISSOURI – Medicaid OREGON – Medicaid
Website:
http://www.dss.mo.gov/mhd/participants/pages/hipp.
htm
Phone: 573-751-2005
Website:
http://healthcare.oregon.gov/Pages/index.aspx
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
MONTANA – Medicaid PENNSYLVANIA – Medicaid
Website:
http://dphhs.mt.gov/MontanaHealthcarePrograms/HI
PP
Phone: 1-800-694-3084
Website:
http://www.dhs.pa.gov/provider/medicalassistance/he
althinsurancepremiumpaymenthippprogram/index.ht
m
Phone: 1-800-692-7462
NEBRASKA – Medicaid RHODE ISLAND – Medicaid
Website: http://www.ACCESSNebraska.ne.gov
Phone: (855) 632-7633
Lincoln: (402) 473-7000
Omaha: (402) 595-1178
Website: http://www.eohhs.ri.gov/
Phone: 855-697-4347
NEVADA – Medicaid SOUTH CAROLINA – Medicaid
Medicaid Website: https://dwss.nv.gov/
Medicaid Phone: 1-800-992-0900
Website: https://www.scdhhs.gov
Phone: 1-888-549-0820





To see if any other states have added a premium assistance program since August 10, 2017, or for more
information on special enrollment rights, contact either:

U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
1-866-444-EBSA (3272) 1-877-267-2323, Menu Option 4, Ext. 61565

Paperwork Reduction Act Statement

According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no persons are required to respond to a
collection of information unless such collection displays a valid Office of Management and Budget (OMB) control number.
The Department notes that a Federal agency cannot conduct or sponsor a collection of information unless it is approved by
OMB under the PRA, and displays a currently valid OMB control number, and the public is not required to respond to a
collection of information unless it displays a currently valid OMB control number. See 44 U.S.C. 3507. Also,
notwithstanding any other provisions of law, no person shall be subject to penalty for failing to comply with a collection of
information if the collection of information does not display a currently valid OMB control number. See 44 U.S.C. 3512.

The public reporting burden for this collection of information is estimated to average approximately seven minutes per
respondent. Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden, to the U.S. Department of Labor, Employee
Benefits Security Administration, Office of Policy and Research, Attention: PRA Clearance Officer, 200 Constitution Avenue,
N.W., Room N-5718, Washington, DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137.

OMB Control Number 1210-0137 (expires 12/31/2019)
SOUTH DAKOTA - Medicaid WASHINGTON – Medicaid
Website: http://dss.sd.gov
Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-
health-care/program-administration/premium-payment-
program
Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/
Phone: 1-800-440-0493
Website: http://mywvhipp.com/
Toll-free phone: 1-855-MyWVHIPP (1-855-699-8447)
UTAH – Medicaid and CHIP WISCONSIN – Medicaid and CHIP
Medicaid Website: https://medicaid.utah.gov/
CHIP Website: http://health.utah.gov/chip
Phone: 1-877-543-7669
Website:
https://www.dhs.wisconsin.gov/publications/p1/p10095.p
df
Phone: 1-800-362-3002
VERMONT– Medicaid WYOMING – Medicaid
Website: http://www.greenmountaincare.org/
Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/
Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP
Medicaid Website:
http://www.coverva.org/programs_premium_assistance.
cfm
Medicaid Phone: 1-800-432-5924
CHIP Website:
http://www.coverva.org/programs_premium_assistance.
cfm
CHIP Phone: 1-855-242-8282