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State of Montana
DPHHS-HCS-272A
Department of Public Health and Human Services (DPHHS)
(Rev 12/13)
Health
Coverage
Renewal Form
06/06/2022
Respond by: 07/11/2022
Case number:
Renew Your Benefits – Due [DATE]
You are currently receiving health coverage through Medicaid/Healthy
Montana Kids. Your benefits will end if you do not complete this renewal.
• Call 1-888-706-1535 (TTY: 711). The call is free.
How to
complete your
• Go to apply.mt.gov and click Sign In/Create Account.
To create an account, you will need the case number on the top right of this page.
renewal
If neither of the above options are possible, please follow these steps:
1. Answer all the questions on the form.
2. Read the information we have filled in about you and each member of
your household. Make sure you give us information about every
person living in your household orlisted on your tax return. Add any
missing information. Cross out any information that isn’t right and
write in the correct information.
3. Sign and date the form at the bottom of Section 12.
4. Return the form to us by one of these ways:
• Mail to:
DPHHS
PO Box 202925
Helena, MT 59620-2925
• Fax: 1-877-418-4533
• Drop off at your local OPA: To find anoffice near you, visit
https://dphhs.mt.gov/hcsd/OfficeofpublicAssistance
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 1 of 18
.
What happens next
We will review the information you give us and see if you still qualify for
Medicaid/Healthy Montana Kids. We will send you a letter with our final
decision. We will check your answers using information from computer
data sources, including the Social Security Administration, the
Department of Homeland Security and others. If the information does not
match, we may ask you to send more information.
If you no longer qualify, we will tell you at least 10 days before your
coverage ends. We will also tell you about other affordable health
coverage you might qualify for through HealthCare.gov, and we will send
your information to them. We will tell you how you can get help signing
up.
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 2 of 18
Mailing address:
Apartment #:
City (mailing):
State:
ZIP code:
Best phone number to reach you:
Home Cell Work
Number:
Other phone number, if you have one:
Home Cell Work
Number:
EXAMPLE
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1
Your contact information
Review your contact information here Correct any wrong or missing information here.
Name (first, middle, last & suffix):
Home address:
Apartment #:
City (home):
State:
ZIP code:
Email address, if you have one:
2
We need information about who files tax returns
You can still renew if you do not file tax returns
Will anyone
in the household file a federal tax return next year to report income earned this year?
Yes If yes, answer all of the questions below
No If no, answer the question marked with a star * below
Person
1: Name (first, middle, last & suffix)
If
this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
Person 2: Name (first, middle, last & suffix)
This is a second tax filer in the household
If this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
*
If anyone will be claimed as a dependent on someone else's tax return, write the name of the tax filer and the dependents. Answer
only if different than what you reported above or if you did not fill in any information above
Name of tax filer:
Name of dependents:
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 3 of 18
Person 2
Check here if this
DPHHS has this person’s Social Security number.
person is no longer
DPHHS does not have this person’s Social Security number. Write it in the spaces below.
_ _ _ - _ _ - _ _ _ _
living in the
household
If this person is an immigrant, for their immigration status:
You need to fill in the information below. You do not need to fill in the information below because DPHHS has it.
Check here if this person has eligible immigration status and fill in the document type:
and ID number: See Attachment D for more information about eligible immigration status and document types.
EXAMPLE
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1
These are the people in your household who
3
get health coverage and need to renew now
Person
Check here if this
DPHHS has this person’s Social Security number.
person is no longer
living in the
DPHHS does not have this person’s Social Security number. Write it in the spaces below.
household
_ _ _ - _ _ - _ _ _ _
If this person is an immigrant, for their immigration status:
You need to fill in the information below. You do not need to fill in the information below because DPHHS has it.
Check here if this person has eligible immigration status and fill in the document type:
and ID number: See Attachment D for more information about eligible immigration status and document types.
We need more information about people not listed in Section 3
4
Tell us about anybody else in your household or on your tax return.
Other person: Name (first, middle, last & suffix):
DPHHS has this person’s Social Security number.
Check here if this person is no longer living in the household.
DPHHS does not have this person's Social Security Number
Write it here if this person is applying for health insurance coverage:
Date of birth (month/day /year):
_ _ _ - _ _ - _ _ _ _
This person is: Male Female
This person may choose not to give the Social Security number if he or
she is not applying, but it helps us to have it.
How is this person related to you? Self
Check here if this person has health coverage
Check here if this person wants health coverage and fill out Attachment A
Other person: Name (first, middle, last & suffix):
DPHHS has this person’s Social Security number.
Check here if this person is no longer living in the household.
DPHHS does not have this person's Social Security Number
Date of birth (month/day /year):
Write it here if this person is applying for health insurance coverage:
This person is:
Female
Male
_ _ _ - _ _ - _ _ _ _
How is this person related to you? Spouse of
This person may choose not to give the Social Security number if he or
she is not applying, but it helps us to have it.
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 4 of 18
DPHHS has this person’s Social Security number.
DPHHS does not have this person s Social Security Number
Write it here if this person is applying for health insurance coverage:
_ _ - _ _ - _ _ _ _
person may choose not to give the Social Security number if he or
is not applying, but it helps us to have it.
Check here if this person is no longer living in the household.
Date of birth (month/day /year):
This person is: Male Female
How is this person related to you?
EXAMPLE
Check
here
if
this
person
has
health
coverage
Ii]
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Check here if this person wants health coverage and fill out Attachment A
Other person: Name (first, middle, last & suffix):
DPHHS has this person’s Social Security number.
Check here if this person is no longer living in the household.
DPHHS does not have this person's Social Security Number
Write it here if this person is applying for health insurance coverage:
_ _ _ - _ _ - _ _ _ _
This
person may choose not to give the Social Security number if he or
she
is not applying, but it helps us to have it.
Date of birth (month/day /year):
This person is: Male Female
How is this person related to you?
Check here if this person has health coverage
Check here if this person wants health coverage and fill out Attachment A
Other person: Name (first, middle, last & suffix):
'
_
This
she
Check here if this person has health coverage
Check here if this person wants health coverage and fill out Attachment A
Other person: Name (first, middle, last & suffix):
DPHHS has this person’s Social Security number.
Check here if this person is no longer living in the household.
DPHHS does not have this person's Social Security Number
Write it here if this person is applying for health insurance coverage:
Date of birth (month/day /year):
_ _ _ - _ _ - _ _ _ _
This person is: Male Female
This
person may choose not to give the Social Security number if he or
she
is not applying, but it helps us to have it.
How is this person related to you?
Check here if this person has health coverage
Check here if this person wants health coverage and fill out Attachment A
Tell us about other health insurance coverage people have
5
Include anyone in Sections 3 and 4 with health coverage and anyone who is applying for health insurance
coverage. Please update any information about health insurance (other than Medicaid) that is no longer
correct, and cross out any information that is no longer valid
If any household members have new health insurance coverage, please provide information below
Name of insurance company: Policy number:
Address: Group number:
Policy Holder Name:
SSN:
Type of
insurance:
Medicare
COBRA Continuation
Tricare Veteran's health coverage
Group
Individual Student Other Health Coverage
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 5 of 18
Check here if anyone on this form is offered health insurance through a job, even if they are not enrolled
in it.
Check here if any of the insurance plans you listed is a state employee benefit plan.
6
Tell us more about the people listed on this form
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is blind or terminally ill, write his or
name here.
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
EXAMPLE
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Yes No If yes, name of employer:
Is this insurance provided by an employer?
List everyone who is on this policy:
If anyone who is renewing or applying for health insurance coverage has a medical, mental health, or
substance use condition that limits his or her ability to work, go to school, or take care of daily activities
(like bathing or dressing), write his or her name here.
If anyone who is renewing or applying for health insurance coverage lives in a long term care facility, group
home, or nursing home, or regularly gets medical care, personal care, or health services at home or in
another community setting (like adult day care), write his or her name here.
her
If anyone who is renewing or applying for health insurance coverage is between the ages of 18 and 22 and
is also a full-time student, write his or her name here.
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone who is renewing or applying for health coverage enrolled for credit in any Montana university
system unit, a tribal college, or any other accredited college within Montana offering at least an associate
degree, write his or her name here.
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone in your household has been discharged from US Military services within the last 12 months, write
his or her name here.
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 6 of 18
pregnant, write her information below.
7
EXAMPLE
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Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is between the ages of 18 and 26 and
was in foster care at age 18, write his or her name here.
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone listed on this form (whether renewing or applying for health insurance coverage or not) is
Names (first, middle, last & suffix):
How many babies are expected and due date?
Names (first, middle, last & suffix):
How many babies are expected and due date?
If anyone who is renewing or applying for health insurance coverage is disabled, write his or her name here
Names (first, middle, last & suffix):
Names (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is disabled and under age 22
attending school
Names (first, middle, last & suffix): Name of the School -
How many hours in a week do they attend?
Names (first, middle, last & suffix): Name of the School -
How many hours in a week do they attend?
Check here if we may forward this application to Children's Special Health Services if a child in your
family has been diagnosed with a medical condition (e.g. asthma, cleft palate, diabetes).
Condition(s)
Names (first, middle, last & suffix):
Check here if you would like information sent to you if a child in your family needs or receives treatment
for a Serious Emotional Disturbance (SED).
Names (first, middle, last & suffix):
Check here if anyone who is renewing or applying for health insurance coverage is an American Indian
or Alaska Native, and fill out Attachment B.
Tell us about work
Fill in the information below for everyone in your household or on your tax return who has income from a job
(not self employed) whether or not they are renewing or applying for coverage. If someone has more than
one job, tell us about all jobs. You can tell us about self-employment on the next page.
Make a copy of this page if you need space for more jobs or people. Cross out any information that is not
correct about members of your household. Write in any new information.
Job 1
: Name of the person who is working (first, middle, last & suffix):
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 7 of 18
Yearly
Monthly
Weekly
Yearly
Monthly
Weekly
City:
State:
ZIP code:
much does this person get paid (before taxes)?
Average hours worked each week:
EXAMPLE
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Employer name:
Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid? Hourly Every two weeks
Monthly
Weekly
Twice a month
How much does this person get paid (before taxes)?
Yearly
Average hours worked each week:
Job 2
: Name of the person who is working (first, middle, last & suffix):
Employer name: Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid? Hourly Every two weeks
Twice a month
How much does this person get paid (before taxes)?
Average hours worked each week:
Job
3
: Name of the person who is working (first, middle, last & suffix):
Employer name:
Employer phone number:
Employer address:
How often are wages or tips paid? Hourly Every two weeks
Twice a month
How
List anyone in your household who has changed jobs or has worked fewer hours in the past four months.
1. Name (first, middle, last & suffix):
This person stopped working This person is now working fewer hours This person changed jobs
2. Name (first, middle, last & suffix):
This person stopped working
This person is now working fewer hours
This person changed jobs
If anyone in your household is self-employed, we need to know about their work.
See the instructions below for more information about deductions.
Cross out any information that is not correct about members of your household. Write in any new information
1 Name (first, middle, last & suffix):
Type of work:
Business Name:
How much net income will this person get from self-employment this month? Amount:
Subtract the expenses below from your gross income to get an amount for your net self-employment income.
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 8 of 18
• Car and truck expenses (for travel during the workday, not commuting)
• Depreciation
• Employee wages and fringe benefits
• Property, liability, or business interruption insurance
• Interest (including mortgage interest paid to banks, etc.)
• Legal and professional services
• Rent or lease of business property and utilities
Commissions, taxes, licenses and fees
• Advertising
• Contract labor
• Repairs and maintenance
• Certain business travel and meals
• Deductible self-employment taxes
• Cost of self-employed health insurance
• Contributions to a self-employed SEP, SIMPLE, or
qualified retirement plan
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 9 of 18
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Tell us about other income
8
Cross out any information that is not correct about members of your household. Write in any new information.
Unemployment How much? How often?
Name (first, middle, last & suffix):
Source:
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Social Security
How much?
How often?
Name (first, middle, last &
suffix):Source:
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Pensions
How much?
How often?
Name (first, middle, last & suffix):
Source:
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Retirement accounts How much? How often?
Name (first, middle, last & suffix):
Source:
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Railroad Retirement Accounts
How much? How often?
Name (first, middle, last & suffix):
Source:
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Alimony Received How much? How often?
Name (first, middle, last & suffix):
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Farming/Fishing(Profit after business exp)
How much? How often?
Name (first, middle, last & suffix):
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Rental income or Royalties(Profit after bus exp)
How much?
How often?
Name (first, middle, last & suffix):
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
Other income type How much? How often?
Name (first, middle, last & suffix):
Weekly
Monthly
Every two weeks
Twice a month
Yearly
Other
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 10 of
Other deductions How much? How often?
Name (first, middle, last & suffix):
Weekly Every two weeks Yearly
Monthly Twice a month Other
Weekly
Every two weeks Yearly
Monthly
Twice a month Other
Owner’s Name:
Full Value:
Percent Own:
Resource Type:
Tell us about resources
9
Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:$
Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:$
Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:$
EXAMPLE
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If anyone in your household has deductions, tell us what kind. Cross out any information that is not correct.
Write in any new information
Student loan interest paid How much? How often?
Alimony paid to someone else How much?
Name (first, middle, last & suffix):
How often?
Weekly
Every two weeks Yearly
Monthly Twice a month Other
Name (first, middle, last & suffix):
List the names of anyone whose income changes from month to month. Also tell us how much you think their
income will be for the year. Make a copy of this page if you need space for more people
1.
Check here if you do not know what the income will be this year.
2.
Check here if you do not know what the income will be this year.
3.
Check here if you do not know what the income will be this year.
General Resources
(including bank accounts, cash, property, trusts, life insurance, stocks, etc.)
Please update any resource information that is no longer correct. Cross out any resources that you no longer
own, and enter any new resources in the blank lines. Remember to provide current verification of resources
listed below.
Applicable For -
Resource Type:
Description:
Description:
Owner’s Name:
Full Value:
Percent Own:
Resource Type:
Description:
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 11 of 18
Full Value: Percent Own: Amount Owed:
How Often Paid: Amount: Date Last Paid:
Vehicle Use:
Owner’s Name:
Value:
Amount Owed:
Resources Transferred
Percent Own:
Tell us about expenses
10
EXAMPLE
Owner’s Name:
Full Value: Percent Own:
Vehicles
(including cars, trucks, motorcycles, boats, snowmobiles, All Terrain Vehicles (ATV), trailers,
campers, etc.)
Please Update any vehicle information that is no longer correct. Cross out any vehicles that you no longer
own, and enter any new vehicles in the blank lines.
Applicable For -
Vehicle Year/Make/Model/Type:
Vehicle Use:
Owner’s Name:
Vehicle Year/Make/Model/Type:
Vehicle Use:
Owner’s Name:
Full Value:
Percent Own:
Amount Owed:
Vehicle Year/Make/Model/Type:
Full
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No
Question
Yes
1. Did you or your spouse sell, trade, or give away money, vehicles, property (including your home) or anything of value in
the past 60 months?
2. Did you or your spouse transfer any assets to a trust in the past 60 months?
3. Did you or your spouse forgive a debt owed to you in the past 60 months?
If you answered "Yes" to any question, please explain:
Child Support, Dependent Care, and Alimony Expenses That You Pay
Please update any
expenses that are no longer correct, and cross out any expenses that are no longer paid. This includes any
payments made for a dependent outside of the home. Enter any new expenses in the blank lines provided.
Applicable For -
Type of Expense:
Who Pays Expense:
Who is it Paid For:
Shelter and Utility Expenses That You Pay
Please update any shelter and utility expenses that are no
longer correct, and cross out any expenses that are no longer paid. Enter any new shelter/utility expenses in
the blank lines provided.
Applicable For -
Type of Expense:
Who Pays Expense:
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 12 of 18
Tell us about Medicare
11
Amount:
How Often Paid:
Date Last Paid:
EXAMPLE
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Amount: How Often Paid: Date Last Paid:
Blind and Disabled Expenses That You Pay
Please update expenses that are no longer correct, and
cross out any expenses that are no longer paid. Enter any new expenses in the blank lines provided.
Applicable For -
Type of Expense:
Who Pays Expense:
Amount:
How Often Paid:
Date Last Paid:
Medical Expenses That You Pay
Please update expenses that are no longer correct, and cross out any
expenses that are no longer paid. Enter any new expenses in the blank lines provided.
Applicable For -
Type of Expense:
Who Pays Expense:
Medicare Information
this includes information about enrollment in Medicare Part A, Part B, or Railroad
Retirement coverage.
Please update any Medicare information that is no longer correct, and cross out any information that is no
longer valid. Enter information about any new Medicare coverage in the blank lines provided.
Applicable For -
Medicare Number:
Who is Enrolled:
Type of Coverage:
Medicare Status:
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 13 of 18
Yes, I give the Marketplace permission to check my income on tax returns (check one box):
5 years (the longest time) 4 years 3 years 2 years 1 year
No, I do not give permission to use my tax returns.
Date:
EXAMPLE
Read and sign this application
12
Renewal of coverage in future years
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Read the statement below and check one box.
To make it easier to check my income at renewal time for coverage in future years, other than health
coverage, I give permission to the Marketplace to use income information from my tax returns for the number
of years I checked below.
for
Your rights and responsibilities
• I am signing this renewal form under penalty of perjury. That means
that have provided true answers to all the questions on this form to
the best of my knowledge, and I know that I may be subject to
penalties under federal law if I provide false or untrue information.
• I know that I must tell DPHHS if anything changes and is different
from what I wrote on this form. I can call 888-706-1535 to report
any changes. I understand that a change in my information might
affect whether someone in my household qualifies for coverage.
• If I think DPHHS has made a mistake, I can appeal its decision. To
appeal means to tell someone at DPHHS that I think the action is
wrong, and ask for a fair review of the action. I know that I can find
out how to appeal by contacting DPHHS at 888-706-1535.
Voter's Registration
If you are not registered to vote where you live now, would you like to register to
vote? Yes No
If you do not check Yes or No, we will assume you have decided
not to register to vote at this time. If you would like help filling out a
voter registration application form, we will help you. The decision
whether to seek or accept help is yours. You may fill out the
application form in private. Applying to register or declining to
register to vote will not affect your eligibility or benefits
If you believe that someone has interfered with your right to:
1. register to vote, or
2. decline to register to vote, or
3. privacy in deciding whether to register or in applying to register to vote, you may
file a complaint with the Secretary of State, PO Box 202801, Helena MT
59620-2801.
Telephone number: 1-406-444-7911
• I understand that if I do not qualify for health coverage, DPHHS will
send my information to the Marketplace so they can see if I qualify.
DPHHS will check my answers using information from computer data
sources, including the Social Security Administration, the Department
of Homeland Security and others. If the information does not match,
DPHHS may ask me to send more information.
• I understand that, after my death, DPHHS can file a claim against my
estate to recover money that the state paid for coverage provided to
me. This process must happen if I am in a medical institution and not
expected to return home, or if I am 55 years of age or older and the
state pays for my nursing facility services, home and community based
services, or related hospital and prescription drug services. The
amount recovered by the DPHHS will not be more than the amount
Medicaid paid for my care.
• I understand that when I send in this form, it means I have permission
from everyone whose information is on the form to submit their
information to DPHHS and receive any communications about their
eligibility and enrollment.
• I understand that DPHHS is authorized to collect information on this
form, and other supporting information including Social Security
numbers, under the Patient Protection and Affordable Care Act (Public
Law No. 111-148), as amended by the Health Care Education
Reconciliation Act of 2010 (Public Law 111-152) and the Social
Security Act.
• I know that under federal law, discrimination is not permitted on the
basis of race, color, national origin, sex, age, sexual orientation,
gender identity, marital status or disability. I can file a complaint of
discrimination by visiting hhs.gov/ocr/office/file.
Please check if you are interested in
receiving a discount on your telephone bills if
you are approved for Medicaid.
Sign and date below. If you want an authorized representative or want to change the authorized
representative you have now, fill out Attachment C.
Check here if you are an authorized representative.Sign below and fill out Attachment C.
Signature of household contact or authorized representative:
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 14 of 18
No If no, answer all of the questions below.
Check here, if this person has eligible immigration status and fill in the document type:
ID number: See Attachment D for more information about eligible immigration status and document types.
Name of the person applying:
Tell us about citizenship
EXAMPLE
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e
_
..
__
,
__
People applying for health coverage for the first time
For people listed in Section 4
Attachment A
Tell us about anyone in your household who wants to apply for health coverage. Do not answer these questions
for people who already have health coverage. If more than two people are applying, make a copy of this page.
Name (first, middle, last & suffix)
Name of the person applying:
Tell us about citizenship
Is this person a U.S. citizen or U.S. national?
Yes If yes, go to "Tell us more information about this person"
and
Check here, if this person has lived in the U.S. since 1996.
Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military.
Tell us more information about this person
Check here, if this person lives with at least one child under the age of 19, and is the main person taking care of this child.
Check here, if this person is 18 years or younger and has a parent living outside of the household.
Check here, if this person wants help paying for medical bills from the last three months.
Tell us about race and ethnicity. You may choose not to answer these questions. This answer will not be
used to make a decision about your eligibility, but will help determine your out-of-pocket expense.
If this person is Hispanic/Latino, check all that What is this person's race? Check all that apply:
White Asian Indian Korean Guamanian or Chamorro
apply:
Black or African Chinese
Vietnamese Samoan
Mexican Mexican American
American Filipino Other Asian Other Pacific Islander
Chicano/a Puerto Rican
Cuban
American Indian Japanese Native Hawaiian Other
or Alaska native
Other
Name (first, middle, last & suffix)
Is this person a U.S. citizen or U.S. national? Yes If yes, go to "Tell us more information about this person"
No If no, answer all of the questions below.
Check here, if this person has eligible immigration status and fill in the document type:
and
ID number: See Attachment D for more information about eligible immigration status and document types.
Check here, if this person has lived in the U.S. since 1996.
Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military.
Tell us more information about this person
Check here, if this person lives with at least one child under the age of 19, and is the main person taking care of this child.
Check here, if this person is 18 years or younger and has a parent living outside of the household.
Check here, if this person wants help paying for medical bills from the last three months.
Tell us about race and ethnicity. You may choose not to answer these questions. This answer will not be
used to make a decision about your eligibility, but will help determine your out-of-pocket expense.
If this person is Hispanic/Latino, check all that
apply:
Mexican Mexican American
Chicano/a Puerto Rican
Cuban Other
What is this person's race? Check all that apply:
White Asian Indian Korean Guamanian or Chamorro
Black or African Chinese Vietnamese
Samoan
American Filipino Other Asian
Other Pacific Islander
American Indian Japanese Native Hawaiian
Other
or Alaska native
If anyone applying for Medicaid has medical bills from the last three months, send the medical bills to DPHHS, PO Box 202925, Helena, MT
59620-2925. Medicaid may help pay past bills.
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 15 of 18
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
no, does this person qualify to get these services?
Yes
No
EXAMPLE
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American Indian or Alaska Native family member (AI/AN)
To help you fill out Section 6
Attachment B
Tell us about your American Indian or Alaska Native family member(s)
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health
programs. They may not have to pay co-pays and may get special monthly enrollment periods.
If more than two people are American Indian or Alaska Native, make a copy of this page.
1. Name (first, middle, last & suffix):
If
List any income that includes money from these sources:
• Payments from a tribe for natural resources, usage rights, leases, or royalties
• Payments from natural resources, farming, ranching, fishing, leases, or royalties from land
designated as Indian trust land by the Department of Interior (including reservations and
former reservations)
• Money from selling things that have cultural significance
• Money from tribally managed gaming income
2. Name (first, middle, last & suffix):
How much income?$
How often?
Weekly Twice a month
Every two weeks Yearly
Monthly
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
If no, does this person qualify to get these services?
Yes
No
List any income that includes money from these sources:
• Payments from a tribe for natural resources, usage rights, leases, or royalties
• Payments from natural resources, farming, ranching, fishing, leases, or royalties from land
designated as Indian trust land by the Department of Interior (including reservations and
former reservations)
• Money from selling things that have cultural significance
• Money from tribally managed gaming income
How much income?$
How often?
Weekly Twice a month
Every two weeks Yearly
Monthly
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 16 of 18
If yes, has any of his or her information changed?
Yes No
Date:
signature:
Home
Phone number:
Number:
ZIP code
City
State
Address:
Home
Phone number:
Number:
ZIP code
City
State
Address:
EXAMPLE
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Assistance with completing this application
Attachment C
An authorized representative is a trusted friend, partner, relative or lawyer you choose to sign your renewal form,
get information about this renewal form, and act for you with this agency.
If you have an authorized representative now, please answer these questions.
We show that you chose this person as your authorized representative:
Do you still want this person to be your authorized
representative?
Yes No
If your authorized representative's information has changed, or if you would like a different authorized representative, please write the new
information here:
Name of authorized representative:
Apartment #
Cell Work Other
By signing, you allow this person to sign your renewal form, to get information about this renewal form, and to act for you with this agency.
Your signature:
Date:
If you do not have an authorized representative and want one, please answer these questions.
Check here if you want an authorized representative. Answer the questions below.
Apartment #
Cell Work Other
By signing, you allow this person to sign your renewal form, to get information about this renewal form, and to act for you with this agency.
Your
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 17 of 18
Paroled into the U.S.
Conditional entrant granted before 1980
Battered spouse, child and parent
Victim of Trafficking and his/her spouse, child, sibling or parent
Granted Withholding of Deportation or Withholding of Removal, under
the immigration laws and under the Convention against Torture (CAT)
vidual with Non-immigrant Status (includes worker visas,student visas,
and citizens of Micronesia, the Marshall Islands, and Palau)
Temporary Protected Status (TPS) and Applicant for Temporary
Protected Status (TPS)
Deferred Enforced Departure (DED)
Family Unity beneficiary
Deferred Action Status (Deferred Action for Childhood
Arrivals (DACA) is not an eligible immigration status for applying for health
insurance
Immigration document types
Removal, under the immigration laws or under the
Convention against Torture (CAT)
• Registry Applicants (with Employment Authorization)
• Order of Supervision (with Employment Authorization)
• Applicant for Cancellation of Removal or Suspension of
Deportation (with EAD Employment Authorization)
• Applicant for Legalization under IRCA
(with Employment Authorization)
• Legalization under the LIFE Act (with Employment
Authorization)
• Lawful Temporary Resident
• Member of a federally-recognized Indian tribe or American
Indian Born in Canada
• Resident of American Samoa
• Administrative order staying removal issued by the
Department of Homeland Security
EXAMPLE
►
►
MONTANA
Attachment D
Eligible immigration status list
Helpful information about immigration status and document types to
help you fill out Section 3
If you see the person's status below, go back to Section 3 and check the Yes box
• Lawful Permanent Resident (LPR or Greencard holder)
• Asylee
• Refugee
• Cuban or Haitian entrant
•
•
•
•
•
• Indi
•
•
•
•
•
• Applicant for Special Immigrant Juvenile Status
• Applicant for Adjustment to LPR Status
• Applicant for Asylum
• Applicant for Withholding of Deportation or Withholding of
People who are not citizens, but who are eligible to apply for health insurance coverage, must put their immigration documents and ID numbers
on Section 3. A list of documents and ID numbers is below. If your document type is not listed, you can write the document name. If you have
questions, or are eligible but have no document, call 1-888-706-1535.
• Alien registration number
Permanent Resident Card (I-551, also known as Green Card)
• Alien registration number
• Card number
Temporary I-551 Stamp (on passport or I-94, I-94A)
• Alien registration number
Immigrant Visa (with temporary I-551 language)
• Alien registration number
• Passport number
Employment Authorization Card (EAD or I-766)
• Alien registration number
• Card number
• Expiration date
• Category code
Arrival/Departure Record (I-94 or I-94A)
• I-94 number
Arrival/Departure Record in foreign passport (I-94)
• I-94 number
• Passport number
• Expiration date
• Country of issuance
Foreign passport
• Passport number
• Expiration date
Country of issuance Reentry Permit (I-327)
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 18 of 18
Refugee travel document (I-571)
• Alien registration number
Certificate of Eligibility for Nonimmigrant (F-1) Student Status
(I-20)
• Alien registration number or an I-94 number
• Description of the type or name of the document
Certificate of Eligibility for Exchange Visitor (J-1) Status
(DS2019)
• SEVIS ID
Notice of Action (I-797)
• Alien registration
number or an I-94 number
Other
• Alien registration number or an I-94 number
• Description of the type or name of the document
You can also list these documents or statuses:
• Document indicating a member of a federally
recognized Indian tribe or American Indian born in
Canada This is considered an eligible immigration
status for Medicaid/HMK, but not for a Qualified Health
Plan [QHP]
• Office of Refugee Resettlement (ORR) eligibility letter (if
under 18)
• Document indicating withholding of removal
• Administrative order staying removal issued by the
Department of HomelandSecurity (DHS)
• Certification from U.S. Department of Health and
Human Services (HHS)Office of Refugee
Resettlement (ORR)
• Cuban/Haitian entrant
• Resident of American Samoa
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 19 of 18
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MONTANA
EXAMPLE
Questions?
Call the Montana Public Assistance Helpline at 1-888-706-1535. The call is free.
(TTY: 711). You can call Monday - Friday, 8:00am - 5:00pm Mountain Time.
Page 20 of 18
