HIPP

Instructions

What is HIPP?

The Health Insurance Premium Payment (HIPP) Program pays for health insurance premiums when the MO HealthNet Division (MHD) determines it costs less to buy health insurance to cover medical care than MO HealthNet to pay for the care as a primary payor. HIPP pays the health insurance premiums for certain Medicaid-eligible individuals (or their families). The goal is to reduce overall costs for both the member and MO HealthNet.

Who Can Apply?

Someone in your household must be MO HealthNet eligible and currently covered
Someone in your household must have access to health insurance from another source (e.g. employer-based policies, personal policies, credit unions, church affiliations, labor unions, memberships in organizations)

Who is Not Eligible?

MO HealthNet participants are not eligible for the HIPP program if they are:

covered by a Managed Care Plan
are eligible for or enrolled in Medicare
if the policy is court-ordered

What Does It Cover?

HIPP pays for premiums, copays, coinsurance and deductibles for health insurance available from another source (e.g. employer-based policies, personal policies, credit unions, church affiliations, labor unions, memberships in organizations).

How to Apply

Complete and submit the application form and include a copy of the policy information.

Questions?

HIPP may be contacted at (573) 751-2005.

Section 1. Policyholder Information

Does anyone in your household have access to health insurance through a source other than MO HealthNet?

Yes

Applied

Important: If you answered no, then you are not eligible for HIPP. Do not complete the rest of the form.

Policyholder First Name

Policyholder Last Name

Policyholder Name

Policyholder Social Security Number

Phone Number

Street Address

City

State

Zip

Section 2. Health Insurance Information

Health Insurance Name

Health Insurance Phone Number

Claim Mailing Address

City

State

Zip

Health Insurance Policy Number

Health Insurance Policy Group Number

Important: You must submit copies of the front and back of your health insurance cards, schedule of benefits, or summary of coverage that describes the policy. The application cannot be processed without this information.

Section 4: List All Persons That Can Be Covered Under the Policy Including Policyholder

Name

Birthdate

Are you enrolled with MO HealthNet?

Yes

App

Social Security #

DSS DCN or  MO HealthNet ID #

Section 5: Care Coordinator Information (For Individuals with HIV/AIDS only)

Signature of Care Coordinator (if applicable)

Date

Care Coordinator Agency/Affiliation

Phone Number

Title

Section 6: Signature

My signature below guarantees that my answers on this form are correct, true and complete to the best of my knowledge. I authorize insurers and employers to release any information on myself or my dependent(s) needed to determine eligibility for the HIPP program.

I have agreed to submit this application by electronic means. By signing this application electronically, I certify under penalty of perjury that all declarations made in this eligibility statement are true, accurate, and complete, to the best of my knowledge, for each household member for whom I am applying, including the information concerning citizenship and alien status. I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.

Signature of Policyholder

Date

If you are a Veteran in the state of Missouri and are interested in learning more about benefits and resources available to you and your dependents, visit mvc.dps.mo.gov/MoVeteransInformation/Survey/DSS.

Please attach supporting documents, such as a copy of the front and back of your current health insurance card and your schedule of benefits or summary of coverage that explains your health plan policy

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APPLICATION FOR HEALTH INSURANCE PREMIUM PAYMENT (HIPP) PROGRAM