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Form 100 (Rev. 02/2014) Document No. 350701-14-0 7 -0 2 D ELAWARE H EALTH AND S OCIAL S ERVICES (DHSS) A PPLICATION FOR F OOD B ENEFITS , C ASH , M EDICAL , AND C HILD C ARE A SSISTANCE Welcome to the State of Delaware Health and Social Services (DHSS) Apply faster online Apply faster online at www.assist.dhss.delaware.gov This includes anyone wishing to apply for Medical Assistance only. Who can use this application?  Use this application to apply for anyone in your home including an y tax dependents who are out of the ho me.  Apply even if you or your child already has health coverage. You co uld be eligible for lower-cost or free cove rage.  Families that include immigrants can apply. You can apply for your chil d even if you aren’t eligible. Applying won’t affect your immigration status or chances of becoming a permanent resident or citi zen.  If someone is helping you fill out this application, you ma y need to complete Appendi x C.  If applying for Medical Assistance only, you may be able to us e a short form. What you may need to apply  Social Security Numbers (or document numbers for an y legal immigr ants)  Employer and income information for everyone in your household (for example, from paystubs, W-2 forms, or wage and tax statement s)  Policy numbers for any current health insu rance  Information about any job-related health insurance available to your family. You may need to complete Appendix A. Why do we ask for this information? We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We'll keep all the information you provide private and secure, as required by law. What happens next? Please use the stamped self-addressed env elope to mail your signed application. If you don’t have all the information we ask for, sign and submit your application anyway. We’ll follow-up with you. You’ll get instructions on the next steps. If you don’t hear from us, call 1-800-372-2022. Get help with this application  Phone: Call our Customer Relations Unit at 1-800-372-2022 .  In person: There may be social workers/case managers in your ar ea who can hel p.  En Español: Llame a nuestro centro de ayuda gratis al 1-866-843-7212.  In a language other than English: Call 1-866-843-7212 .  TTY users: Call 711 or 1-800-232-5460. Form 100 (Rev. 02/2014) 1 D ELAWARE H EALTH AND S OCIAL S ERVICES (DHSS) A PPLICATION FOR F OOD B ENEFITS , C ASH , M EDICAL , AND C HILD C ARE A SSISTANCE Welcome to the State of Delaware Health and Social Services (DHSS) We help Delawareans in need by providing food benefits, m edical, child care, and cash assistance. We can provide information about other helpful services in your community . You can answer only the questions related to the program(s) you are applying for. If you answer ALL the questions on the Assistance A pplication, we can see if you are eligible for all programs. A friend or relative, or anyone that you wish, may help you complete this application. Your application is not complete until you sign the last page. Return the application to us. At your interview, you will need to show us:  Proof of who you are  Proof of child care costs (only for cash assistance)  Proof of your address  Proof of money you have received in the last 30 days STEP 1 Tell us about yourself. (We need one adult in the household to be t he contact person for your application.) For which program(s) are you applying?  Cash Assistance  Food Benefits  Medical Assistance  Child Care First Name, Middle Name, Last Name, & Suffix Home Address City State Zip Code Mailing Address (if different from Home Address) City State Zip Code Primary Telephone Secondary Telephone Preferred Methods of Contact I want to receive information about this application and future communication by: ☐ Email Address ☐ U.S. Mail E-Mail Address:________________________________________________________________________________________________ Preferred spoken or written language (if not English) If you wish to have someone else manage your case and act as your representative, please complete Appendix C. For Food Benefits, the day we get this first page of the application with your name, address, and signature sets the date benefits may start if you sign and return the completed application to DHSS within 30 days. __________________________________________________ __________________________ Applicant’s Signature (Required) Date __________________________________________________ _________________________ Authorized Representative’s Signature Date Form 100 (Rev. 02/2014) 2 D ELAWARE H EALTH AND S OCIAL S ERVICES (DHSS) A PPLICATION FOR F OOD B ENEFITS , C ASH , M EDICAL , AND C HILD C ARE A SSISTANCE Delaware’s Emergency Food Benefit If your household has little or no income right now, you may be able to receive emergency food benefits within 7 days from the day we receive your completed application . You may be able to get emergency food benefits in seven days if:  Your household expects to receiv e less than $150 in income this month  Your household does not have more t han $100 in cash or bank accounts  Your household is a migrant or seasonal farm worker household  Your household’s ren t, mortgage, and utilities are more than your household’s gross monthly income and liquid resources combined Delaware’s Food First Electronic Benefits Transfer (EBT) Card We issue food benefits on an EBT card. To use your food benefits, you must have an EBT card and a Personal Identification Number (PIN). When we approve your benefit s, our EBT vendor will mail your card to you if you never had one before. You can also go to a card issuance site to get your card. In each of the headings in this application, you will s ee program symbols. These symbols will help you to identify the questions you must answer for the program(s) you are requesting. Symbols Programs Terms Definition Medical Assistance Programs (doctors, hospitals, prescriptions, labs, and x-rays) - free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP) - affordable, private health insurance plans through the Marketplace - a new tax credit that can immediately help pay your premiums for health coverage Alien: A person who is not a U.S. citizen Child Care Assistance (help with the cost of child care) EBT card: E lectronic B enefit T ransfer—a plastic card that you use at a store to buy food. Cash Assistance - Temporary Assistance for Needy Families (TANF) - General Assistance (GA) – Refugee Cash Assistance (RCA) Eligible: Meeting all of the guidelines to get benefits. Food Supplement Program (help with monthly food expenses) Household: A person or a group of people who live together and buy food and fix meals together. Signature Required ABAWD: Able Bodied Adult Without Dependents—An adult aged 18 through 50 years old, without dependents, and physically able to work. Form 100 (Rev. 02/2014) 3 STEP 2 Tell us about yourself and the people in your household. Are you?  Single  Married  Divorced  Civil Union  Separated  Widowed  Unmarried Partnership Instructions Fill in the blocks for all of the people who liv e with you. If you are applying for me dical assistance and file taxes, we need to know about everyone on your tax return. Race: B = Black/African American W=White Ethnic Group: H=Hispanic/Latino PI = Native Hawaiian/Pacific Islander A=Asian N=Non-Hispanic/Latino I = American Indian/Alaskan Native (If an yone in your household is American Indian/Al askan Native, also complete Appendix B.) Last Name First Name, Middle Name Relation to you Are you applying for this person? Sex M/F Birth Date mm/dd/yyyy Social Security Number* Race/ Ethnic Group (optional) U.S. Citizen? Answer for applicants only. ** Self  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No  Yes  No  M  F  Yes  No *We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-07 78. ** Applies to applicants for health coverage only. Complete this section for legal alien applicants only. 1. Do applicants have eligible immigration status?  Yes. Complete the section below. Name Immigration Document Type Document ID number Have you lived in the U.S. since 1996? Are you or your spouse or parent a veteran or an active-duty member of the U.S. military? 2. Has anyone ever received cash, food, or child care assistance in another state?  Yes  No What benefits? _______________ Name of state? ________________ M onth/Year ________________________ 3. Has anyone ever been disqualified for cash or food assistance in another state?  Yes  No What benefits? ______________ _ Name of state? __________________ Month/Year ________________________ Form 100 (Rev. 02/2014) 4 4. Is anyone in your household in violation of pr obation or parole or fleeing prosecution?  Yes  No (Applies to TANF, food benefits, and general assistance.) 5. Has anyone been convicted of a drug felony after August 22, 1996?  Yes  No (Applies to TANF and general assistance.) 6. Have you or any member of your household been convic ted of trading food benefits for drugs after September 22, 1996? (Applies to food benefits.)  Yes  No 7. Have you or any member of your household been convic ted of buying or selling food benef its over $500 after September 22, 1996? (Applies to food benefits.)  Yes  No 8. Have you or any member of your household been convicte d of fraudulently receiving duplicat e food benefits in any state after September 22, 1996? (Applies to food benefits.)  Yes  No 9. Have you or any member of your household been convicte d of trading food benefits for guns, ammunitions, or explosives after September 22, 1996? (Applies to food benefits.)  Yes  No 10. Answer the questions below if a parent(s) of any child under 18 does not live in your household. Child’s Name Absent Parent’s Name Absent Parent’s Date of Birth Absent Parent’s Social Security Number Absent Parent’s Address Absent Parent’s Employer 11. Are there any children under the age 19 living in the household?  Yes  No If yes, fill in below. Parent or Caregiver’s Name Child’s Name STEP 3 Tell us about your health care. Is anyone in your household offered health coverage from a job (even if the coverage is from someone else’s job, such as a parent or spouse)? If yes, you’ll need to complete Appendix A.  Yes  No Is this a state employee benefit plan?  Yes  No Other than Medicaid does anyone in your household have health insurance or Medicare?  Yes  No If yes, provide the following information: Name of Policy Holder Name of Insurance Who is Covered Circle what is Covered Policy Number Doctor · Hospital · Lab Tests · X-rays Doctor · Hospital · Lab Tests · X-rays Doctor · Hospital · Lab Tests · X-rays 12. Name anyone in your household who is pregnant due date ___________________ How many babies are expected during this pregnancy? __________ 13. Name anyone who has a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, working, etc.) or live in a medica l facility or nur sing home _______________________________ . 14. Name anyone who was injured in the last 2 years (car accident, work related injury, medical malpractice, etc.). __________________________________________________________________________________________ Form 100 (Rev. 02/2014) 5 15. Does anyone plan to file a tax return for current year ?  Yes  No (You can still apply for medical assistance even if you don’t file a tax return. ) If yes, please fill in below and answer question A. If no, skip to question B. Name of Tax Filer Who will be claimed as a Tax Dependent A. Will anyone file jointly with a spouse?  Yes  No If yes , name of spouse: B. Will you be claimed as a dependent on someone’s tax return?  Yes  No If yes , please list the name of the tax filer and how you are related to the tax filer: 16. Do you want help paying for medi cal bills from the last 3 months?  Yes  No 17. Name anyone in your household who was in Delaware Foster Care at age 18 or older and received Delaware Medicaid Benefits: STEP 4 Tell us about the money people in your household get.  Employed  Not employed  Self-employed If anyone is currently employed, tell us about Skip to question 30. Skip to question 28. his or her income. Start with question 18.  CURRENT JOB 1 18. Please list the person’s name: 19. Employer name and address 20. Employer phone number ( ) – 21. Wages/tips/commission (before taxes)  Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly $ 22. Average hours worked each WEEK  CURRENT JOB 2 23. Please list the person’s name: ( If y our household has more j obs, attach another sheet of p a p er. ) 24. Employer name and address 25. Employer phone number ( ) – 26. Wages/tips/commission (before taxes)  Hourly  Weekly  Every 2 weeks  Twice a month  Monthly  Yearly $ 27. Average hours worked each WEEK  SELF-EMPLOYMENT 28. Please list the person’s name: 29. If self-employed, answer the following questions: a. Type of Work b. How much gross income will you get from this self-e mployment this month? $ c. How much net income (profits once business expenses are paid) will you get from this self-emp loyment this month? $ Form 100 (Rev. 02/2014) 6 ☐ CHANGE IN EMPLOYMENT 31. In the past year, did anyone:  Change jobs  Stop working  Start working fewer hours  None of these 32. Has anyone in your household quit a job in the last 30 days?  Yes  No If yes, employ er name ________________________________________________________________________ 33. Is anyone in your household a migrant or seasonal worker?  Yes  No If yes, who? ________________________________________________________________________________ 34. Is anyone in your household on strike?  Yes  No If yes, who? ________________________________________________________________________________ STEP 5 Which of the following do you have? Complete this section for Cash Assistance Only 35. Does anyone in your household have any vehicles (don’t include your car)?  Yes  No If yes, provide the following information: Make Model Year Amount Still Owed $ $ 30.  OTHER INCOME Where does the money come from? Who gets the money? How much do they get? How often are they paid? Social Security $ Supplemental Security Income (SSI) $ VA Benefits $ Pensions $ Retirement Accounts $ Unemployment Compensation $ Workers Compensation $ Child Support $ Alimony Received $ Work Study $ Money Earned from Interest or Dividends $ Net Farming/Fishing $ Net Rental/Royalty $ Other Income $ Complete questions 32 - 34 for Food Benefits Only Form 100 (Rev. 02/2014) 7 36. Does anyone have or own any land, buildin gs, or houses other than the one you live in?  Yes  No If yes, who owns it? __________________________________________________________________________ 37. Does anyone receive income from these properties?  Yes  No If yes, how much? $ __________________________________________________________________________ 38. Does anyone in your household have any of the following? Type of Account Yes or No Name on the account Account Number Balance Bank or Credit Union  Yes  No $ Stocks or Bonds  Yes  No $ Savings Certificates  Yes  No $ IRAs or Keogh  Yes  No $ Trust Funds  Yes  No $ Cash On Hand  Yes  No $ Other  Yes  No $ STEP 6 Tell us about your tax deductions .  Alimony paid $ _________ How often?  Student loan interest $ _________ How often? Type:  Other tax deductions* $ _________ How often? *For other potential deductions, refer to your current tax return form 1040 under the Adjusted Gross Income section. STEP 7 Tell us about your medical expenses . If you or anyone in your household has medical expenses and are age 60 or older, or blind, and/or receiving Federal disability benefits (SSA, SSI, VA), please list the name of the pers on and the amount of the medical expenses paid monthly. Name Name Hospitalization $ Hospitalization $ Prescription drugs $ Prescription drugs $ Doctor $ Doctor $ Eye Care $ Eye Care $ Dental $ Dental $ Insurance Premiums $ Insurance Premiums $ Transportation for medical care $ Transportation for medical care $ Other $ Other $ Check all that apply, and give t he amount and how often you pay it. If you pay for certain things that can be deducted on a tax return, telling us about them could make the cost of health coverage a little lower. NOTE: You shouldn’t include a cost t hat you already considered in y our answer to net self-employment (question 29c). Form 100 (Rev. 02/2014) 8 STEP 8 Tell us about your household expenses . Please tell us about your bills. (Copies of bills may be needed.) Shelter: What are your shelter expenses (ent er what you are required to pay)? 39. Rent: $ _______________ per month Is this Section 8, HUD or other rental assistance?  Yes  No Does your rent include meals (room and board)?  Yes $ ____________  No Or are you paying for meals only?  Yes $ ____________  No 40. Mobile Home Lot Rent $ _______________ per month 41. Mortgage/ Mobile Home $ _______________ per month 42. Second Mortgage or Home Equity Loan $ _______________ per month 43. Homeowner’s Insurance $ _______________ per month 44. Property Taxes $ _______________ per month 45. Special Assessment $ _______________ per month 46. Condominium/Association Fees $ _______________ per month Utilities: Check the boxes that apply and fill in the amount.  Electric $ ______________  Air Conditioning (central or window unit) $ ______________  Heat (gas, electric, oil, propane, wood, kerosene) $ ______________  Gas (cooking) $ ______________  Water/Sewer $ ______________  Trash $ ______________  Telephone $ ______________  HUD/WHA/DSHA (utility allowance ch eck) $ ______________  Excess Utilities Only $ ______________ Other: 47. Dependent Care Expenses?  Yes $ ____________  No 48. Legally-obligated Child Support Payments?  Yes $ ____________  No Form 100 (Rev. 02/2014) 9 Reporting and Verifying Expenses: Please be sure to enter all of your ex penses so that you can qualify for the full amount of food benefits that you need. If yo u do not put an expense down, we will not be able to count it as we decide the amount of aid to give you.  Shelter (rent/mortgage/lot) expenses;  Homeowner’s Insurance;  Real estate taxes;  Utility expenses (gas/electric/oil);  Water and sewage expenses;  Garbage expenses;  Phone expenses;  Medical expenses;  Dependent care expenses;  Child support expenses paid to children who do not live in your household. Do You Need Child Care? Please tell us why you need child care?  Working  High School or GED completion  Education/training (as part of DSS Employment & Training Program (E&T))  Health (explain): _______________________________________________________________________  Other (explain): ________________________________________________________________________ Child(ren)’s Name(s) Needing Child Care How many hours needed? Provider name, address and phone number Provider ID number DHSS Provider Or Self-arranged Date Care Began Is Anyone in Your Household in School? Complete this section for Cash Assistance, Food Supplement, and Child Care Only Complete the table for anyone in your hous ehold attending school, including trade school. Person(s) In School Name of School Full/Part Time Grade Expected Graduation Date if 16 or Older Form 100 (Rev. 02/2014) 10 Authorizations Authorization for Receipt of Pregnancy Prevention Information If you wish to receive information, you can call Planned Parenthood at 1–800–230–PLAN (7526). To get teen pregnancy information, call the Alliance for Adolescent Pregnancy Prevention at 1–800–499–WAIT (9248). You can also call the Delaware Helpline at 211 or 1–800–464–4357 for the Public Health Family Planning clinic in your area. Penalties For the Food Supplement, Cash and Medical Assistance Programs Although providing Social Security Numbers is voluntary, y ou understand that if you fail to give Social Security Numbers you or a member of your household may be denied se rvices. Your Social Security Number will be used to determine initial and ongoing eligibility. Non-lawful aliens ar e not required to give a Social Security Number. We will use your Social Security Number to check information in our records with other Federal, State, and Local agency computer matching systems. If you give us false information on purpose, we will take legal action against you. If you receive benefits that you should not get, you will be responsible to repay those benefits during your period of eligibility and after you are no longer receiving benefits. An individual will not be able to get Food Benefits or Cash Assistance if:  he/she is fleeing to avoid prosecution, custody or confinement after a conviction that is a felony, or  violating a condition of probation or parole imposed under a Federal or State law Penalties in the Cash Assistance Program Do Not give false information or hide information to get or continue to get Cash Assistance . If... You will ...  Any member of your household breaks a Temporary Assistance for Needy Families (TANF) rule on purpose  lose cash assistance for 12 months for the first violation  lose cash assistance for 24 months for the second violation  lose cash assistance permanently for the third violation  Any applicant or recipient gives false information in order to obtain benefits  be subject to penalties that include a fine of up to $500 and imprisonment up to 6 months  Any member of your household is found guilty of misrepresenting his or her place of residence in order to get multiple benefits in two or more states for the same month from programs funded under TANF  lose cash assistance for 10 years  Any member of your household is convicted of a felony for having, using, or selling controlled substances  lose cash assistance permanently Form 100 (Rev. 02/2014) 11 TANF Job Quit Penalties If an individual quits a job without good cause the entire TANF case will close for one month or until the individual meets work and training requirements for f our weeks in a row, whichever is later. TANF Work and Training Penalties When an individual does not comply with work and training the entire TANF case will close for one month or until the individual meets work and training requirements for four weeks in a row, whichever is later. Penalties in the Food Supplement Program If you... You will lose food benefits...  Hide information or make false statements  Use EBT cards that belong to someone else  Use food benefits to buy alcohol or tobacco  Trade or sell benefits or EBT cards  12 months for the first offense  24 months for the second offense and  permanently for the third offense  Trade food benefits for controlled substances, such as drugs  for 24 months for the first offense and  permanently for the second offense  Trade food benefits for firearms, ammunition or explosives  Permanently  Trade, buy or sell food benefits of $500 or more  Permanently  Give false information about who you are and where you live so you can get extra food benefits  10 years for each offense You can also be fined up to $250,000 or put in prison for up to 20 years or both, for doing these things. You may also be charged under Federal laws. The information you give us will be checked to make sure your household is eligible for food benefits and Cash Assistance. Federal, State, and Local officials will check the information you give us. The information you give us may also be checked by other Federal Aid programs and Federally-Aided State programs, such as School Lunch and Medicaid. If any inf ormation given is found to be incorrect, you may be denied Food Benefits/Cash Assistance. If you give false information on purpose, legal action may be taken against you. You may also have to pay back the amount of benefits you should not have received. For Food Benefits Nondiscrimination Statement The U.S. Department of Agriculture prohibits discri mination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual's income is derived from any public as sistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If y ou wish to file a Civil Rights program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Departm ent of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). Form 100 (Rev. 02/2014) 12 For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish or call the State Information/Hotline Numbers (c lick the link for a listing of hotline numbers by State); found online at http://www.fns.usda.gov/snap/contact_info/hotlines.htm. USDA is an equal opportunity provider and employer. For Cash Assistance, Medical Assistance, and Child Care Nondiscrimination Statement I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file . What You Need To Know About the Medical Assistance Program For the Food Supplement, Cash and Medical Assistance Programs I understand and agree :  I will apply for and accept other benefits that I may be eligible to get such as Unemployment Compensation, Social Security, or Medicare.  By law, as a condition of eligibility, I assign all rights to medical support and to payment for medical care from any third party to DHSS.  To allow DHSS, directly or through its agents or the Diamond State Health Plan or the Delaware Healthy Children Program, to have access to all medical and school-based health and related services records of every member of my household who is eligible for Medical Assistance. This will allow DHSS to administer the medical assistance program, coordinate care, determine medical necessity, and evaluate or pay for pending or incurred medical services.  I confirm that no one applying for medical assistance on this application is incarcerated (detained or jailed). If not, _______________________________ is incarcerated. I understand that I cannot receive Medical Assistance or CHIP benefits while incarcerated. We need this information to check your eligibility for help paying for medical assistance if you choose to apply. Your answers will be checked using information from electronic databases. If the information does not match, you may be asked to send proof. Renewal of coverage in future years To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time. Yes, renew my eligibility automatically for the next  5 years (the maximum number of years allowed), or for a shorter number of years:  4 years  3 years  2 years  1 year  Don’t use information from tax returns to renew my coverage. Form 100 (Rev. 02/2014) 13 I understand and agree:  I will automatically receive child support servic es from the Division of Child Support Enforcement (DCSE).  I must cooperate with DCSE in establishing paternity and obtaining medical support for any child receiving medical assistance.  DCSE is authorized to deduct directly from my support payments, any and all monies owed to the Division of Social Services.  I will not be eligible for benefits if I fail to cooperate with DCSE unless a good cause is established. My child(ren) may still be eligible.  Pregnant women are not required to cooperate in establishing paternity and obtaining medical support. Some Medicaid programs require you to enroll in a managed care organization. To enroll in a managed care organization (MCO), call the Health Benefits Manager at 1-800-996-9969. Disclosure of Information For All Programs All information and documentation gathered for determining your Cash Assistance, Food Supplement, Child Care and Medical Assistance eligibility or other program related use is confidential. Each program provides safeguards, restricting the use and disclosure of informat ion about you to purposes directly connected with the administration of the program. Releasing information concerning your eligibility to anyone not authorized to receive the information is a violation of State and Federal law and may result in legal action. We will keep your eligibility information confidential, unless you give us permission to release information to others. Certifications and Signatures Certification of Citizenship and Alien Status I certify, under penalty of perjury, that I, and any other members of my household, are U.S. citizens or aliens in lawful immigration status. Non-lawful aliens may be e ligible for emergency services and labor and delivery only. Certification of Head of Household Selection I have read and have had explained to me the provisions about selecting a head of household. I have selected the following person to be the head of household and I certify that all adult members in my household agree to this selection. ________________________________________________________________________________________________ (Head of Household Designee) Certification of Understanding and Accuracy of Application Answers I understand the questions on this application and the penalty for hiding or giving false information or breaking any of the rules listed in the penalty warning. I certify, under penalty of perjury, that all my answers are correct and complete including information about the citizenship or alien status of each household member applying for benefits. I understand and agree to provide documents to prove what I have said. I understand and agree that DHSS may contact other persons or organizations to obtain the necessary proof of my eligibility and level of benefits. I have read, or have had read to me, all statements on this form and the information I give is true and complete to the best of my knowledge. I understand that I could be penalized if I knowingly give false information. I Form 100 (Rev. 02/2014) 14 understand that all information I give is confidential and federal and state laws limit disclosure of information about me. I agree to allow Delaware Health and Social Services, or its representatives, to act as my agent in recovering money spent by its medical assistance programs when other money from insurance, estates, etc. is available to pay my medical bills. I have a right to request a Fair Hearing if I am not sa tisfied with any decision made about my eligibility or benefits. An attorney or any other person I choose may represent me. I have read, or had read to me, and understand the current Rights and Responsibilities. I have received a copy of the Rights and Responsibilities from the DHSS worker. The person who filled out step 1 should sign this application. If you are an authorized representative, you may sign here as long as you have provided the information required in Appendix C. Applicant’s Signature Date Witness Authorized Representative’s Signature Date Witness Spouse/Partner’s Signature (Not required for medical assistance) Date Witness For Persons Who Cannot Speak English Translation services were offered or a family member or other person was present to translate. Translator’s Signature Date Phone Number & Agency/Relationship DELAWARE HEALTH AND SOCIAL SERVICES APPENDIX A Health Coverage from Jobs You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of this page for each job that offers coverage . Tell us about the job th a t offers co v er ag e . T ak e the Empl oy er Cov erage T ool on the next page to the empl oy er who offers c o v er age to help you an sw er these que stions. You only need to include this page when you send in your applic ation, not the Empl o y er C o v er age T ool. EMPL OYEE Inf orm a tion 1. Empl oy ee name (Fir s t, Middl e , La s t) 2. Employee Social Security number - - EMPL OYER Inf orm a tion 3. Empl oy er name 4. Empl oy er Identific a tion Number (EIN) - 5. Empl oy er add r e s s 6. Empl oy er phone number ( ) – 7 . City 8. S t a t e 9 . ZIP c ode 1 0 . Who can w e c ontact about empl o y ee health c o v e r age a t this jo b ? 11. Phone number (if dif f e r ent f r om ab o v e ) ( ) – 12. Email add r e s s 13. Are you cur rently eligible for c o v er age offered by this employer , or will you be c ome eligible in the next 3 months ? Yes ( C ontinu e ) 13a. If you’ re in a waiting or pr oba tionary period, when can you enroll in co v er ag e ? (mm / dd/ yyy y) Lis t the names of an y one else who is eligible for co v er age from this job . Name: Name: Name: No ( S t op her e and go to Step 5 in the applic ation) Tell us about the health plan offered by this empl o y er . 14. Does the employer offer a health plan that meets the minimum value standard*? Y es (Go to question 15) No (Stop and return form to employee) 15. For the lowest -cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco c essation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay i n premiums for this plan? $ b . How often ? Weekly Every 2 weeks Twice a month On ce a month Quar terly Y early 16. What change will the employer make for the new plan year (if known)? Employer won’t offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest -cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ b. How of ten? Weekly Every 2 weeks Twice a month Once a month Quarterly Ye arly Date of change (mm/dd/yyyy): * An employer -sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) EMPL OYER COVER AGE T OOL Use this tool to help ans w er que s tions in Appendix A about any empl o y er health co v er age th a t you’ re eligible f or ( e v en if it ’ s from another person ’s job, lik e a par ent or spous e ). The in form ation in the numbe r ed bo x es bel ow ma t ches the bo x es on Appendix A. For e x ampl e , the ans w er to ques tion 14 on this page should ma t ch que s tion 14 on Appendix A. Wri te your name and Social Security number in bo x es 1 and 2 and ask the empl o y er to fill out the r es t of the form. C omplet e one tool for each empl o y er tha t offers health co v er age . EMPL OYEE Inf orm a tion 1. Empl oyee name (Fir st, Middl e, Last) 2. Employee Social Security number - - EMPL OYER Inf orm a tion 3. Empl oyer name 4. Empl oyer Identific ation Number (EIN) - 5. Empl oyer add res s 6. Empl oyer phone number ( ) – 7. City 8. S ta t e 9. ZIP c ode 10. Who can we contact about empl o y ee health co v er age at this job? 11. Phone number (if dif ferent fr om ab o v e) ( ) – 12. Email add res s 13. Are you cur rently eligible for c o v er age offered by this employer , or will you be c ome eligible in the next 3 months ? Yes ( C ontinu e ) 13a. If you’ re in a waiting or pr oba tionary period, when can you enroll in co v er ag e ? (mm / dd/ yyy y) Lis t the names of an y one else who is eligible for co v er age from this job . Name: Name: Name: No ( S t op her e and go to Step 5 in the applic ation) Tell us about the health plan offered by this empl o y er . 14. Does the employer offer a health plan that meets the minimum value standard*? Y es (Go to question 15) No (Stop and return form to employee) 15. For the lowest -cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has wellnes s programs, provide the premium that the employee would pay if he/ she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs. a. How much would the employee have to pay in premiums for this plan? $ b . How often ? Weekly Every 2 weeks Twice a month On ce a month Quar terly Y early 16. What c hange will the employer make for the new plan year (if known)? Employer won’t offer health coverage Employer will start offering health coverage to employees or change the premium for the lowest -cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) a. How much will the employee have to pay in premiums for that plan? $ b. How of ten? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy): * An employer -sponsored health plan meets the “minim um value standard” if the plan’s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Appendix A (Rev. 08/2013) Appendix B (Rev. 08/2013) Delaware Health and Social Services (DHSS) APPENDIX B American Indian or Alas ka Native Family Member (AI /AN) Comple te this appendix if you or a family member are American Indian or Alas ka Native. Submit this with your Applic ation for Health Cov erage & Help Paying Costs. Tell us about your American Indian or Alas ka Native family member (s). American Indians and Alask a Nati ves can get servi ces from the Indian Health Servi ces, tribal health prog rams, or urban Indian health progr ams. They also may not have to pay cost sharing and may get special monthly enr ollment periods. An swer the foll owing ques tions to ma ke sure your family gets the mo st help pos sibl e. NOTE: If you have mo re people to includ e, ma ke a copy of this page and attach. AI/AN PERSON 1 AI/AN PERSON 2 1. Name (Fir st Nam e, Middle Nam e, Las t Nam e) Fir s t Middle Fir s t Middle La s t La s t 2. Member of a feder ally rec ogni zed trib e? Yes If yes , tribe name No Yes If yes , tribe name No 3. Has this person ever got ten a servi ce from the Indian Health Servi ce, a tribal health progr am, or urban Indian health pr og ram, or th rough a ref erral from one of these progr am s? Yes No If no , is this person eligible to get servi ces from the Indian Health Servi ce, tribal health pr og rams, or urban Indian health progr ams, or th rough a referral from one of these progr am s? Yes No Yes No If no , is this person eligible to get servi ces from the Indian Health Servi ce, tribal health pr og rams, or urban Indian health progr ams, or th rough a referral from one of these progr am s? Yes No 4. Certain mone y received may not be coun ted for Medicaid or the Child ren’ s Health Insur an ce Progr am (CHIP). List any income (amount and how often) repor ted on your applic ation that includes mon ey from these sou rces: • Per capita payments from a tribe that come from natural resou rces, usage rights, leases, or royalties • Payments from na tu ral resou rces, farming, ranching, fishing, leases, or royalties from land designat ed as Indian tru st land by the Department of In terior (including reser vations and former reser vation s) • Mon ey from selling things th at hav e cultu ral significan ce $ How often? $ How often? DELAWARE HEALTH AND SOCIAL SERVICES APPENDIX C Assistanc e with Completing this Applica tion You can choose an authorized representative for  Medical Assis tance  Cash Assistance  Child Care  Food Benefits  EBT Card You can give a tru s t ed person permi ssion to talk about this applica tion with us, see your inform ation, and act for you on ma tt ers r ela t ed to this applic ation, including getting inform ation about your applic ation and signing your applic ation on your behal f . This person is called an “authori z ed r epr esent a ti v e . ” If you ever need to change y our authori z ed r epr esent a tiv e , contact the Delaware Health and Social Services (DHSS) . If you’ re a legally appoint ed r epr esent a ti v e f or someone on this applica tion, submit pr oof with the applic a tion. 1. Name of authorized representative (First N ame, Middle N ame, Last N ame, & Suffix ) 2. Address 3. Apartment or Suite Number 4. City 5. State 6. Zip Code 7. Phone Number ( ) – Authorized Representative For My EBT Card I, ________________________________________ want ________________________________ __________ Your Name Your Representative’s Name to be my representative to be issued an Electronic Benefit Transfer (EBT) card for my food benefit account and will be able to use it to purchase food. I understand that this gives the representative access to my food benefits and that any benefits spent by the representative wi ll not be replaced. 8. Organiz ation name 9 . ID number (if applicabl e ) By signing, you all ow this person to sign your applica tion, get official inform ation about this applic a tion, and act for you on all futu r e ma tt ers with this agen c y . 10. Your sign a tur e 11. Date (mm / dd/ yyy y) For certifie d applic atio n counselors , navig ators , agents , an d brokers onl y . C omple t e this section if you’ re a certified applic ation c ounselor , navig ator , agent, or broker filling out this applic ation for somebody els e . 1. Applic ation start da t e (mm / dd/ yyy y) 2. Fir st Nam e , Middle Nam e , La st Nam e , & Suffix 3. Organiz ation name 4. ID number (if applicabl e ) Appendix C (Rev. 0 1/2014 )