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The BHSF Form 1-MPP is a crucial document for individuals with disabilities who are seeking healthcare coverage under Medicaid, specifically designed for those who are working and aged between 16 and 64. This application must be completed with care, as it gathers essential information about the applicant's identity, residency, and income sources. Applicants need to provide details about their living situation, including home and mailing addresses, as well as contact numbers, to ensure effective communication. Inquire about language preferences is a key aspect of the form, acknowledging that assistance is available for those who might struggle with English. Furthermore, the form prompts individuals to report their employment status, income from various sources, and any existing health insurance coverage. It also seeks information regarding assets and resources, which is vital for determining eligibility. The BHSF Form emphasizes the importance of accuracy; applicants must fill every section and verify the information they provide is true, as any misrepresentation could lead to serious repercussions. Additional sections cover medical conditions, healthcare providers, and awareness of the Medicaid Purchase Plan, underscoring the comprehensive approach to ensuring applicants receive the benefits they need.

Bhsf 1 Mpp Example

BHSF Form 1-MPP

Rev. 04/05

Prior Issue Obsolete

II

For Agency Use Only

Request date

 

(Application date)

Date mailed

Agency Rep

To protect your application date, we must receive this application by

 

.

(for agency use only)

What language do you speak best? … English … Spanish … Vietnamese … Other (specify) What language do you write best? … English … Spanish … Vietnamese … Other (specify)

If you do not speak English we can get interpreter services to help at no cost to you. If you need help to fill out this form, call your local Medicaid office or call us toll free at 1+888+544-7996. If you are deaf or have hearing problems, call the TTY line toll free at 1+800+220-5404.

This application is to get healthcare coverage for persons with disabilities who work and who are at

least age 16 but not yet age 65. If you want Medicaid for anyone else, check ( ) this …. We will send you information about applying for other Medicaid coverage. Please fill out every item on this form. If an answer to a question is none or 0, write “none”. If you need more space for any item, use a separate sheet.

1.Tell us who YOU are, where YOU live, and where YOU get your mail:

Name

 

 

 

Parish

 

 

 

 

Home address

 

City

 

 

State

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing address

 

City

 

 

State

 

Zip code

 

 

 

 

 

 

 

 

 

 

 

 

Home phone ( )

 

Daytime phone (

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Tell us about yourself and your spouse. You do not have to give your spouse’s Social Security number if he or she is not applying. If given, the number will only be used to verify assets.

You do not have to give race information. If you choose to do so, use the following codes: 1=White; 2=Black; 3=American Indian/Alaskan; 4=Asian; 5=Hispanic/Latino; 6=Hawaiian/Pacific Islander; 7=Hispanic/Latino & Other; 8=Multi-Race, Not Hispanic; 9=Unknown

Name - first, middle initial, last

Social Security

Date of birth

Sex

Race

US citizen/

Louisiana

Relation to you

 

number

Month

Day

Year

M/F

 

Legal alien

resident

 

 

Yes

 

No

 

Yes

 

No

 

self

 

 

 

 

 

 

 

 

 

 

…

…

…

…

 

 

 

 

 

Yes

 

No

 

Yes

 

No

 

spouse

 

…

…

…

…

 

3.Tell us about EACH job or business that you have. Show the amount of total or gross income before any deductions, not your take-home pay. (Send copies of pay check stubs or other proof of your earnings for last month. If you are self-employed, send copies of your most recent federal tax form with all schedule attachments. Send other proof if you do not have tax forms.)

Employer name, address & phone OR

Amount

How often do

# of hours

Self-employment information

paid

you get paid?

worked per week

$

$

4.Do you get any money like the kinds listed below? … Yes … No

Social Security

Unemployment

Money from friends

Retirement/Pensions/Annuities

Workman’s Compensation

or relatives

Veteran’s Benefits

Interest/Dividends/Royalties

Any other not listed

(Show all money that you get and send proof of the income. You do not have to send proof of Social Security or Unemployment income.)

 

Income type

 

Source name,

 

 

How much

 

How often

 

 

 

address, & phone

 

 

do you get?

 

do you get it?

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

$

Have you ever applied for money from any of these sources? … Yes … No If Yes, when and from which ones?

5.Do you have Medicare or other health insurance? … Yes … No If Yes, answer the following. (Send proof of coverage and premium payment.)

Insurance company name,

Group/policy number

Monthly

 

Policy covers:

address, & phone

cost

hospital

doctor

ambulance

 

 

 

 

…

 

…

…

 

 

 

 

 

 

 

 

 

 

…

 

…

…

 

 

 

 

 

 

 

Can you get health insurance from your employer? … Yes … No

6.Do you, or you jointly with your spouse, have any assets or resources like those listed below? … Yes … No If Yes, give us the following information. (Send proof of ownership and value.)

 

Asset/Resource

Company name, address, & phone;

Value

Amount owed

 

 

Account number and/or description

 

 

 

 

 

Checking/Savings accounts (type)

 

$

 

 

 

 

 

 

 

Certificates of Deposit

 

$

 

 

Retirement accounts

 

$

 

 

Annuities/Trusts

 

$

 

 

Stocks/Bonds

 

$

 

 

Vehicles (if more than one)

 

$

$

 

Property, other than your home

 

$

$

 

Other (please be specific)

 

$

$

7.Did you ever apply for or get Social Security Disability or Supplemental Security Income (SSI)

benefits? … Yes … No If Yes, when?

 

Was a decision made? … Yes … No

If Yes, what was the decision?

 

 

 

 

 

 

8.What is your disability?

Tell us about the doctors or other medical providers who care for you:

Provider’s name(s)

Address & phone of this medical provider

9.Where did you find out about the Medicaid Purchase Plan?

Rights and Responsibilities

I declare that I am a U.S. citizen or in this country legally.

The information I gave on this form is true and correct to the best of my knowledge. I realize if I knowingly give information that is not true OR if I knowingly hold back information, I may get health benefits for which I am not eligible. If that happens, I can be lawfully punished for fraud. I may also have to pay Medicaid back for any medical bills which are paid incorrectly.

I understand that the information I give about my situation will be checked. I agree to help do that, and to let Medicaid get information it needs from government agencies, employers, medical providers, and other sources. If I refuse to help with this process or in later reviews caused by reported changes, or as part of a Recipient Eligibility review, it will mean that I can’t get Medicaid until I do help.

I know that Social Security numbers will only be used to get information from other government agencies to prove my eligibility.

I agree to tell Medicaid within 10 days if 1) I move out of state; 2) there are changes in where I live or get my mail; 3) there are any changes in other health insurance coverage; 4) there is any change in my work status.

By accepting Medicaid, I agree that any medical payments received from other sources will be sent to the Department of Health and Hospitals for any services that were covered by Medicaid.

I can ask for a Fair Hearing if I think the decision made on my case is unfair, incorrect or being made too late.

Medicaid can’t treat me differently because of my race, color, sex, age, disability, religion, nationality or political belief. If I think they have, I can call the U.S. DHHS Regional Office for Civil Rights in Dallas, TX at 1+800+368-1019 or write to Louisiana’s Department of Health & Hospitals, Human Resources at P. O. Box 1349 Baton Rouge, LA 70821-1349.

Signature of Applicant or Authorized Representative

 

Date

 

 

 

Signature of Agency Representative, if applicable

 

Date

File Breakdown

Fact Name Detail
Form Title BHSF Form 1-MPP
Form Revision Date Rev. 04/05
Purpose of the Form This application is designed for individuals with disabilities who work, aged 16 to 64, to apply for healthcare coverage.
Agency Contact Assistance is available by calling the local Medicaid office or toll-free at 1-888-544-7996.
Interpreter Services No-cost interpreter services can be obtained for those who do not speak English.
Medicare and Health Insurance Applicants must disclose if they have Medicare or other health insurance, including specific details about coverage.
Income Reporting Total or gross income from employment must be reported, and documentation such as pay stubs is required.
Asset Disclosure Applicants must declare any assets or resources, providing details and proof of ownership.
Rights and Responsibilities The form emphasizes the responsibility of the applicant to provide truthful information and report any changes affecting their eligibility.

Guide to Using Bhsf 1 Mpp

Completing the BHSF 1 MPP form is an important step in applying for healthcare coverage for persons with disabilities who are of working age. To ensure a smooth application process, follow these steps carefully and provide all necessary information.

  1. Start with your personal information: Fill in your name, parish, home address, city, state, zip code, mailing address, home phone number, and daytime phone number.
  2. Next, provide details about yourself and your spouse: Include your spouse's name, Social Security number, date of birth, sex, race, U.S. citizenship status, and your relation to them (e.g. self, spouse).
  3. List your employment or business details: For each job or self-employment, provide the employer's name, address, phone number, gross income, how often you get paid, and the number of hours worked per week. Remember to attach proof of your earnings.
  4. Indicate whether you receive any additional income: Check "Yes" or "No" and provide details about Social Security, unemployment, retirement benefits, or any other sources of income, including amounts and frequency.
  5. Disclose any existing health insurance: Check if you have Medicare or any other form of health insurance. If yes, submit the insurance company details, policy number, monthly cost, and what the policy covers.
  6. Report on your assets and resources: Answer whether you or you jointly with your spouse have any significant assets. If yes, provide details about the value and type of accounts, properties, or other resources, as well as documentation of ownership and value.
  7. State whether you have previously applied for Social Security Disability or SSI benefits: If yes, provide details about when you applied and any decisions made.
  8. Describe your disability and medical providers: Include your medical provider's names, addresses, and phone numbers who care for your disability.
  9. Share how you learned about the Medicaid Purchase Plan.
  10. Finally, sign the application confirming all information is true to the best of your knowledge and date your signature. If applicable, an agency representative should also sign and date the form.

Get Answers on Bhsf 1 Mpp

  1. What is the purpose of the BHSF 1 MPP form?

    The BHSF 1 MPP form is designed for individuals with disabilities who work and are between the ages of 16 and 64 to apply for healthcare coverage through Medicaid. It helps gather essential information to determine eligibility for benefits, ensuring that individuals receive the necessary support.

  2. How do I know if I am eligible to apply?

    Eligibility for the BHSF 1 MPP form requires that you have a disability, are employed, and fall within the age range of 16 to 64 years. Additionally, it is important to have a legal residency status in the U.S. Review the requirements carefully on the form or contact your local Medicaid office for assistance.

  3. What information should I provide about my income?

    You must provide details about all sources of income, including wages, Social Security, unemployment benefits, and any other forms of financial assistance. It is essential to report gross income before deductions and to include documentation such as pay stubs or tax forms to support your claim.

  4. Can I get help filling out the form?

    If you need assistance completing the BHSF 1 MPP form, you can contact your local Medicaid office for help. Additionally, the application process provides free interpreter services if language barriers exist. Do not hesitate to seek help to ensure all information is accurately reported.

  5. What documents should I submit with the application?

    You will need to provide proof of income, health insurance, and assets. This can include copies of pay stubs, tax forms, insurance coverage documents, and proof of ownership for any significant assets. Ensure that all required documents are attached to avoid delays in the processing of your application.

  6. What happens if I give false information?

    Providing incorrect information on the BHSF 1 MPP form can result in severe consequences. You may face legal penalties for fraud, and Medicaid could require repayment for benefits received incorrectly. Honesty in your application is crucial to avoid these risks.

  7. How will I know the status of my application?

  8. What if I need to report changes after submitting my application?

    After submitting your application, you are required to report any changes in your living situation, income, or health insurance coverage within 10 days. This ensures that your eligibility for Medicaid remains accurate and up to date. Failure to report these changes could affect your benefits.

Common mistakes

Filling out the BHSF 1-MPP form can be a straightforward process, but mistakes often occur. One common error is neglecting to provide all requested information. Each section requires specific details, and failing to complete even one can delay your application. Ensure that you answer every question and, if necessary, include additional sheets for longer responses.

Another mistake is not adhering to the guidelines regarding how to indicate “none” or “0”. The instructions clearly state that these should be written explicitly. Omitting this critical detail can lead to confusion and might cause your application to be poorly assessed.

People often forget to include consistent contact information. It’s important that both your home and mailing addresses, as well as phone numbers, are accurate. Inconsistent or incorrect information can make it difficult for the agency to reach you or process your application.

Providing incomplete details about employment and income is also a common pitfall. Make sure to report your gross income and include documentation such as paycheck stubs. This information is crucial for assessing your eligibility for the program.

Claiming income from all necessary sources is essential. Some applicants may overlook reporting smaller income streams or benefits, believing they are insignificant. However, every dollar counts in the eligibility process, so be sure to list all sources of income accurately.

Another mistake is misunderstanding the importance of detailing your medical providers. Providing complete information about those who treat your disability is vital. Incomplete details can hinder the verification process of your disability status.

Some individuals neglect to sign and date the application. A missing signature may cause processing delays or even lead to the application being dismissed altogether. Thus, ensure you take the time to read the declaration and complete this final step.

Finally, do not underestimate the importance of keeping a copy of your completed form. Lack of documentation can lead to complications in future communications. Retain a copy for your records to easily reference your submission and any pending status.

Documents used along the form

When applying for Medicaid or any healthcare benefits related to disabilities, the BHSF 1 MPP form is just one of several essential documents. Each of these documents serves a unique purpose, contributing to a comprehensive application process. Understanding these forms is crucial for applicants as they navigate the healthcare system.

  • Medicaid Application Form: This is the primary form used to apply for Medicaid benefits. It collects personal information, income details, and other essential data to determine eligibility.
  • Proof of Income Documentation: This includes recent pay stubs, tax returns, or any other documents that verify the applicant's income. Such proof helps establish how much the applicant earns, playing a critical role in the eligibility assessment.
  • Social Security Administration Forms: If applicable, these forms relate to benefits like Social Security Disability or Supplemental Security Income (SSI). Providing this information can bolster an applicant's case for Medicaid coverage.
  • Medical Provider Documentation: Letters or statements from doctors or healthcare providers detailing the applicant's disability are often required. These documents validate the need for healthcare coverage based on medical conditions.
  • Asset Declaration Form: Some states require a separate form to list all assets owned by the applicant or their spouse. This helps determine eligibility based on resource limitations.
  • Health Insurance Information: A summary or proof of any existing health insurance coverage can be necessary. This includes details about other insurance plans or Medicare, which may interact with Medicaid benefits.
  • Family Size Documentation: This could be a simple form that outlines household members. Family size can affect income requirements and eligibility thresholds, making this information vital.
  • Authorized Representative Form: If someone is helping the applicant with the Medicaid process, this form designates them as an authorized representative. It allows that individual to communicate with Medicaid on the applicant's behalf.
  • Fair Hearing Request Form: Should there be a need to contest a Medicaid decision, this form is used to request a fair hearing. It outlines the applicant’s rights to appeal decisions that impact their healthcare coverage.

By gathering these documents and understanding their purposes, applicants can more effectively navigate the Medicaid application process. Each piece of information plays a role in assessing eligibility and can greatly influence the outcome of an application.

Similar forms

  • Medicaid Application Form: Like the BHSF Form 1-MPP, a standard Medicaid application collects personal information, income details, and asset declarations to determine eligibility for health coverage.
  • Social Security Disability Insurance (SSDI) Application: Both applications require comprehensive personal and financial information to assess eligibility for benefits related to disability, ensuring the applicant meets specific criteria.
  • Supplemental Security Income (SSI) Application: Similar to the BHSF Form, the SSI application checks income and resources to decide if an individual qualifies for needs-based assistance, particularly for those with limited means.
  • Food Assistance Program Application: Both forms ask for income and household information to evaluate eligibility for food assistance, focusing on financial resources and living arrangements.
  • Temporary Assistance for Needy Families (TANF) Application: Just like the BHSF Form 1-MPP, the TANF application requires personal details and an overview of financial status to provide necessary support for families in need.
  • Healthcare Marketplace Application: Both documents help individuals access health insurance. They require similar income and demographic information to determine eligibility for coverage options.
  • CHIP Application: The Children's Health Insurance Program (CHIP) application mirrors the BHSF Form 1-MPP by requesting information about household income and other factors to cover children's health insurance needs.
  • Housing Assistance Application: This application seeks details about income and family structure to establish eligibility for affordable housing, drawing parallels to the BHSF Form's criteria for program participation.
  • Low-Income Home Energy Assistance Program (LIHEAP) Application: This application, like the BHSF Form 1-MPP, assesses household income levels to determine eligibility for energy assistance programs.
  • Medicaid Waiver Program Application: Both forms require detailed information about health status and finances to grant access to specialized Medicaid waivers, which provide additional services beyond standard coverage.

Dos and Don'ts

When filling out the BHSF 1 MPP form, there are important dos and don'ts to keep in mind. Following these guidelines can help ensure your application is processed smoothly and accurately.

  • Do fill out every item on the form completely.
  • Do provide accurate and truthful information to the best of your knowledge.
  • Do include proof of income, such as pay stubs or tax documents, when applicable.
  • Do specify any language preferences clearly to receive the appropriate support.
  • Do use additional sheets if you need more space for your answers.
  • Don’t leave any sections blank; if an answer is none or zero, write “none.”
  • Don’t forget to sign and date the form before submission.

By adhering to these dos and don'ts, you can help facilitate a more efficient application process and avoid potential delays.

Misconceptions

Understanding the BHSF Form 1-MPP can often lead to confusion. Here are some common misconceptions about this important document:

  • The form is only for individuals over 65. Many people believe that the BHSF Form 1-MPP is only applicable to seniors. However, this application is specifically designed for individuals with disabilities who are at least 16 years old but not yet 65. It caters to younger people with disabilities who are in the workforce.
  • Filling out the form is optional. Some might think that submitting this form is just a suggestion. In reality, completing it is crucial for obtaining healthcare coverage. The form must be filled out completely to ensure that the applicant can receive the necessary medical benefits.
  • Language services are not available. A few individuals may assume that help with language is not provided. This is not correct. If English is not your first language, interpreter services can be accessed at no charge. This support is intended to assist you in completing the application accurately.
  • Providing information about my spouse is mandatory. Although many people feel compelled to share their spouse’s details, it is not always necessary. You do not have to give your spouse’s Social Security number unless they are applying for benefits. You can choose what level of information you feel comfortable sharing.
  • I don’t need to provide proof of income. This misconception could lead to delays in processing. It is essential to submit proof of income, especially if you're self-employed or have other sources of income. Without proper documentation, your application may face setbacks.

By addressing these misconceptions, individuals can approach the BHSF Form 1-MPP with a clearer understanding, ensuring a smoother application process for their healthcare coverage.

Key takeaways

  • The BHSF Form 1-MPP is designed to help individuals with disabilities obtain healthcare coverage. It is specifically for those who are at least 16 years old but not yet 65.
  • It is vital to fill out every item on the form completely. If there is a question that does not apply to you, write “none” to indicate that the question has been addressed.
  • If needed, assistance is available. You can contact your local Medicaid office or call the dedicated toll-free number for support when filling out the form.
  • You must provide your Social Security number and other personal information, though this is not required for your spouse unless they are also applying. This number will only be used for verification of assets.
  • Documentation is important. It is required to submit proof of income, assets, health insurance, and any other relevant financial information. This will support your application and help in verifying your eligibility.
  • Keep track of your application date. It is important for determining your eligibility and ensuring you receive coverage starting as soon as possible.
  • Your rights are protected. If you believe the Medicaid decision regarding your application is unfair, you have the right to request a Fair Hearing.