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Click ‘Get Form’ to open it in the editor.
Begin by entering the applicant's full name, Social Security Number, and daytime telephone number in the designated fields.
Provide the applicant’s home address, including street, city, state, and ZIP code.
In the next section, input details about the health insurance policy: name of the insurance carrier, policy start date, premium billing address, and policy number.
Indicate the total monthly premium and total number of people covered under the policy.
Answer eligibility questions regarding Medi-Cal enrollment and other requirements by checking 'Yes' or 'No' as applicable.
Finally, sign and date the application before submitting it to ensure all information is complete and accurate.
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What is the phone number for Dhcs third party liability?
Telephone Assistance: You can call our Phone Support Unit to speak with a live representative at (916) 445-9891. Hours of operation: Monday through Friday, from 8:00 a.m. to 5:00 p.m., and closed from 12:00 p.m. to 1:00 p.m.
Is HIPP taxable?
No, you are not required to report the HIPP reimbursement, nor the pre-tax health insurance premiums on your tax return. Health Insurance Premium Payments are not taxable as long as the payments meet the IRS guidelines for qualified medical expenses.
What is HIPP in healthcare?
The Health Insurance Premium Payment (HIPP) program is a voluntary program for qualified members with full scope Medi-Cal coverage. HIPP approved Medi-Cal eligible members shall receive services that are unavailable from third party coverage and offered by Medi-Cal.
What is a HIPP notice?
Californias Health Insurance Premium Payment (HIPP) Program requires all California employers (including those not covered by COBRA) to provide terminating employees with notice of special state programs that pay COBRA premiums under certain circumstances.1
What does Hipp stand for in insurance?
Health Insurance Premium Payment (HIPP) Program.
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The Department of Health Care Services requires employers with 20 or more employees to provide the Health Insurance Premium Payment (HIPP)opens in a new tab notice, DHCS 9061, to certain employees covered under the program. Employers must notify any covered, terminated employees of their Cal-COBRA continuation rights.
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