The PA CH 600 form serves as a crucial gateway for families with children and pregnant women seeking health care benefits through Pennsylvania's Medicaid program or the Children’s Health Insurance Program (CHIP). This form, accessible for completion at www.compass.state.pa.us, offers a streamlined, confidential process for applicants to connect with the essential health services their families need. It underscores Pennsylvania's commitment to ensuring easy and affordable health protection for every family, emphasizing the inclusion of wide-ranging health care coverage from checkups and immunizations to emergency services and mental health support.
The PA CH 600 form is a crucial document for families and pregnant women in Pennsylvania seeking health care coverage under Medicaid or the Children’s Health Insurance Program (CHIP). It functions as an application for individuals to access a variety of medical services, ranging from check-ups, immunizations, and sick visits to more specialized care such as vision and hearing tests, emergency room visits, lab tests, mental health, and substance abuse treatment. The application process is facilitated by the availability of online submission, but it also emphasizes providing assistance for those who need help filling out the form, including a helpline and support for individuals with hearing impairments. It's noteworthy that this form also caters to the needs of families with children who have disabilities or special health care needs, ensuring that such conditions don't hinder their eligibility for coverage. Moreover, the PA CH 600 clarifies the pathways for application processing, indicating that applicants not qualifying for one program may be considered for the other (CHIP or Medicaid), thus providing a safety net to ensure children receive necessary coverage. This introduction not only ensures that potential applicants understand the significance of this form but also underscores the commitment of Pennsylvania's health care system to provide accessible and comprehensive coverage to its younger residents and expecting mothers.
Important information about health care benefits.
Ask someone to read this to you.
APPLICATION FOR
Health Care Coverage
This application may be used by families with children or by pregnant women
who apply for health care benefits under the Medicaid program or the
Children’s Health Insurance Program (CHIP).
You can apply online at www.compass.state.pa.us
Health Care in Pennsylvania
Easy, affordable protection for your family
PA 600 CH.1 (SG) 12/06
Information about Health Care Coverage
Please note: If you need Medicaid benefits for families without children, cash assistance, or food stamps, you must complete a different application. Please call your County Assistance Office and they will send you the proper form.
If you need help: You can get help with this form. For help, you can call the Helpline at
1-800-842-2020 or ask for help at the County Assistance Office. If you are hearing impaired, call TDD 1-800-451-5886.
Health Care Coverage May Include:
•
Checkups
Immunizations
• Sickvisitsandprescriptiondrugs
• Visiontestingandeyeglasses
Emergencyroomcare
• LabtestsandX-rays
• Hearingtestingandhearingaids
Mentalhealthandsubstanceabusetreatment
Questions You Might Have
Q: Which program can my children enroll in?
A:WhetheryourchildrenenrollinMedicaidorCHIPdependsmostlyonyourincomeandtheages ofyourchildren.Youmayapplytotheprogramofyourchoice.Thisapplicationwillworkforboth programs.
•IfyouapplyfirsttoMedicaid,butarenoteligible,theapplicationwillbesenttoaCHIPprogram toseeifyouareeligible.
•IfyouapplyfirsttoCHIP,butarenoteligible,theapplicationwillbesenttotheCounty AssistanceOfficetoseeifyouareeligibleforMedicaid.
•Ifthishappens,youwillgetalettertellingyouwhathashappenedtotheapplicationandwhatto expect.
Q: How will I know if my family is eligible?
A:Youshouldreceivealetterfromtheprogramyouappliedtowithin30days.Thisletterwilltellyouwho iseligiblefortheprogramandwhoisnot.Ifsomeonedoesnotgetintotheprogram,theletterwilltell youwhyandwhatyoucandonext.
Q: What if someone in my family has a disability or a special health care need?
A:Youcannotbeturneddownforcoveragebecauseyouhaveadisabilityoraspecialneed.Ifyouor yourchildhasadisabilityoraspecialhealthcareneed,ahigherincomelimitcanbeusedwhenyou applyforMedicaid.Youmayalsobeabletoreceiveadditionalservices.
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▲ A f t e r c o m p l e t i o n - R e m o v e p a g e s 3 t h r o u g h 1 0 a t p e r f o r a t i o n a n d m a i l i n s u p p l i e d e n v e l o p e - K e e p f r o n t a n d b a c k c o v e r . ▲
Application for Health Care Coverage
Si necisita este información en español, llame al teléfone: 1-800-842-2020
What language do you prefer?
___ Spanish
___English
___Other (specify)____________________________
¿Qué idioma prefiere usted?
___ Español
___Inglés
___Other (especifique) ________________________
This form is for two programs: Medicaid (also known as Medical Assistance) and CHIP (Children’s Health Insurance Program).
All information you provide on this form will be shared between the two programs if necessary. It is confidential.
Medicaid: Provides health care coverage for children under age 21, pregnant women, and other adults.
CHIP: Provides health care coverage for children under age 19 who do not have health insurance and who are not eligible for Medicaid.
Whether your children are enrolled in CHIP or Medicaid will depend mostly on your income and the ages of your children.
1.Fill out the form. Please print.
2.Attach proof of all income your household received during the last 30 days.
•Proof includes pay stubs, award letters or checks.
•Make sure the pay stubs show a full month’s income and the pay period. (If paid every week, attach four pay stubs. If paid every two weeks attach two pay stubs.) Also, an employer can write a letter that states what the monthly pay is if there are no pay stubs.
•If self employed, copies of tax returns or receipts, or other records count as proof of income.
•The information you attach should show what the income is before taxes and deductions.
3.If you are applying for someone who is not a U.S. Citizen, please attach proof of alien status. (You do not need to attach proof of alien status if this is an emergency application for Medicaid.)
4.Mail or take this form to your local County Assistance Office. Call 1-800-842-2020 if you do not know where to send your form.
5.If you need help with this application, please call 1-800-842-2020, or if you are hearing impaired call TDD 1-800-451-5886.
I.Tell us who you are and where you live.
Last name (Parent/Caretaker)
First Name
Middle Initial
Social Security Number *
Street Address
City
County
State
Zip
Home Phone
Work Phone
Best time to call
*If you are not applying for yourself, you can leave this blank.
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II. Please list the people who live with you. Start with yourself.
Are you
Is this person
applying for
a student
How is this
a U.S.
this person?
Sex
Is this
Birthdate
under age 19?
person related
Citizen? *
Last name, first name, MI
Yes/No?
M or F
person:
MM/DD/YY
Social Security Number*
to you?
Married
Yourself
■
Single
Divorced
Self
Separated
Widowed
Person 2
Child
Stepchild
Spouse
Other
___________
Person 3
Person 4
Person 5
Person 6
Person 7
Person 8
*If you are not applying for this person, you can leave the Social Security Number space and the U.S. citizen space blank.
Are you, or is anyone who lives with you a stepparent?
■■ yes
■■ no
(if the answer is no, skip to section III)
Do the stepchildren live with you?
If yes, tell us:
Stepparent’s name: ________________________________________________________________________________
Stepparent for which children? ________________________________________________________________________
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III. Income and Expenses.
Please tell us about the income of any child or adult you have listed on this application.
How often is the income
Does anyone have income from:
received?(weekly,
Amount of monthly income before taxes and
(Please check YES or NO)
YES
NO
Whose income is this?
bi-weekly, monthly, etc.)
deductions
Employment
Employer’s Name:
Social Security Income
Supplemental Security income (SSI)
Pension/Retirement
Worker’s Compensation
Unemployment Benefits
Dividends/Interest
Self Employment (Including babysitting and
room and board paid to you.)
Child Support/Alimony
Public Assistance
Other (Specify)
Some of your expenses can help make you eligible. Please tell us what
you pay for child care and adult care, and what you pay for
transportation to go to work.
Child Care & Adult Care Expenses Transportation Expenses
Name of child or disabled adult
Monthly expense amount
How much does it cost you to get to work each week if you ride with another person or take a bus, subway, or trolley?
If you drive to work, how many miles do you drive each week?
If you have a car, how much is your monthly payment?
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IV. Health Insurance
Medicaid can sometimes pay bills that your other health insurance doesn’t cover. If you or someone you are applying for has health insurance, please complete this section.
Does anyone you are applying for have health insurance?
■■ yes ■■ no
If yes, please fill in the next section and tell us all you can about the insurance. If no, skip this section.
If you have more than one kind of insurance, please fill in a box for each policy.
If more than one person has insurance, please fill in a box for each person.
Insurance Company
Who holds this policy?
Who is covered?
What is covered?
Hospital care
Prescriptions
Visions
Doctor’s visits
Dental
Policy number
Group number/name
When did this insurance start?
When did this insurance stop? (Leave blank if you are still covered)
Car Insurance
Car insurance will often pay for injuries that occur in an accident.
Medicaid will pay for only what the car insurance doesn’t cover.
Do you have car insurance? ■■ yes ■■ no
If yes, please fill in the next section. If no, you can leave it blank.
Insurance company name
Policy expiration date
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Health Insurance from Your Employer
Medicaid can sometimes buy health insurance for you or your children from your employer.
Please help us decide if this is possible by completing this section.
Please check yes or no
Can you get health insurance for yourself through your work?
If yes, would you have to pay for it?
Can you get health insurance for your children through your work?
In the last 30 days, did anyone in your family lose a job where they had health insurance?
V. Special Qualifying Information
If someone you are applying for has a disability or a special health care need, a higher income limit can be used when your family applies for Medicaid. Additional services are available.
Please help us find out if anyone you are applying for is eligible for these programs.
no If yes, tell us who?
Are you, or is anyone who lives with you, pregnant?
■■
yes
Name: ______________________________________________________________________
Due date: __________________________
no
Do you, or does anyone who lives with you have a disability or a special health care need?
If yes, tell us who, and about their needs?
Name: __________________________________________
What is the disability or condition (optional): ____________________________
Did anyone receive Supplemental Security income (SSI) in the past? ■■ yes ■■ no (If NO, you can skip this section) If yes, who? ________________________________________________________________________________________
Name: ________________________________
What is the disability or condition (optional): ________________________
Help with Unpaid Medical Bills
You may be able to get help from Medicaid for unpaid medical bills from the last 3 months.
Do you have any unpaid medical bills for anyone you are applying for? ■■ yes ■■ no
If yes, please give us copies of the bills and proof of income for those months.
•Make sure the pay stubs show a full month’s income and the pay period. (If paid every week, attach four pay stubs. If paid every two weeks attach two pay stubs.)
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VI. Optional Information
None of these answers will affect your application for health care coverage.
Help with Child Support and Health Insurance
If you are eligible for Medicaid, you may be able to get help with child support payments and with health insurance for your child if he or she has a parent who does not live with you. Please complete the section below. Your children can still receive health care coverage if you do not complete this section.
Name of absent parent:
________________________________________________________________
check if deceased
Absent Parent’s Street Address
Date of Birth:
Social Security Number
Which child(ren) is/was this parent responsible for?
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Optional Information (continued)
Please help us help other families by answering these questions.
How did you learn about CHIP and Medicaid? (You can check more than one box)
■ at the County Assistance Office
■ through a local community organization
■ through my children’s school
■ through CHIP
■ at my doctors office
■ through a family member
■ the 1-800-986-KIDS Helpline
■ at the hospital
■ through a friend or neighbor
■ on TV
■ through my work
■ other___________________________
■ on the radio
Did your children have health insurance in the past six months? ■■ yes ■■ no
If yes, please tell us if they lost their health insurance because:
■my job stopped providing health insurance for my children
■my job raised the cost of health insurance for my children
■the health insurance was too expensive
■my children no longer got health insurance through a child support order
■I no longer have a job
■other reason: __________________________________________________________________________________________________
What school district do you live in? ____________________________________________________________________________________
Racial and Ethnic Information
Racial and ethnic information about the people who live with you. Start with yourself.
Name
Race (check all that apply)
Ethnicity
Hispanic
African American
Native Alaskan/American Indian
Asian
Native Hawaiian/Pacific Islander
Non Hispanic
Caucasian
Asian (Indian subcontinent)
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VII. You have certain rights and responsibilities. They are:
MEDICAID:
I understand that the information on this form will be kept confidential.
I authorize the release of personal, financial, and medical information for the purpose of determining eligibility and for review of the CHIP and Medicaid programs.
I understand that I must report all changes in my household or financial situation to the County Assistance Office within one week.
I understand that I can request a hearing if I do not agree with a decision made on this application.
I understand that my situation is subject to verification from employers, financial sources and other third parties.
I understand that Medicaid applicants must provide their Social Security Number. This number may be used to check the information on this application.
I understand that I have a right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health coverage may be denied or limited for a pre-existing condition. If I enroll in a group health plan that has a pre-existing condition, I can get credit for the time I received Medicaid.
I certify that all information on this application is true under penalty of perjury.
I certify to the best of my knowledge that I understand my rights and responsibilities.
CHIP:
I have read and fully understand this application. The information that I have given is true and correct.
I understand that there may be penalties for knowingly giving false information.
I understand that if some or all of my children do not qualify for CHIP, they may qualify for Medicaid. If this is the case, I will allow CHIP to give my name and the information on this application to the Department of Public Welfare.
I agree to help in the review of the CHIP program. I understand this may include interviews, and a review of my child’s health records and application form.
Signature of Applicant
or person applying for applicant(s): ______________________________________________________ Date: ______________________
Certification of Citizenship or Alien Status
By signing my name below, I certify that the persons that I am applying for are U.S. citizens or aliens in lawful immigration status. I know I must sign this in order to be eligible for Medicaid under law. (An alien who is applying only for Medicaid emergency health benefits does not have to sign this certification.)
Sign Here:____________________________________________________________________________
For Office Use Only
Source of Application: ■■ Helpline ■■ CAO ■■ CHIP Contractor (specify)__________________ ■■ Other (specify)_____________________
Date Received:
/
Categories: ______________________________________________
__________________________
File Cleared By/Date:
Screened By/Date: ________________________________________
AP Registration#:
Provider #: ______________________________________________
County: __________________________________ District: ____________________________ Record #: __________________________
■■ Authorized
■■ Not Authorized
■■ Reason Code ______________________________________________________________
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Filling out the PA Ch 600 form is a key step to applying for health care coverage for families with children or pregnant women under Medicaid or the Children's Health Insurance Program (CHIP) in Pennsylvania. Following the steps to complete this form correctly ensures that the application will be processed without unnecessary delays. Keep all the needed documents handy before you start filling out the form to make the process smoother. Here is how to do it:
After submitting the form, expect a letter within 30 days informing you whether your application for Medicaid or CHIP was successful, detailing who in your family is eligible. If any family member is not accepted into the program, the letter will explain why and outline the next steps you can take. It's essential to provide accurate and complete information to ensure a smooth application process for health care coverage.
Which program can my children enroll in, Medicaid or CHIP?
Enrollment for your children in either Medicaid or the Children's Health Insurance Program (CHIP) primarily depends on your family's income and your children's ages. This form allows you to apply for either program with the same application. If you initially apply to Medicaid and your children are not eligible, your application will be forwarded to a CHIP program to determine eligibility there, and vice versa. You will receive a letter explaining the outcome of your application and any next steps.
How will I know if my family is eligible for health care coverage?
Within about 30 days of submitting your application, you should receive a letter from the program you applied to. This letter will inform you about which family members are eligible and which are not, along with reasons for any ineligibilities. The letter will also guide you on what actions you can take if someone in your family was not approved for the program.
What if someone in my family has a disability or a special health care need?
Individuals with disabilities or special health care needs cannot be denied coverage. When applying for Medicaid, if you or your child has a disability or a special health care need, you may qualify for Medicaid under a higher income limit and possibly receive additional services tailored to meet these needs.
What documents are required when submitting the PA CH 600 form?
To complete the PA CH 600 form, you will need to attach proof of all income your household received in the last 30 days, such as pay stubs, award letters, or checks. Ensure the documents show a full month's income and reflect the pay period accurately. If self-employed, tax returns, receipts, or other records are acceptable as proof of income. For non-U.S. citizens applying for coverage, proof of alien status is required unless it's an emergency Medicaid application. After gathering the necessary documents, mail or take the form to your local County Assistance Office.
Here are five common mistakes to watch out for when filling out the PA CH 600 form:
To avoid these mistakes:
By paying close attention to these details, you can help ensure your application for health care coverage is processed smoothly and efficiently.
Filling out the PA 600 CH form, an Application for Health Care Coverage, is a critical step for individuals in Pennsylvania seeking access to Medicaid or the Children's Health Insurance Program (CHIP). However, completing and submitting this application is often just the beginning of the process. To ensure a comprehensive and swift application process, several additional forms and documents are commonly utilized alongside the PA 600 CH form. Below is a list of these vital documents, each serving a specific purpose in bolstering an application or fulfilling procedural requirements.
Collecting and preparing these documents in conjunction with the PA 600 CH form can significantly streamline the application process, ensuring that applicants receive accurate and timely assistance. It’s important for applicants to closely follow the instructions provided by the Pennsylvania Department of Human Services and to reach out for help if they encounter any difficulties. Having a thorough and properly documented application not only aids in the efficient processing of health care benefit requests but also maximizes the potential for receiving comprehensive coverage tailored to the applicants' needs.
The PA CH 600 form is similar to the federal application for Healthcare Marketplace insurance, commonly known as the application for health insurance through the Affordable Care Act (ACA). Both applications seek to determine eligibility for healthcare coverage based on income, household size, and other criteria. Like the PA CH 600 form, the Healthcare Marketplace application can be filled out online, by phone, or through a paper form. They both require detailed personal information, income data, and information about household members. Additionally, they offer health coverage options for individuals, families with children, and pregnant women, although the specific programs and benefits may vary between the two. While the PA CH 600 form specifically determines eligibility for Medicaid and CHIP within Pennsylvania, the Healthcare Marketplace application covers a broader range of insurance options available across the entire United States.
Another document similar to the PA CH 600 form is the application for Supplemental Nutrition Assistance Program (SNAP) benefits, often referred to as food stamps. Although the primary purpose of the SNAP application is to provide nutritional assistance rather than healthcare coverage, both applications gather detailed information about household composition, income, and expenses to determine eligibility for benefits. They are designed to ensure that assistance reaches those most in need based on financial criteria. Both forms are accessible through state government websites and require similar documentation to verify income and other eligibility factors. While they serve different needs—healthcare coverage versus food assistance—they share the goal of supporting low-income families and individuals by providing essential benefits.
When you set out to fill the PA CH 600 form for Health Care Coverage, smoothing the path to securing the essential health care your family needs can be greatly helped by following some straightforward dos and don'ts. Navigating this process with a clear understanding can make all the difference. Here are a few key points to keep in mind:
DOs
DON'Ts
Following these dos and don'ts can help ensure that the process of applying for health care coverage through the PA CH 600 form goes as smoothly as possible, leading you one step closer to securing the healthcare protection your family needs.
When dealing with the PA CH 600 form, which is vital for applying for health care coverage in Pennsylvania through Medicaid and the Children’s Health Insurance Program (CHIP), it's crucial to be informed about what it entails. However, there are several misconceptions that can lead to confusion and misinformation. Here are four common misunderstandings:
This is not true. While the form is designed primarily for families with children and pregnant women seeking health care benefits, it's part of a broader set of services that can cover other adults under specific circumstances. While the application is centered on these groups, Medicaid offers coverage for a wider range of beneficiaries, including adults under certain qualifications.
Many people think they need to fill out different applications for Medicaid and CHIP. However, the PA CH 600 form simplifies the process by serving as a single application for both programs. The decision on which program you qualify for is made based on the information provided in this one application, streamlining the process significantly.
This misconception could prevent families from seeking further assistance. In reality, if you apply for one program and are found ineligible, the PA CH 600 form allows your application to be automatically considered for the other program. This ensures that families have every opportunity to receive the health care coverage they need without additional paperwork.
This assumption could deter non-English speakers from applying due to language barriers. The form, however, is accessible in multiple languages, including Spanish. This is part of an effort to make health care coverage accessible to everyone in Pennsylvania, regardless of their primary language.
Understanding these aspects of the PA CH 600 form can help dispel confusion and ensure that individuals and families are better informed about their health care coverage options in Pennsylvania. It's always advisable to reach out directly to county assistance offices or the specified helplines for personalized assistance and clarifications.
Filling out the PA CH 600 form is essential for families seeking health care coverage under Medicaid or the Children's Health Insurance Program (CHIP) in Pennsylvania. Here are seven key takeaways to consider:
Understanding these key points can streamline the application process, ensuring that families and pregnant women in Pennsylvania can access the health care coverage they need.
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