Connect for Health Colorado
You hereby authorize Stride Health, Inc. to act as your Broker of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on Connect for Health Colorado. By submitting your application, you agree to the Connect for Health Colorado Terms of Use and Privacy Policy. You also acknowledge and agree to the following:
By completing and signing the State of Colorado Application for Public Assistance and other documents required to determine whether I'm eligible for public assistance benefits AND by accepting benefits that I am eligible to receive, I understand the following information and agree to the following requirements:I must tell the truth; it is a crime to lie on this application.
I may have to give papers that show what I've told you is true.
I must tell you of any changes in money I get.
I must tell you of any changes to the information I gave you on my application.
If I think you made a mistake, I can ask for an appeal or fair hearing.
The discrimination policy of Connect for Health Colorado is as follows: Following 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.
The Department of Health Care Policy and Financing (HCPF) is the state agency responsible for Medical Assistance Programs in Colorado such as Health First Colorado (Colorado Medicaid) and Child Health Plan Plus (CHP+). The County Departments of Human/Social Services and Medical Assistance Sites are agencies that receive and process applications for all public assistance programs. In this statement, the term "department" is used to refer to all agencies
Connect for Health Colorado (the Marketplace) is a marketplace for individuals, families and small employers in Colorado to shop for health plans and to access federal tax credits that can reduce monthly premiums and out of pocket costs.
The department will tell you if your benefits change.
The department will take back any benefits you should not have received.
I understand that if I am eligible for Advance Premium Tax Credit (APTC) and/or Reduced Co-pays and Deductibles these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC and/or Reduced Co-pays and Deductibles may impact my annual tax liability. I will be given the option to apply all, some or none of any APTC amount I may be eligible for to my monthly premium.
I understand that my answers, together with any supplements or additional pages, are the basis for the policy that is issued. I agree that no insurance or financial assistance program will be effective until the date specified by the insurance company or organization providing the certificate, policy, or notice. This application, or the information contained herein, will become a part of the contract when coverage is approved and issued.
I know I or another applicant may be automatically provided enrollment into Health First Colorado (Colorado Medicaid) or Child Health Plan Plus (CHP+) if we are eligible.
I must give the department all needed proof and documents before qualifying for benefits.
I know I have 10 calendar days to report any changes if I am enrolled in Health First Colorado (Colorado Medicaid) or Child Health Plan Plus (CHP+). Changes are to be reported to my local county office for Health First Colorado (Colorado Medicaid) or to CHP+. I know I have 30 calendar days to report any changes to Connect for Health Colorado if I am receiving Advance Premium Tax Credits, Reduced Co-Pays or Deductibles or I am enrolled in a Qualified Health Plan. I understand that a change in my information could affect my eligibility and eligibility for member(s) of my household.
If there is an absent parent(s) from my home and I am applying for Health First Colorado (Colorado Medicaid), I must seek medical support from the absent parent(s). I may contact Child Support Enforcement for assistance.
I am responsible for paying fees and co-payments for myself and my family if they are required for Medical Assistance benefits.
If enrolled in Health First Colorado (Colorado Medicaid) and other insurance is paying for medical care, Health First Colorado (Colorado Medicaid) will pay last.
The information I give on the application and in the application interview is confidential. But, the department can use or share the information with other program(s) that any of my family members are getting or are applying (i.e. the Women, Infants & Children (WIC) program). The information can only be used for purposes of treatment, payment, determining eligibility, and other program and administrative operations, or other purposes permitted by law for my family members or me.
I know that it is unlawful to receive Advance Premium Tax Credits and Reduced Co-Pays and Deductibles from two state Marketplaces at the same time.
It is a crime to lie on the application or to take benefits that I know that my family and I are not eligible to receive and I may be subject to criminal prosecution for knowingly providing false information. Giving false information may be punished by a fine of up to $250,000 or a jail term of up to 20 years, or both.
Any insurance carrier or agent of an insurance carrier who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
The department will notify me in writing of how and when to tell the department of any changes.
If I do not tell the truth on my application or if information is left off of the application, or if I do not report changes to the department, as required, I may lose my assistance, and I may have to pay the department for the assistance received when I was not eligible, including Medical Assistance received and medical premium payments. Income tax refunds the persons on my application and I might get, may be taken to pay back money to the department.
The law says the department must check the immigration status and citizenship for anyone who is applying. They will not check immigration status of family members who are not applying for benefits. I may be requested to verify proof of non-citizen registration documentation received from the United States Citizen and Immigration Service (USCIS) for every non-citizen member in my house who is applying for benefits. The department will verify information with USCIS and any information received from USCIS may affect my eligibility and benefits. Federal law (Public Law 97-98) requires me to give the department the Social Security number and/or alien registration number of all persons who are applying for public assistance. I must also provide the Social Security number and/or alien registration number for all sponsors. For medical assistance and adult financial programs, sponsor information will be verified with USCIS and the information received from USCIS may affect sponsor repayment for my eligibility and benefits. My sponsor is responsible for reimbursing the state for benefits I receive.
I do not have to be a U.S. citizen to apply for assistance. Both U.S. citizens and qualified non-citizens may be eligible for Medical Assistance. Please do not let the fear about immigration status stop you from seeking benefits for your family. Receiving Medical Assistance will not stop you from gaining lawful permanent residence or U.S. citizenship.
Privacy Act Information: The Department is authorized to collect information on the application, including Social Security numbers and will confirm information that may affect initial or ongoing eligibility and payments for all persons listed on my application. I am allowing the Department to use Social Security numbers and other information from my application to request and receive information or records to confirm the information in my application. Food assistance will be denied to individuals that do not provide a Social Security number, and Social Security numbers will be used and disclosed in the same manner for both eligible and ineligible members.I release the department from all liability for sharing this information with other agencies for this purpose. For example, the department may get and share information with any of the following agencies: Social Security Administration; Internal Revenue Service; United States Customs and Immigration Services; Colorado Department of Labor and Employment; Financial institutions (banks, savings and loans, credit unions, insurance companies, etc.); child support enforcement agencies; employers; courts; and other federal or state agencies; and for food assistance, law enforcement officials for the purposes of apprehending persons fleeing to avoid the law. If I think the department made a mistake, I can ask for a Fair Hearing. The department will tell me in writing how to make an appeal. I may request an appeal for any action on any program except for the CHP+ program.
If I think the CHP+ program made a mistake, I can ask for an appeal. CHP+ tells me about how to make an appeal in writing.
I will immediately notify the State of any medical claim or lawsuit I have. I will cooperate with the State in collecting the medical bills the State has paid. The State may collect from any insurance company or court settlement for medical bills that the State has paid. If I am on Medical Assistance and receive money for the same medical bills that the State has paid, I will give the money to the State. I assign to the State all rights to payment for medical expenses and treatment. I also assign my right to appeal a denial of benefits by another party responsible for payment for the benefits to the State.
Federal and Colorado state law require the Department of Health Care Policy and Financing to recover all medical assistance benefits, including capitation payments, paid on behalf of Health First Colorado (Colorado Medicaid) clients from the estates of deceased Health First Colorado (Colorado Medicaid) clients who were permanently institutionalized. For Health First Colorado (Colorado Medicaid) clients who were over the age of 55 when benefits were provided, the Department recovers payments for nursing facility services, home and community-based services, and related hospital and prescription drug services. There are certain exemptions to estate recovery. For further information, please contact your county and request the “Medical Assistance Estate Recovery Program” brochure.
Domestic violence information and services are available to me. If I ever feel I am in immediate danger I will call 911. If I would like to receive information regarding safety and services in Colorado, I will call the Colorado Coalition Against Domestic Violence at 303-831-9632 or toll free at 1-888-778-7091. I may also find the location of services near me by going to Domestic violence. The National Domestic Violence Hotline at 1-800-799-SAFE (7233) or TTY 1-800-787-3224 or ndvh.org can also provide information. If I am a survivor of domestic violence, sexual assault, or stalking the Address Confidentiality Program (ACP) can provide me with a legal substitute address to use instead of my real address for use with state and local government agencies. I can find out more about ACP at acp.colorado.gov. If I need or receive either of these services I will tell my department worker.
If you have a legal guardian, he or she should sign below. If you have a power of attorney or an authorized representative, either you or that person may sign this application. If anyone else is helping you fill out the application, you should sign the application yourself.
I have agreed to submit this application for myself and/or my family. By signing this application electronically, I certify that I have reviewed this application; that I understand and agree to the Rights, Responsibilities and Penalties; and that under penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. I have received information on how to apply, what information is available, and what I may need to give the application site to help me with getting benefits.
I understand the questions and statements on this application.
I have read and understand my Rights & Responsibilities in the box above.
I understand the penalties for giving false information or breaking the rules.
I understand that the application site may contact other persons or organizations to obtain needed proof of my eligibility and level of benefits.
I understand that failure to report or verify any listed expenses will be seen as a statement by me that I do not want to receive a deduction for the unreported or unverified expenses.
I understand I can be punished by law if I do not tell the complete truth.
I understand that an electronic signature has the same legal effect and can be enforced in the same way as a written signature.
I have read the Rights and Responsibilities.