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Effective Date: 



Updated: 8/2001


To apprise applicants and clients who have private health insurance of

  • the effect that the private health insurance has on their eligibility for Medicaid;
  • how their private health insurance benefits are to be used in relation to Medicaid benefits; and
  • their responsibilities for reporting any change in private health insurance coverage, including premium changes.

When to Prepare

Prepare Form H1222 when an applicant or recipient reports coverage under a private health insurance policy not previously reported on Form H1039, Medical Insurance Input.

Number of Copies

Prepare an original and one copy.


Send the original to the applicant or client at his mailing address or that of the responsible party. A self-addressed envelope is included to facilitate a response. File the copy in the case record.

Form Retention

Keep the copy according to the retention requirements for the case record.

Detailed Instructions

Inside Address — Enter the name of the client and his mailing address or that of his responsible party.

Date — Self-explanatory.

Worker — Self-explanatory.

Office Address and Telephone Number — Enter the caseworker's complete address and telephone number.

Policy No. I and Policy No. 2 — This portion of the form is completed by the client or his responsible party as changes in the client's private health insurance policies occur.

Signature — The individual reporting the changes in the client's private health insurance policies signs here.

Date — The individual reporting the changes in the recipient's private health insurance policies enters the date he signs the signature line addressed above.