Form H1014-A, Children's Health Care Benefits - Final Reminder

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Effective Date
09/2013
H1014-A.pdf (137.62 KB)
H1014-AS.pdf (1.53 MB)


Instructions

Updated: 9/2013

Purpose

  • To remind individuals to send in the redetermination packet to continue health care benefit coverage for children under age 19.
  • To explain the redetermination process and how to complete forms in the redetermination packet.
  • To inform individuals that the Children’s Health Insurance Program (CHIP) coverage may be available if a child is no longer eligible for Medicaid.

Procedure

When to Prepare

Send one copy of the form on the:

  • first of the fifth month in a child's Medicaid six-month continuous eligibility period if the household did not return the redetermination packet in the fourth month.
  • first of the 11th month in a child’s Medicaid 12-month continuous eligibility period if the household did not return the redetermination packet in the 10th month.
  • first week of the 11th month in a child’s CHIP continuous eligibility period if the household did not return the redetermination packet in the 10th month.

Number of Copies and Transmittal

Mail one form to each applicant.

Form Retention

No retention requirements.

Detailed Instructions

The form is self-explanatory.