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Outline

Embarking on the journey of securing health insurance for children in Nevada introduces families to the Nevada Check Up Application form, a beacon for accessing affordable health coverage through the state's Children’s Health Insurance Program (CHIP). Navigating through this application unveils a systematic avenue to address the health needs of children up to 18 years of age who do not qualify for Medicaid and lack other health insurance coverage. The form solicits detailed information about the household, including adults and children's identification, citizenship status, and various household dynamics to assess eligibility accurately. A significant highlight of the application process is its inherent mechanism to direct applicants towards Medicaid if it better suits their eligibility criteria, ensuring families are advised of the most beneficial health coverage pathway. Furthermore, it succinctly captures employment and income details to determine the feasibility of premium payments, tailored according to the family's income bracket relative to the Federal Poverty Level. This streamlined approach, coupled with an option for health plan selection, makes the Nevada Check Up program a critical resource for uninsured children, offering a comprehensive scope of medical, dental, and vision care services. Understanding the form's intricacies helps illuminate the program's intent to facilitate health care access, anchoring on detailed information submission as a gateway to securing children's health insurance in Nevada.

Sample - Nevada Check Up Application Form

Other Adults in Household:

Nevada Check Up (NCU) Application

Children’s Health Insurance Program (CHIP)

Questions regarding this

application? Call:

1-877-KIDS NOW (543-7669)

If previously on Nevada Check Up, please enter family identification number:

Note - We will review your application for possible Medicaid eligibility. If it appears your children may be eligible for Medicaid, we will deny NCU enrollment and may refer your case to the Division of Welfare and Supportive Services (DWSS) for a Medicaid eligibility review.

1)Do you want this application to be referred to Nevada Medicaid if applicable? Yes No

2)Are you currently applying for Medicaid medical assistance for any of the individuals listed? Yes

No

Person or Head of the Household Applying for Child(ren): Please fill in all the information about the person

applying for the child(ren).

 

(1) Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Male Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status - Information received on citizenship status is not reported to INS

 

 

Preferred Language

 

U.S. Citizen

Undocumented Alien

Lawful Permanent Resident (LPR) as of (Date):

 

 

English

Spanish

 

 

 

 

 

 

 

 

 

 

 

Home Address - Number, Apt/Space and Street

 

 

 

City and State

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different than home)

 

 

 

City and State

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Number

 

 

Cell/Message

 

 

 

Work Number

 

 

How many people in

 

 

 

 

 

 

 

 

this household?

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

(

)

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Will this household continue to live in Nevada? Yes *Is your rent or mortgage subsidized by an agency? No

No, explain Yes, amount

List all adults in the household regardless of relationship to child(ren) for which you are applying. If more adults reside in the household, please attach an additional sheet with the same information in the same order as listed below:

 

(1) Last Name

Male

Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen Undocumented Alien Lawful Permanent Resident (LPR) as of (Date):

Relationship to applicant above Spouse Sibling Child Parent Other Relative Other :

 

(2) Last Name

Male

Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen

Undocumented Alien

Lawful Permanent Resident (LPR) as of

 

 

(Date):

Relationship to applicant above

Spouse Sibling Child Parent Other Relative Other :

Page 1 of 6

NCU-0100 (06/10)
Children in Household:

List all children even if they are not U.S. citizens. If more than four children reside in the household, please attach an additional sheet with the same information in the same order as listed below. If Birth Certificates are available, please provide a copy.

(1) Last Name

Male

Female

 

 

First Name

 

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

 

American Indian/Alaska Native

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

 

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

 

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

 

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, name of insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant :

Child

Other:

 

 

Major Medical

Medicare A, B, or D

 

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

 

How often paid:

 

 

(2) Last Name

Male

 

Female

 

 

First Name

 

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

African American

 

Asian

Caucasian/White

Hispanic

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

Is this child

 

Are you applying for

 

Is this child

 

 

disabled and

*Information on citizenship is not reported to INS

pregnant?

 

NCU for this child?

 

 

 

receiving SSI?

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

Undocumented Alien

Yes

No

 

 

 

 

 

 

 

 

 

Yes

No

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

On Nevada Medicaid

Yes, Name of Insurance:

 

No Coverage

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

 

Cancer Dental/Vision

Pharmacy

Reason:

Managed Care (HMO/PPO)

 

 

 

Major Medical

Medicare A, B, or D

Parental Relationship (REQUIRED)

Name of mother :

Name of father:

 

 

 

 

 

 

 

 

Relationship of child to applicant:

Child

Other:

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

 

(3) Last Name

Male

Female

 

 

First Name

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, Name of Insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant:

Child

Other:

 

 

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

 

Page 2 of 6

 

 

 

 

 

 

 

 

 

 

 

NCU-0100 (06/10)

(4) Last Name

Male

Female

 

 

First Name

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, Name of Insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant:

 

Child

Other:

 

 

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

Employment Information: List employment information for each adult residing in the household. *See insert for acceptable income verification (not more than 45 days old).

 

(1) Person Employed - Last, First

 

 

 

Name of Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address

 

Employer Telephone

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Pay - amount before taxes

 

Tips per pay period

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2) Person Employed - Last, First

 

 

 

Name of Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address

 

Employer Telephone

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Pay - amount before taxes

 

Tips per pay period

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Income: Please provide the most current proof (not more than 45 days old) for each income received. List all types of income received by anyone in the household (including children) and leave blank if not applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source of Other Income

 

 

Name of Recipient

 

 

Dollar

 

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support/Alimony

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Payments - select

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

RSDI

SSI

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Payment Source

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment Benefits

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pension Payment and Source

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interest or Dividends (Stocks, Bonds,

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

Trusts, Mutual Funds, Savings, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (such as cash assistance, etc)

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 6

 

 

 

 

 

 

 

 

 

 

 

NCU-0100 (06/10)

Health Plan Selection: Please choose a health plan:

*Note: If you do not choose a health plan preference, we will choose a plan for you (see insert for choices).

Referral Information: How did you hear about Nevada Check Up? (Please check the ONE that applies)

Covering Kids and Families

Welfare

School

WIC

Media (Newspaper, TV and Radio)

Internet

Friend/Family

Doctor/Hospital

Social Services/Health Dept

Child Care Provider

Tribal Resource

Clinic

Other:

 

 

Signature and Affirmation:

It is your responsibility to immediately report to Nevada Check Up any of the following status changes for your children:

OChange of address and phone number

OMoves out of the house or state

OChild(ren) becomes eligible for Medicaid or other health insurance

OA household member becomes deceased

OChild(ren) becomes a resident, inmate of a public institution or a ward of the state

OChild(ren) becomes emancipated and/or married

In signing this document, I hereby apply for health insurance coverage for the named children under the Nevada Check Up program. I agree to adhere to all the required responsibilities to report changes listed on this application. I certify that all information contained is true and accurate to the best of my knowledge and that no facts have been left out.

I hereby release Nevada Check Up from liability, if any, resulting from the disclosure of information contained in this application.

I understand and authorize Nevada Check Up and/or the Department of Health and Human Services to contact any party deemed necessary to verify information presented on the application.

If any of my household members receive Nevada Check Up, I agree to assign all rights to any medical claims, medical support or other payments for medical care. I understand this is a condition of being eligible for Nevada Check Up. I agree to cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by Nevada Check Up. I also understand I must inform Nevada Check Up if any legal action is taken against anyone or if I receive any offer or settlement for the reimbursement of medical care and treatment that may be paid for by Nevada Check Up.

I understand the eligibility determination process may take 45 days. The 45 days starts when a complete application with all necessary, requested and required documentation is received. Once approved, I will be notified by mail of the date coverage begins and my premium amount. If the application is denied or Nevada Check Up makes any other decision with which I don’t agree, including timeliness of the determination within established guidelines, I have the right to request a hearing. The request for hearing must be submitted in writing within 30 days of the date of the denial letter.

A reproduced copy of this authorization constitutes an original copy.

I declare under penalty of perjury under the laws of the State of Nevada that the foregoing is true and correct. (NRS 53.045, NRS 199.120 thru NRS 199.200 and NRS 41.365).

I further understand that the law provides penalties for persons hiding facts or not being completely truthful.

I understand that information provided to NCU may be verified or investigated by federal, state and local officials. If I do not cooperate in the investigation, my child(ren)’s benefits will be denied or terminated. If I make false or misleading statements;

misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, my child(ren)’s benefits may be denied or terminated. I am responsible for repayment of all monies paid for services to which my

child(ren) were not entitled and I may be subject to any criminal and/or civil penalties in accordance with state and federal law.

Applicant Signature:

 

Date:

 

 

 

 

(Mandatory) If not signed, application will be rejected.

Other Adult:

 

Date:

 

 

 

 

Send your completed application or any correspondence to: Nevada Check Up Program 1000 E. William Street Ste 200 Carson City, Nevada 89701

Questions? Call us at (775) 684-3777 or toll free 1-877-KIDS-NOW (543-7669). Our fax number is (775) 684-8792. Spanish speaking staff is always available! You may also visit us on our website: http://nevadacheckup.nv.gov

If you believe someone has interfered with your right to register to vote, your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.

The Department of Health and Human Services, Division of Health Care Financing and Policy, provides services without discrimination of any kind due to race, national origin, color, gender, religion, age or disability (including AIDS and related conditions) as required by federal law.

Page 4 of 6

NCU-0100 (06/10)

1-877-KIDS-NOW (543-7669)

Nevada Check Up

Fax (775) 684-8792

1000 E Williams Street, Suite 200

 

Carson City, NV 89701

What is Nevada Check Up?

The state of Nevada Children’s Health Insurance Program (CHIP) known as “Nevada Check Up” is a federal and state funded program that provides low-cost health care coverage to uninsured children from birth through 18 years of age who meet the program guidelines.

What health services are covered?

Most medically necessary services are covered. Nevada Check Up offers comprehensive medical, dental and medical vision care for children.

What are the eligibility qualifications for Nevada Check Up?

2009

Number of

200% FPL

People in

Max Income

Household

Level

2

$29,140

 

 

3

$36,620

 

 

4

$44,100

 

 

5

$51,580

 

 

6

$59,060

 

 

Children must meet the following conditions:

Not be covered by or appear eligible for Medicaid

Have no other health care coverage or had insurance in the last six months

Not be covered by or have access to the Public Employee Benefits Program (PEBP)

Be a citizen of the United States or a Lawful Permanent Resident (LPR) for five years O Please note that applying for Nevada Check Up will not affect your family’s

immigration status

Meet federal income guidelines (be within 200% of the Federal Poverty Level)

OApplicants that currently exceed the listed 200% FPL may still qualify for our program in the future as the Federal Poverty Levels can change

Be younger than 18 years and 11 months at the time of the application

What about premium payments?

The only cost for Nevada Check Up is a quarterly premium which is determined by family size and income. The premium is charged per family, not per child. Below is a chart which shows the premium amount associated with the Federal Poverty Level (FPL). For American Indian families who are members of federally recognized tribes, or an Eskimo, Aleut or other Alaska Native enrolled by the Secretary of the Interior, quarterly premiums are waived when proof of status (copy of the tribal affiliation card) is provided.

Premium

FPL

 

 

$25

From 36% up to 150%

 

 

$50

From 151% up to 175%

 

 

$80

At or above 176%

 

 

Families are informed of their premium amount once they are enrolled. If families are enrolled during a quarter premiums will be prorated. If your child(ren) were previously on NCU and have an existing unpaid premium balance, children will not be enrolled until payment is received. Payment arrangements can be made which would not exceed 60 days.

Note - Failure to pay premiums will result in disenrollment

Quarters

Due Date

 

 

1st Quarter

October 1st

Oct, Nov, Dec

 

 

 

 

 

 

 

 

 

2nd Quarter

January 1

st

Jan, Feb, Mar

 

 

 

 

 

 

 

 

 

 

3rd Quarter

April 1

st

 

Apr, May, Jun

 

 

 

 

 

 

 

 

 

 

4th Quarter

July 1

st

 

Jul, Aug, Sept

 

 

 

 

 

 

 

 

 

 

 

 

Page 5 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

1-877-KIDS-NOW (543-7669)

Nevada Check Up

Fax (775) 684-8792

1000 E Williams Street, Suite 200

 

Carson City, NV 89701

How often must I re-qualify for Nevada Check Up?

Once a year, Nevada Check Up will send a request for updated information. Recipients will also be requested to send new income verification documents. If you do not respond by the deadline, your children will no longer be covered by Nevada Check Up. Families will only receive notification if their case will be disenrolled.

Health Plan

Families who live in urban Washoe County or urban Clark County are covered by a Managed Care Organization (MCO). You are asked to choose one of the following health plans on page four of the application under Health Plan Selection. If you do not indicate a health plan preference on your application, we will choose a plan for you. Your choice of health plan does not guarantee acceptance into the Nevada Check Up program. Once enrolled, families will receive a member handbook explaining the health plan benefits and can contact the numbers below for information regarding the health plans.

Amerigroup : 1-800-600-4441

Health Plan of Nevada : 1-800-962-8074

For families living in the Fee-For-Service benefit area, services may be obtained from any Nevada Medicaid provider who will accept Nevada Check Up. If you need assistance in locating a provider, please call your local Medicaid District Office:

Carson City (775) 684-3653 Reno (775) 688-2811 Las Vegas (702) 486-1550 Elko (775) 753-1191

Third Party Liability

A condition of being eligible for Nevada Check Up is the agreement to assign all rights to any medical claims, medical support or other payments for medical care. Recipients must cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by the Nevada Check Up Program. Recipients must inform Nevada Check Up if any legal action is taken against anyone or if any offer or settlement is received for the reimbursement of medical care and treatment that may be paid for by the Nevada Check Up Program.

Investigations and Referrals

Information provided to NCU may be verified or investigated by federal, state and local officials. If you do not cooperate in the investigation, which may include a home visit, your benefits will be denied or terminated. If you make false or misleading statements, misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, your benefits may be denied or terminated. You are responsible for repayment of all monies paid for services to which you were not entitled and you may be subject to any criminal and/or civil penalties in accordance with state and federal law.

ADDITIONAL DOCUMENTATION NEEDED FOR A COMPLETE APPLICATION:

Employed

Proof of income - two current and consecutive pay stubs (not more than 45 days old from application date) *If paycheck stubs are not available you need to contact Nevada Check Up for an Earnings Verification Form

Unemployed

Current unemployment award letter if receiving unemployment benefits

Self-employed

Complete copy of last year’s tax return

Last 3 months of personal and business bank statements

Other Income

Current year award letter for RSDI, SSI, Worker’s Compensation, VA Benefits, Disability Benefits, Pension Payments, interest/dividends received, proof of money from property (rent received) and proof of any other income not listed

Proof of child support including amount and frequency per child if applicable

Page 6 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

⇩ Nevada Check Up Application File

Form Specs

Fact Details
Program Name and Purpose Nevada Check Up (NCU) is the Children's Health Insurance Program (CHIP) in Nevada, designed to provide low-cost health care coverage to uninsured children up to 18 years of age who meet specific program guidelines.
Eligibility Review for Medicaid The application includes a review for possible Medicaid eligibility. If children may be eligible for Medicaid, NCU enrollment will be denied, and the case may be referred to the Division of Welfare and Supportive Services (DWSS) for further eligibility review.
Quarterly Premiums Based on Income NCU charges a quarterly premium that varies based on the family's income and size, determined by the Federal Poverty Level (FPL). American Indian families from federally recognized tribes or Alaska Natives have these premiums waived with proper proof.
Governing Laws for Integrity and Compliance The application process is governed by Nevada Revised Statutes (NRS) sections 53.045, 199.120 through 199.200, and 41.365, emphasizing the importance of truthful and accurate application information under penalty of perjury.

How to Fill Out Nevada Check Up Application

If you're looking to apply for Nevada Check Up, the state's Children’s Health Insurance Program (CHIP), preparing accurately is crucial for a smooth process. Nevada Check Up offers comprehensive medical benefits including dental and vision care for children meeting the eligibility criteria. It’s designed for uninsured children under 19 years who do not qualify for Medicaid and meet income requirements. Here's a straightforward guide to help you fill out the Nevada Check Up Application form correctly. This guide aims at making the application steps clear and less daunting.

  1. Before starting, if anyone in your household was previously enrolled in Nevada Check Up, have your family identification number ready.
  2. Check whether you’d like your application to be referred to Nevada Medicaid if applicable. This is important because your child(ren) might be eligible for Medicaid instead.
  3. Indicate if you are currently applying for Medicaid medical assistance for any listed individuals.
  4. Under the section titled ‘Person or Head of the Household Applying for Child(ren)’, fill in the detailed information of the applicant. This includes name, Social Security Number, Date of Birth, Marital Status, Race/Ethnicity, Citizenship Status, Preferred Language, and full contact details.
  5. Provide information about your household, including the total number of people and whether your residence will remain in Nevada. Include details about subsidized rent or mortgage if applicable.
  6. List all adults in the household, attaching an additional sheet if needed, to ensure that the application captures the complete information about the household composition.
  7. For each child in the household, provide their full information as requested on the form, including Social Security Numbers, Date of Birth, Citizenship Status, and details regarding any current health insurance coverage. Remember to specify the relationship to the applicant and fill out details about child care expenses if applicable.
  8. Enter employment information for every adult in the household. Include employer details, gross pay, and frequency of payment and also provide proof of income, which should not be more than 45 days old.
  9. List any other sources of income received by anyone in the household, ensuring to provide current proof for each.
  10. Select a health plan for the children or acknowledge that one will be chosen for you if not selected.
  11. Fill out the referral information section by indicating how you heard about Nevada Check Up.
  12. Read the Signature and Affirmation section carefully, ensuring you understand your obligations and the truthfulness of the information provided. Have the application signed by the applicant and any other adult mentioned in the form.
  13. Review your application thoroughly for accuracy and completeness before sending it to the Nevada Check Up Program at the address provided on the form. Include any additional sheets, proof of income, and documentation necessary to support your application.

Following these detailed steps will guide you towards completing the Nevada Check Up Application with greater confidence. Remember, the accurate and complete submission of this form is crucial for the review process, which may lead to health care coverage for eligible children in your household. Should you have any questions or require clarification, do not hesitate to contact the provided helplines for assistance.

Obtain Clarifications on Nevada Check Up Application

  1. What is Nevada Check Up?

    Nevada Check Up is the state of Nevada Children’s Health Insurance Program (CHIP), a federal and state-funded program that offers low-cost health care coverage to uninsured children up to 18 years of age. It is designed for children who meet certain eligibility criteria. The aim is to provide comprehensive medical, dental, and vision care to those who do not have access to insurance.

  2. How does the application process work for Nevada Check Up?

    To apply for Nevada Check Up, you must complete and submit the NCU application form. The form requires detailed information about the person applying on behalf of the child(ren), including social security numbers, citizenship status, and financial information. Applicants must also answer whether they want the application referred to Nevada Medicaid if applicable. Upon submission, the application will undergo a review process which may include referral to the Division of Welfare and Supportive Services (DWSS) for Medicaid eligibility review if it seems the children may qualify for Medicaid.

  3. What are the eligibility criteria for Nevada Check Up?

    Eligibility for Nevada Check Up depends on several factors:

    • Children must not be covered by Medicaid or any other health care coverage or have had insurance in the last six months.
    • Applicants must not be covered by the Public Employee Benefits Program (PEBP).
    • Eligibility is also based on citizenship or lawful permanent resident status and meeting federal income guidelines, which is within 200% of the Federal Poverty Level (FPL).
    • Children must be younger than 18 years and 11 months at the time of application.

    Applying will not affect your family’s immigration status, making it safe for families of different statuses to apply.

  4. What costs are involved with Nevada Check Up?

    There is a quarterly premium for Nevada Check Up, which depends on family size and income. The program charges one premium per family, not per child. Premium levels range from $25 to $80 based on the family's income as a percentage of the Federal Poverty Level. American Indian or Alaska Native families from federally recognized tribes have their premiums waived upon providing proof of status.

  5. How long does it take to process the Nevada Check Up application, and what happens if I don’t agree with the decision?

    The eligibility determination process for Nevada Check Up can take up to 45 days from when a complete application, with all necessary documents, is received. Applicants will be notified by mail about the coverage start date and premium amount once approved. If the application is denied, or if there’s disagreement with any decision made by Nevada Check Up, including the timeliness of the determination, you have the right to request a hearing. This request must be made in writing within 30 days of the decision letter. Detailed instructions on how to appeal will be provided with the decision notice.

Common mistakes

Completing the Nevada Check Up (NCU) Application form can sometimes be confusing, leading to several common mistakes. These errors may delay the process or affect the eligibility of children for the Children’s Health Insurance Program (CHIP). Recognizing and avoiding these mistakes ensures a smoother application process.

One frequent mistake is incomplete information. The application requires details about all household members, not just the children applying for NCU. Each adult and child’s information must be fully completed, including name, date of birth, social security number, and citizenship status. Leaving sections incomplete may result in the need for further clarification, which can delay the application.

Another common error is failing to attach required documentation. For instance, the application asks for copies of birth certificates for children in the household and proof of lawful permanent residency if applicable. Missing documents can stall the application process as officials will need to request these documents before proceeding.

  1. Not properly disclosing income and employment details can lead to issues in the eligibility review. The form requires accurate information about every source of income and employment for each adult in the household. It is crucial to provide complete details and attach the necessary income verification documents.
  2. Applicants sometimes mistakenly ignore the health insurance section. If the child is currently covered by or eligible for other health insurance, including Medicaid, this must be disclosed. Nevada Check Up is designed for children who do not have access to other health insurance. Therefore, transparency about existing coverage is essential.
  3. Finally, a notable mistake is not choosing a health plan or not indicating a preference. While the application notes that a plan will be assigned if no preference is indicated, it's beneficial for applicants to review the available options and select a plan that best suits their children's needs. This decision can impact the accessibility and convenience of receiving medical services.

In summary, avoiding these mistakes involves filling out the application with complete and accurate information, including all required documentation, and understanding the rules regarding eligibility and health plan selection. By paying close attention to the details and requirements on the Nevada Check Up Application form, applicants can aid the smooth processing of their application and secure adequate health coverage for their children.

Documents used along the form

When applying for Nevada Check Up, several other forms and documents may also be required to complete the application process and ensure accurate eligibility determination. These can vary based on individual circumstances but generally include proof of income, residency, and more. Below is a list of commonly used forms and documents alongside the Nevada Check Up Application form.

  • Proof of Income Documents: These are essential for verifying the household income level. Examples include recent pay stubs, tax returns, unemployment benefits statements, or any documentation of income received by household members.
  • Proof of Nevada Residency: Applicants must demonstrate they reside in Nevada. Documents like a recent utility bill, rental agreement, or a state-issued ID can serve as proof.
  • Birth Certificates for Children: These are required to verify the ages of the children being enrolled.
  • Proof of U.S. Citizenship or Legal Residency: This may include U.S. birth certificates, passports, or lawful permanent resident cards to confirm eligibility based on citizenship status.
  • Social Security Numbers (SSNs): Providing the SSNs for all applying individuals is crucial for processing the application.
  • Previous Health Insurance Information: If the child or any family member was previously insured, documentation such as the insurance policy or termination notice may be needed.
  • Child Care Expense Documents: For households claiming child care expenses, receipts or statements from the child care provider are required.
  • Medical Support Statement: If applicable, documentation regarding any medical support or health insurance coverage provided by a non-custodial parent may be required.

Gathering the correct documents is a crucial step towards successfully applying for Nevada Check Up. It ensures that the application is processed efficiently and helps in determining the correct eligibility and benefits for the children needing health insurance. Applicants should carefully review their forms to ensure all necessary information and documentation is provided.

Similar forms

The Nevada Check Up Application form is similar to several other types of application forms due to its comprehensive approach in collecting personal information, household demographics, and financial details to assess eligibility. Some of these forms and how they compare are listed below:

  • Medicaid Application Forms: Just like the Nevada Check Up (NCU) form, Medicaid applications also require detailed personal, health, and financial information about individuals and families to determine eligibility for medical assistance. Both forms inquire about household income, the number of people in the household, employment status, and whether applicants have access to other health insurance options. The emphasis is primarily on assessing the financial need and eligibility for health coverage programs.
  • Free Application for Federal Student Aid (FAFSA): Although the FAFSA is intended for a different purpose—assisting with educational funding—it similarly collects extensive financial information from applicants and their families. Both the NCU and the FAFSA forms require applicants to report income and other financial resources to establish eligibility for financial assistance. The NCU focuses on health insurance coverage, while the FAFSA determines financial aid for education, yet both are instrumental in providing support based on financial need.
  • State Housing Assistance Programs: Application forms for state housing assistance programs often resemble the Nevada Check Up Application in their requirements for detailed household information, income levels, and other financial indicators to establish eligibility for aid. Both types of applications may ask about the number of people living in the household, their incomes, and whether they receive any form of public assistance. The goal is to evaluate the applicant's financial standing and need for assistance, whether it be for health insurance (as in the case of NCU) or housing support.

Each of these application forms, including the Nevada Check Up Application, serves as a gateway to essential support services, relying on thorough personal and financial information to ensure assistance is provided to those most in need. While the specifics of what each application seeks to achieve vary, the underlying principle of assessing eligibility based on detailed personal and financial information remains a common thread.

Dos and Don'ts

When filling out the Nevada Check Up Application form, it is important to pay attention to both the details you should include and avoid. Following these do's and don'ts will help ensure that your application is complete, accurate, and processed efficiently.

Do:
  • Provide complete and accurate information for every question. If a question is not applicable, mark it as "N/A" instead of leaving it empty.
  • Double-check Social Security numbers and dates of birth for each household member listed to avoid any mistakes that could delay the process.
  • Select "Yes" if you want the application to be referred to Nevada Medicaid if applicable. This ensures that you won't miss out on any potential benefits.
  • Sign and date the application form. An unsigned application is considered incomplete and will be rejected.
Don't:
  • Provide false or misleading information. This can lead to your application being denied, and you may face criminal and/or civil penalties according to state and federal law.
  • Forget to report changes in household status, such as changes in income, address, family size, or other insurance coverage. These changes can affect your eligibility.
  • Ignore the requirement to submit necessary documentation along with your application, such as proof of income, citizenship, or residency. Incomplete applications will delay the approval process.
  • Overlook the section regarding health plan selection. If you do not choose a health plan, one will be chosen for you. It is in your best interest to review the options and choose the one that best meets your family's needs.

Misconceptions

Many people have misunderstandings about the Nevada Check Up (NCU) application form for the Children’s Health Insurance Program (CHIP). Here are seven common misconceptions and the truths behind them:

  • Only children with U.S. citizenship can apply. This is not entirely true. While U.S. citizens are eligible, so are Lawful Permanent Residents (LPR) who have had this status for at least five years, including undocumented aliens under certain conditions. The important factor is the child's need for health coverage, not solely their citizenship status.
  • Applying for Nevada Check Up will affect the family’s immigration status. Many families are concerned that applying for NCU may impact their immigration status negatively. However, information regarding citizenship status is confidential and not reported to the Immigration and Naturalization Service (INS), ensuring that applying for health benefits will not directly affect a family's immigration status.
  • No coverage if previously insured or eligible for Medicaid. The truth is, children who have not had insurance in the last six months or who are not currently covered by or eligible for Medicaid can apply for Nevada Check Up. This program specifically aims to assist uninsured children who do not qualify for Medicaid.
  • The process is available only in English. This is not the case; assistance and application forms are available in both English and Spanish to accommodate a wider range of applicants. Spanish speaking staff is also always available to help with any questions or concerns.
  • It covers only basic health services. Nevada Check Up provides comprehensive medical, dental, and vision care for children. This means most medically necessary services are covered under the program, not just basic health services.
  • Application details are shared with law enforcement agencies. Information provided on the application is confidential and used solely for the purpose of determining eligibility for health coverage. While it's true that information may be verified or investigated by federal, state, and local officials, this is done to ensure accuracy and eligibility, not for law enforcement purposes.
  • There's a high cost to participate. Many people believe that the costs associated with Nevada Check Up are high. However, the program requires only a low quarterly premium based on the family's income level and size, making it an affordable option for health insurance. For some families, especially those with American Indian children who are members of federally recognized tribes, premiums may even be waived.

Understanding the facts about the Nevada Check Up application can help eligible families access necessary health coverage for their children without undue concern about immigration status, language barriers, or financial constraints.

Key takeaways

When it comes to applying for Nevada Check Up (NCU), the state's Children's Health Insurance Program (CHIP), it's important to carefully fill out the application form to ensure your children have access to comprehensive health care coverage. Here are some key takeaways to guide you through the process.

  • Initially, your application may be reviewed for Medicaid eligibility. If your children appear eligible for Medicaid, your NCU enrollment will be denied, and your case may be referred to the Division of Welfare and Supportive Services for a Medicaid eligibility review.
  • The application asks whether you want it to be referred to Nevada Medicaid if applicable. This is a crucial question as it could streamline the process of obtaining coverage for your children.
  • Complete information about the head of the household and all adults living in the household, including citizenship status, is required. Despite asking for citizenship status, the information received is not reported to the Immigration and Naturalization Service (INS).
  • Provide detailed information about each child in your household, including their citizenship status, social security number, and any health insurance they currently have or had in the past. This information is essential for eligibility determination.
  • Employment information for each adult in the household is needed, along with the most current proof of income. This helps in determining the family’s financial eligibility for the program.
  • Applicants must choose a health plan or have one assigned to them if they don't indicate a preference. It's essential to understand the health plan options and select one that best fits your children's healthcare needs.
  • A section on the form is dedicated to premium payments, which are based on family size and income. Understanding how premiums are calculated and their due dates ensures that your children's coverage is not interrupted.
  • By signing the application, you agree to report any changes in your family's status, such as address, household members, or eligibility for Medicaid. You also acknowledge your responsibility for any false information provided which can lead to denials or termination of benefits, and required repayments for services rendered under false pretenses.

Completing the Nevada Check Up application requires attention to detail and honesty in providing all required information. Ensuring accuracy and completeness can help secure health coverage for your children, allowing them to access necessary medical, dental, and vision care. If you have questions or need assistance filling out the form, help is available through the specified contact numbers and website.

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