Rhode Island Health and Human Services
Application for Assistance – Health Coverage/Medicaid Screen

Please read this sheet over if you are applying for health coverage, including Medicaid. If this is the right application for you, answer the questions below and return this form with your completed application. Your answers will help us process your application more effectively.
Applicant's Name __________________________________________ Social Security Number ______________________________
What is the right Health Care/Medicaid application for me?
This is the right health care/Medicaid application if you want: Medicaid long-term services and supports (LTSS). For people who need help with everyday activities and the tasks necessary to live on their own. May be provided in a nursing facility, hospital, assisted living residence, community residences for people with developmental disabilities or chronic conditions, or in someone’s home. OR
  Medicaid for elders and adults with disabilities (EAD). For people who need health coverage EXCEPT for LTSS. Must be 65 or older or 19 to 65 and have a disability and Medicare. Includes Sherlock coverage if working and have a disability OR
Katie Beckett eligibility for children with serious disabilities/conditions (KB). (KB)Coverage for children up to age 19 who have serious disabilities and are cared for at home and do not qualify for Medicaid in another way.
This MAY NOT be the right application if you want ONLY: Medicaid or a private health plan with financial help to cover children, pregnant women, parents/caretakers or adults 19 to 64 who DO NOT have Medicare. You can APPLY ON-LINE AT: www.healthyrhode.ri.gov or call HealthSource RI at 1-855-840-4774.
IF THIS IS THE RIGHT APPLICATION FOR YOU, check all that apply:
[  ] Working adult with disabilities seeking Sherlock Plan eligibility.
[  ] Medicaid or private health plan and other benefits like child care, food assistance or RI Works.
Applying for Medicaid LTSS and:

[  ] Adult with intellectual/developmental disabilities working with Department of Behavioral Healthcare, Developmental Disabilities and Hospitals (BHDDH)

[  ] Living in a nursing home, assisted living residence, BHDDH group home or other supportive residence.

Name of facility/residence _____________________________________ Date of Entry____________________

[  ] Entering a nursing home, assisted living residence, BHDDH group home or other supportive residence.

Name of facility/residence _____________________________________ Date of Entry____________________

[  ] Living in own home or returning soon to own or someone else’s home.

[  ] Already have Medicaid, but looking for LTSS

[  ] Katie Beckett eligibility for a child under age 19

[  ] Working with community agencies, including through the Division of Elderly Affairs (DEA) or BHDDH

Name of agency ____________________________ Contact Information ____________________________

[  ] Elder or adult with disability (age 19 to 64) eligible for or enrolled in Medicare

[  ] I also need help paying my Medicare premiums costs.

RETURN THIS SHEET WITH THE COMPLETED APPLICATION FOR ASSISTANCE

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