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1-877-KIDS-NOWhealth.utah.gov/chipMember Guide
Important Phone NumbersCHIP Premium Line: 1-866-435-7414 (select option 5)CHIP Hotline: 1-877-KIDS-NOW (1-877-543-7669)Health Program Representative (HPR): 1-866-608-9422CHIP Website: www.health.utah.gov/chipCHIP Online Education: www.health.utah.gov/umbMy CHIP Case Number:My Local Eligibility Office:My Doctor:My Local Pharmacy:My Dentist:Health PlansSelectHealth: 1-800-515-2220 or www.selecthealth.orgMolina: 1-888-483-0760 or www.molinahealthcare.comDental PlansPremier Access: 1-877-854-4242 or www.PremierLife.comDentaQuest: 1-800-483-0031 or www.dentaquestgov.comOtherFind an Eligibility Office Near You: 1-888-222-2542DWS Eligibility Services Center: 1-866-435-7414Primary Care Network (PCN): 1-888-222-2542 or www.health.utah.gov/pcnUtah’s Premium Partnership (UPP): 1-888-222-2542 or www.health.utah.gov/uppMedicaid: 1-800-662-9651 or www.health.utah.gov/medicaidGeneral Information: 2-1-1
CHIPChildren’s Health Insurance Program1-877-KIDS-NOW chipMember GuideJuly 2010
Table of ContentsIntroductionWelcomeSummary of Covered BenefitsYour Health Program Representative (HPR)Your Local Eligibility OfficeEnrollment RenewalInterpretive ServicesHIPAA Privacy ActChoosing a Health PlanHow To Choose a Health PlanCountiesHospitalsHow To Choose a Dental PlanCommon Questions about Health PlansPremiums and Co-paysPremiumsCo-paysCo-pay Plans A/B/CMaximum Out-of-Pocket CostsResourcesFind Your Local Eligibility OfficeOut-of-Pocket Maximum Claim FormHealth Plan Selection FormNotice of Privacy Rights5667788891011121415171819202325262729313
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CHIP Member GuideINTRODUCTION
WelcomeWelcome to the Children’s Health Insurance Program (CHIP). Manyworking Utah families who do not have health insurance for theirchildren may qualify for low cost insurance. CHIP offers manybenefits and provides these services through two health plans: SelectHealth Molina Healthcare of UtahAfter you have been approved for CHIP, it is time for you tochoose a health plan so that you can begin using your benefits andservices. CHIP benefits are the same no matter which healthplan you choose. Your local Health Program Representative (HPR)will help you through that process (see page 10).For information about CHIP policies, please see the CHIP PolicyManual by visiting www.utahcares.utah.gov/infosourcechip.Summary of Covered BenefitsCHIP covers the following benefits for your children: Well-child exams ( 0 co-pay)Immunizations ( 0 co-pay)Doctor visitsMedical emergency servicesPrescriptionsHearing and vision examsMental health servicesDental services for prevention and treatment of tooth decay( 0 co-pay for exams and cleanings)Because preventive care is so important in keeping your childhealthy, CHIP does not require a co-pay for well-child exams andimmunizations. For a more detailed list of benefits and co-pays,see page 19. After you choose a health plan, SelectHealth orMolina will send you a booklet describing these services.6
Your Health Program RepresentativeYour HPR will help you choose your health and dental plans, aswell as: Offer free classes to you about how CHIP works Answer general questions about your health plan Give online education tools about CHIP atwww.health.utah.gov/umbSee “How to Choose a Health Plan” on page 10 for moreinformation.Your Eligibility OfficeAn eligibility representative from the Department of WorkforceServices (DWS) reviews your CHIP application, determines if youare eligible, and conducts your annual enrollment renewal. Youmust call the eligibility office if you have a: Change in the number of family members living at home Change of address, phone number, or move out of state Change in health insurance coverage (Let them know within10 days if your child enrolls in other health insurance or ifinsurance becomes available through your work.)You do not need to call your eligibility worker when your incomechanges. However, if your income goes down a lot, you may wantto call your eligibility office to see if you qualify for lowerco-pays, premiums, or for a different medical assistance program.To talk to an eligibility worker, call the Eligibility Services Centerat 1-866-435-7414. To find an eligibility office near you, call1-888-222-2542.Eligibility Concerns. When you apply for CHIP, you may be told youare not eligible. If you feel you may have been treated unfairly,you have the right to: Talk with an eligibility worker or his/her supervisor Call the DWS Office of Constituent Services at 1-800-331-4341 Ask for a fair hearing7
Enrollment RenewalCHIP reviews your enrollment every twelve months from the timeyou started. At that time, CHIP will send you a renewal form. You will need to complete the form and follow theinstructions on the renewal form. If you are still eligible for CHIP, you will continue to pay yourpremiums (see page 18).It is important to complete the renewal process on time or yourcase may be closed. If your case is closed for more than a month,you will need to call the DWS Eligibility Services Center andre-apply.Interpretive ServicesIf you are deaf or hearing impaired, or speak another language,you can get an interpreter. When you call the CHIP hotline orCHIP premium office, CHIP provides an interpreter over thephone to help you. If you need interpretive services at yourdoctor or dentist’s office, call you health plan (SelectHealth/Molina) or dental plan (Premier Access/DentaQuest) before yourappointment to make arrangements.Health Insurance Portability andAccountability Act (HIPAA)The HIPAA Privacy Act describes how medical information aboutyou may be used and disclosed and how you may get theinformation. The Utah Department of Health is committed toprotecting your medical information, providing this notice to you,and abiding by the terms of the notice (see page 32).Reference: www.health.utah.gov/hipaa8
CHIP Member GuideCHOOSING AHEALTH PLAN
How To Choose a Health PlanCHIP has two health plans: SelectHealth and Molina. You maychoose the one you want. Both plans offer the same CHIPbenefits.Follow the steps below to choose your health plan:1. Decide between SelectHealth and Molina If you are approved for CHIP, you will get a letter asking youto choose a health plan. It is critical that you choose your health plan as soon as youare approved, so that you can take full advantage of thebenefits and services offered by CHIP. Your HPR will help you choose your plan. Use the following charts (pages 11-13) to help you decidewhich medical plan is best for your family.2. Contact your Health Program Representative (HPR). Once you have chosen a health plan, contact your HPR by: Email. Send an email to chiphpr@utah.gov withyour plan choice, case number, names of parent/guardian and children, and contact information. Mail. Using the “Health Plan Selection Form” (page 29),mail it to:BMHC CHIP HPRPO Box 143108, SLC, UT 84114 Fax. Using the “Health Plan Selection Form” (page 29),fax it to: (801) 237-0743 Phone. Call you HPR using the following phone numbers:If you live in Salt Lake County:Call toll-free:(801) 526-94221-866-608-9422Note: If you do not tell your HPR which health plan you want,one will be chosen for you.10
CountiesThis is a list of counties where CHIP services are offered. CHIPbenefits are the same no matter which plan you choose. Contactthe health plans if you need more information.CountiesAvailableBeaverBox randIronJuabKaneMillardMorganPiuteRichSalt LakeSan re.com 11
HospitalsThis is a list of hospitals where CHIP services are offered.Hospitals12SelectHealthMolina Allen Memorial HospitalAlta View HospitalAmerican Fork HospitalAshley Regional Medical CenterBear River Valley HospitalBear Lake Memorial HospitalBeaver Valley HospitalBlue Mountain HospitalBrigham City Community HospitalCache Valley Specialty HospitalCassia Regional Medical CenterCastle View Memorial HospitalCentral Valley Medical CenterDavis Hospital & Medical CenterDelta Community Medical CenterDixie Regional HospitalFillmore Community MedicalCenterFranklin County Medical CenterGarfield Memorial HospitalGunnison Valley HospitalHeber Valley Medical CenterHuntsman Cancer HospitalIntermountain Medical CenterJordan Valley HospitalKane County HospitalLakeview HospitalLDS HospitalLogan Regional HospitalMcKay Dee Medical CenterMilford Valley Memorial HospitalMountain View HospitalMountain West Medical CenterOgden Regional Medical Center*Requires prior approval from the health plan *
Hospitals (continued)HospitalsSelectHealthOneida County HospitalOrem Community HospitalThe Orthopedic SpecialtyHospitalPark City Medical CenterPioneer Valley HospitalPrimary Children’s MedicalCenterRiverton HospitalSalt Lake Regional MedicalCenterSan Juan HospitalSanpete Valley HospitalSevier Valley Medical CenterSt. Marks HospitalTimpanogos Regional HospitalUintah Basin Medical CenterUniversity of Utah HospitalUtah Valley Regional MedicalCenterValley View Medical CenterMolina * *Requires prior approval from the health plan13
How To Choose a Dental PlanCHIP has two dental plans: Premier Access and DentaQuest.Wasatch Front. If you live along the Wasatch Front (includingSalt Lake, Utah, Weber and Davis counties) you have the choiceto choose between DentaQuest and Premier Access.The benefits and co-pays for Premier Access and DentaQuest arethe same but the list of dentists may be different. Please checkwith your current dentist to see which dental plan they accept.Or you may contact each plan toll-free, to find out if your dentistis already in their network.Once you have selected your dental plan, contact your HPR withyour dental plan selection: Email. Send an email to chiphpr@utah.gov withyour plan choice, case number, names of parent/guardian and children, and contact information. Mail. Using the “Health Plan Selection Form” (page 29),mail it to: BMHC CHIP HPR, PO Box 143108, SLC, UT84114 Fax. Using the “Health Plan Selection Form” (page 29),fax it to: (801) 237-0743 Phone. Call you HPR using the following phone numbers:If you live in Salt Lake County:Call toll-free:(801) 526-94221-866-608-9422Note: If you do not tell your HPR which dental plan you want,one will be chosen for you.Non-Wasatch Front. If you live in any other county besides SaltLake, Utah, Weber and Davis, you will have Premier Access asyour dental plan. Before you receive dental treatment, pleasecheck with your dentist to make sure they accept Premier Accessinsurance.14
Common QuestionsWhat will my health and dental plans do for me? Process your claims Send you medical and dental ID cards Send you a booklet of health care providers for youto choose from Pre-authorize procedures when needed Answer your questions about benefitsWhen will I get my medical and dental cards?You will receive your ID cards within 2-3 weeks afterselecting your health plan for each child enrolled in CHIP. Ifyou do not get your card or if you lose it, call your plan.What should I do if my children need health care before weget the CHIP ID cards?Call your HPR or health plan. In some cases you will needto pay for services and then be reimbursed.Will I get a new card if I add a family member to CHIP?Yes. Contact your eligibility worker to add a family memberto CHIP. After that, you will get a card for that child.Who provides CHIP dental benefits?DentaQuest and Premier Access are the dental plans forCHIP. If you live along the Wasatch Front area (includingSalt Lake, Utah, Weber and Davis counties) you have thechoice to choose between DentaQuest and Premier Access.If you live in any other county besides Salt Lake, Utah,Weber and Davis counties, you will have Premier Access asyour dental plan.How do I know what is covered by CHIP?Your health and dental plans will send you a packetthat includes information about covered benefits, preauthorization, and a list of providers you may use. Callyour health plan if you do not receive it within 4-6 weeks.15
Do we have to use a participating provider?Yes. Both your health and dental plans require you to use aprovider that participates in their networks.Do I need to get a referral before I can see a specialist?Check with your health and dental plan before visiting aspecialist.Which pharmacies can I use?You may use any SelectHealth approved or Molina approvedpharmacy. Your health plan will send you more details.Can I get help in coordinating my medical services?Yes. SelectHealth and Molina offer case managementservices to help you coordinate your medical services.Contact your health plan for more information.Can I change my health and dental plans?You must stay with your selected health and dental plansthrough June 30 of each year. However, you can changeyour plan during the yearly plan switch period from May tomid-June. Any changes made at that time will be effectiveJuly 1 of that year. You will get a letter each year toremind you of the yearly plan change period.If you move to a different county within Utah, you mustcall your HPR because your current health or dental planmay not be available in your new county.For more information, contact your HPR (see page 10).Are there any other benefits I should know about?Call SelectHealth or Molina to learn about incentives orother programs they may offer.16
CHIP Member GuidePREMIUMS& CO-PAYS
Premiums*Depending on your income, you may need to pay a premium (upto 75) every quarter. The premium is a set amount no matterhow many children you have.The Department of Workforce Service (DWS) Business Office willsend an invoice when your premiums are due. You will receive anew invoice every three (3) months, starting with the first monththat your child enrolled in CHIP.DWS has monthly payment options available for you, too. Justcall the DWS Business Office and ask.You may choose any of the following ways to pay your premiums: Online: www.jobs.utah.gov/mycase Phone: DWS Business Office 1-866-435-7414 (select option 5)(Monday - Thursday, 7 a.m. - 5:30 p.m.) Mail: Department of Workforce ServicesBusiness OfficeP.O. Box 143250Salt Lake City, UT 84114-3250Late Fee. It is very important that you pay your premium ontime. If you do not pay it by the due date, a 15 late fee will becharged to your account. You will then have to pay the premiumand the late fee to keep your child on CHIP. If you do not payyour premium, your case will be closed.18
Co-pays*Most CHIP families will need to pay a co-pay for medical anddental services. Based on your income, a representative fromyour local eligibility office will determine which CHIP Co-pay PlanA, B, or C you are eligible for. The co-pay plan you are assignedto will be listed on your CHIP ID card. The next few pages outlinethe benefits and co-pays for each plan. Preventive care serviceslike immunizations and well-child exams do not have a co-pay.Deductible. Plan A does not have a deductible. However, PlanB and Plan C require that you pay a deductible. A deductible isthe part of a claim that is not covered by CHIP. You must pay thedeductible first before CHIP can pay the remaining cost of thesebills. This applies to inpatient, outpatient hospital, and majordiagnostic services.*Co-pay plans and premiums are based on your income. AmericanIndians/Alaska Natives do not pay premiums or co-pays.19
CHIP Co-Pay Plan AOut-of-Pocket Maximum5% of family’s annual gross income, includingdental expenses*Premium 0Pre-existing ConditionNo waiting periodMedical BenefitsDeductibleNoneWell-Child Exams 0Immunizations 0Doctor Visits 3Specialist Visits 3Emergency Room 3Ambulance5% of approved amountUrgent Care Center 3Ambulatory Surgical & Outpatient Hospital 3Inpatient Hospital Services 50Lab & X-ray 0 for minor diagnostic tests and x-rays; 3 for major diagnostic tests and x-raysSurgeon 0Anesthesiologist 0PrescriptionsPreferred Generic DrugPreferred Brand Name DrugNon-Preferred Drug- 1- 1- 5% of approved amountMental Health ServicesINPATIENT HOSPITAL - 50OUTPATIENT VISIT- 3Residential Treatment5% of approved amount (25 day limit per year)Physical Therapy 3 (20 visit limit per year)Chiropractic VisitsNot a covered benefitHome Health & Hospice Care 3Medical Equipment & Supplies 3Diabetes Education 0Vision Screening 3 (1 visit limit per year)Hearing Screening 3 (1 visit limit per year)Dental Benefits20Deductible 0Maximum Benefit (Preventive, Basic & Major services) 1,000 per year, per childPreventive Services- Routine exams and cleanings (2 per year), topicalfluoride, x-rays 0Basic Services- Fillings, extractions, oral surgery 0Major Services- Crowns, bridges, dentures, endodontics, periodontics5% of approved amountOrthodontics5% of approved amount (12-month waiting period & 1,000 lifetime maximum**)Specialists- Endodontists, oral surgeons, periodontists, pediatricspecialists, prosthodontists5% of approved amount* CHIP will send you an approval letter, telling you the out-of-pocket maximum amount for your family.** Orthodontic services are not included in the annual maximum benefit.
CHIP Co-Pay Plan BOut-of-Pocket Maximum5% of family’s annual gross income, including dentalexpenses*Premium 30/family/quarterPre-existing ConditionNo waiting periodMedical BenefitsDeductible 40 per familyWell-Child Exams 0Immunizations 0Doctor Visits 5Specialist Visits 5Emergency Room 5; 10 for non-emergencyAmbulance5% of approved amount after deductibleUrgent Care Center 5Ambulatory Surgical & Outpatient Hospital5% of approved amount after deductibleInpatient Hospital Services 150 after deductibleLab & X-ray 0 for minor diagnostic tests and x-rays; 5% ofapproved amount after deductible for major diagnostictests and x-raysSurgeon5% of approved amountAnesthesiologist5% of approved amountPrescriptionsPreferred Generic DrugPreferred Brand Name DrugNon-Preferred Drug- 5- 5% of approved amount- 5% of approved amountMental Health ServicesINPATIENT HOSPITAL - 150 after deductibleOUTPATIENT VISIT- 5Residential Treatment5% of approved amount after deductible (25 day limitper year)Physical Therapy 5 (20 visit limit per year)Chiropractic VisitsNot a covered benefitHome Health & Hospice Care5% of approved amount after deductibleMedical Equipment & Supplies5% of approved amount after deductibleDiabetes Education 0Vision Screening 5 (1 visit limit per year)Hearing Screening 5 (1 visit limit per year)Dental BenefitsDeductible 0Maximum Benefit (Preventive, Basic & Major services) 1,000 per year, per childPreventive Services- Routine exams and cleanings (2 per year),topical fluoride, x-rays 0Basic Services- Fillings, extractions, oral surgery5% of approved amountMajor Services- Crowns, bridges, dentures, endodontics, periodontics5% of approved amountOrthodontics5% of approved amount (12-month waiting period & 1,000 lifetime maximum**)Specialists- Endodontists, oral surgeons, periodontists, pediatricspecialists, prosthodontists5% of approved amount* CHIP will send you an approval letter, telling you the out-of-pocket maximum amount for your family.** Orthodontic services are not included in the annual maximum benefit.21
CHIP Co-Pay Plan COut-of-Pocket Maximum5% of family’s annual gross income, including dentalexpenses*Premium 75/family/quarterPre-existing ConditionNo waiting periodMedical BenefitsDeductible 500 per child; 1,500 per familyWell-Child Exams 0Immunizations 0Doctor Visits 20Specialist Visits 35Emergency Room 200; 400 for out-of-network hospitalAmbulance20% of approved amount after deductibleUrgent Care Center 35Ambulatory Surgical & Outpatient Hospital20% of approved amount after deductibleInpatient Hospital Services20% of approved amount after deductibleLab & X-ray 0 for minor diagnostic tests and x-rays; 5% ofapproved amount deductible for major diagnostic testsand x-raysSurgeon20% of approved amountAnesthesiologist20% of approved amountPrescriptionsPreferred Generic DrugPreferred Brand Name DrugNon-Preferred Drug- 15- 25% of approved amount- 50% of approved amountMental Health ServicesINPATIENT HOSPITAL - 20% of approved amount afterdeductibleOUTPATIENT VISIT- 35Residential Treatment50% of approved amount after deductible (25 day limitper year)Physical Therapy 35 after deductible (20 visit limit per year)Chiropractic VisitsNot a covered benefitHome Health & Hospice Care20% of approved amount after deductibleMedical Equipment & Supplies20% of approved amount after deductibleDiabetes Education 0Vision Screening 35 (1 visit limit per year)Hearing Screening 35 (1 visit limit per year)Dental Benefits22Deductible 50 per child; 150 per familyMaximum Benefit (Preventive, Basic & Major services) 1,000 per year, per childPreventive Services- Routine exams and cleanings (2 per year), topicalfluoride, x-rays 0Basic Services- Fillings, extractions, oral surgery20% of approved amount after deductibleMajor Services- Crowns, bridges, dentures, endodontics, periodontics50% of approved amount after deductibleOrthodontics50% of approved amount (12-month waiting period & 1,000 lifetime maximum**)Specialists- Endodontists, oral surgeons, periodontists, pediatricspecialists, prosthodontistsTalk to your dental plan for an estimate of additionalcharges.* CHIP will send you an approval letter, telling you the out-of-pocket maximum amount for your family.** Orthodontic services are not included in the annual maximum benefit.
Big Title Out-of-Pocket CostsMaximumCon vel iriusto ea acilla amconse consequam velit aute feumWhat is the most I will need to pay?san hent nis nis eugue magnismod dolut wissequisit nit iure conYouwillnitnotaciduipsumpay more than5% ofutyourfamily’s utpat.incomeDuntforhendrefeuisatumsanla feuguerilthepremiumsand co-payseach plantat,yearvel utetincosthentofduissequipissequat,commolorecore ,sisit, se mod eratet, se tet prat. Alit adit nonsequ ismolutvel elittellingyoutheout-of-pocketmaximum.ilisit vel duiscilisl ex el ing endigna faccum verostrud modignibheugiam esecte magnit praesenit landrem inis adipit lum ipsumWhat happenswhen I sumhavevenispaidadthemaximumpocket?quationseea conullaortat,quisl iureout-ofmagnisnos nonulput Oncenisl elyouutpateluptatutpatatio eafeum yourzzrilishavedolentreached5% ofyourpratfamily’sincome,auguerciexercilvelpayin endremfamilywill iquamet,no longerquamhave toco-pays zzriurefor thateugiatyear. nostrud mod magna facidunt venissequi tat iliquat ad te mod dolorpercillumvolore convertrackingad magnitveliquatumexpenses?ipsumsa ndiaWhen shouldI m dolendipit,quietadiatefacipitirillandrethe day your child becomes eligible estruddoloremnummyWe have included a form to help you track these expensesnim dolestood ercillaneugiamconullaorefeuguethroughoutthe planyear (July1 - June30). vercinSee theutpatum“Outationsetat. Duisi.of-PocketMaximum Claim Form” on page 27.In ecte magnim quam aci tat. Lor suscin heniat, volor sisl eaHow do I show that I have paid the maximum out-of-pocket?faccummy nulput alit dip eu feugait dolore molore magna core Eachtimenullayou paya co-pay,write sciduntlor si.on the“Out-of-Pocket Maximum Claim Form” (page 27). Once the co-pays add up to your 5% maximum or more,mail or fax the completed claim form to:CHIP, PO Box 144102, Salt Lake City, UT 84114-4102Fax: (801) 538-6860 You can get more claim forms by calling 1-866-772-1261or downloading it from health.utah.gov/chip/resources.What happens next? CHIP will make sure you have met your 5% maximumout-of-pocket costs. If you have met your maximum, CHIP will send you aletter verifying your out-of-pocket maximum is met andthat you do not owe co-pays through June 30 (the end ofthe plan year). You can use the letter to show your health careprovider that you do not owe co-pays until you get anew card. Your health plan will send you a new medical cardshowing that no co-pay is due.23
Big TitleCon vel iriusto ea acilla amconse consequam velit aute feumsan hent nis nis eugue magnismod dolut wissequisit nit iure conhendre feuis nit aciduipsum atumsan ut la feugueril utpat. Duntvel ute tin hent duisseq uipissequat, commolore tat, core velissisit, se mod eratet, se tet prat. Alit adit nonsequ ismolut vel elitilisit vel duiscilisl ex el ing endigna faccum verostrud modignibheugiam esecte magnit praesenit landrem inis adipit lum ipsumquationse ea conullaor sum venis ad tat, quisl iure magnis nos nonulput nisl el utpate dolent luptat utpat prat atio ea feum zzrilisauguerci exercil iquamet, quam vel in endrem zzriure eugiat nostrud mod magna facidunt venissequi tat iliquat ad te mod dolorpercillum volore con ver ad magnit ecte veliquatum ipsumsa ndiatiniam dolor sim dolendipit, qui et adiate facipit irillandre dignafacipissi elis nullaortio odolor susto dolestrud dolorem nummynim dolesto od ercillan eugiamcon ullaore feugue vercin utpatumationse tat. Duisi.In ecte magnim quam aci tat. Lor suscin heniat, volor sisl eafaccummy nulput alit dip eu feugait dolore molore magna coredolendre dolenis nulla autpatie faciliquat, suscidunt lor si.24
CHIP Member Guide
Find Your Local Eligibility OfficeCall 1-888-222-2542 during regular business hours to find your local office.Your local eligibility office can also help you if you have family members onMedicaid, Primary Care Network (PCN), or Utah’s Premium Partnership forHealth Insurance (UPP).You may also call the DWS Eligibility Services Center at 1-866-435-7414 tospeak with an eligibility worker regarding your case.Find Your Local Tribal/Indian Health Services OfficeNameConfederated Tribes ofGoshute Indian ReservationFort Duchesne Indian HealthServices ClinicIndian Walk-In Center, UrbanProgramNavajo Health Systems, Inc.Blanding Family PracticeMontezuma CreekCommunity Health CenterMonument Valley HealthCenterNavajo Mountain HealthCenterNorthwestern Band ofShoshonePaiute Indian Tribe of UtahUte Mountain Ute Health Center26ContactPhoneChristine Steele(435) 234-1194Kaye Black(435) 722-5122Jackie Shirley(801) 486-4877Kathy Redd(435) 678-3601Altheda Dee(435) 651-3778Altheda Dee(435) 651-3778Sara Ateno(928) 672-2494Gayla Pena(435) 734-2286Medical Clinics(general information)(435) 586-1112 or1-800-658-5340Shivwits Clinic(435) 688-8198Cedar City Clinic(435) 867-1520Koosharem Clinic(435) 893-0977Kanosh Clinic(435) 759-2610Joanna Smith(970) 565-4441x. 247
- - - - - - - - - - - - - - - - - - - -You may tear out this page. - - - - - - - - - - - - - - - - - - - -Out-of-PocketMaximum Claim FormMy out-of-pocket maximum is: Parent/Guardian Name:Health and Dental Plan:We have provided this form to help you keep track of your children’s medicaland dental services. After your out-of-pocket maximum is met, return thisform to CHIP (see below). Complete one line for each co-payment or coinsurance you pay. You do not need to submit receipts, but keep them for yourrecords.You may submit claim forms up to one year after the end of the plan year inwhich the expenses occur. The plan year is July 1 - June 30.Child’sNameDate of Did youvisit or pay thisclaimbill? Y/NHealth Care Provider’sAmount ofName and Mailing Address co-pay orco-insuranceSubtotal on this page:Grand Total (for all pages) Return form to:CHIP, PO Box 144102, SLC, UT 84114-4102Fax: (801) 538-6860E-mail: chip@utah.gov27
Date ofvisit orclaimDid you Health Care Provider’spay this Name and Mailingbill? Y/N AddressSubtotal on this page:TOTAL from both pages:Return form to:CHIP, PO Box 144102, SLC, UT 84114-4102Fax: (801) 538-6860E-mail: chip@utah.gov28Amount ofco-pay orco-insurance- - - - - - - - - - - - - - - - - - -You may tear out this page. - - - - - - - - - - - - - - - - - - - -Child’sName
- - - - - - - - - - - - - - - - - - -You may tear out this page. - - - - - - - - - - - - - - - - - - - -Health Plan Selection FormOnce you have chosen a health and dental plan, please mail or fax thisform to your HPR. Or e-mail chiphpr@utah.gov with your plan choice andthe information below.(Please print clearly)Case #Name ofParent/GuardianName(s) ofchild/childrenContactInformation(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of Birth(Address, City, State, Zip)(Daytime Phone)(Cell phone)(E-mail address)My Choice ofHealth Plan o SelectHealtho MolinaMy Choice of (Salt Lake, Utah, Weber, and Davis County Residents Only)Dental Plan o Premier Accesso DentaQuestNote: You must stay with your selected health plan through June 30 ofeach year.Return form to:BMHC CHIP HPR, PO Box 143108SLC, UT 84114-3108Fax: (801) 237-0743E-mail: chiphpr@utah.gov29
(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of Birth(First, Last)Date of BirthReturn form to:BMHC CHIP HPR, PO Box 143108SLC, UT 84114-3108Fax: (801) 237-0743E-mail: chiphpr@utah.gov30- - - - - - - - - - - - - - - - - - -You may tear out this page. - - - - - - - - - - - - - - - - - - - -Name(s) ofchild/children:
Utah Department of Health, Division of Medicaid and Health FinancingNotice of Privacy RightsThis notice describes how medical information about you may beused and disclosed and how you may access this information. Pleasereview it carefully. Effective: 04/14/2003The Utah Department of Health, Division of Medicaid and Health Financing (DMHF) is committedto protecting your medical information. DMHF is required by law to maintain the privacy of yourmedical information, provide this notice to you, and abide by the terms of this notice.Confidentiality Practices and UsesDMHF may use your health inform
Important Phone Numbers CHIP Premium Line: 1-866-435-7414 (select option 5) CHIP Hotline: 1-877-KIDS-NOW (1-877-543-
