1. Completing the LA HAP Application Download and print the application here.

2. Which forms do I fill out? →If you did not have insurance but are now enrolling in an insurance plan, fill out the LA HAP application for “No Insurance” and the Insurance Add/ Change form for your new insurance plan. →If you have insurance but are enrolling in a different insurance plan, fill out the LA HAP application for your existing insurance plan and the Insurance Add/Change form for your new insurance plan. →If you have insurance OR don’t have insurance and you are not changing anything, fill out the LA HAP application only. See www.lahap.org  “Forms and Applications” for more information on which forms to submit when.www.lahap.org

3. Step 1: Applicant Assistance Information Page 1

4. Which LA HAP services do I need? Insurance premiums are the monthly cost your insurance company charges you to be a member. Insurance copays and deductibles are the costs your doctor might charge you when you visit their office, or when you visit the pharmacy. Medical copays and deductibles are paid at the doctor’s office, hospital, lab, etc. Drug co-pays and deductibles are usually paid at the pharmacy

5. Which LA HAP services do I need? No Insurance” medications only This option is only for clients who do NOT have insurance LA HAP covers the full cost of HIV medications LA HAP does not cover the cost of other medications LAHAP does not cover any medical costs

6. Step 2: Applicant and Contact Information Page 1

7. Residential address : where you live Mailing address : where you want your mail sent Include proof of Louisiana residency with your application Is your residential address different from the address on your proof of residency document? That’s ok, but explain why in “Step 13: Additional Comments” See www.lahap.org  “Forms and Applications” for acceptable types of residency documentation.www.lahap.org Please answer

8. LA HAP will not leave a message unless you say they can. If you do not wish LA HAP to call at all, check “no home phone”/”no cell phone”/”no work phone” Alternate Contact is optional If you do not want LA HAP to talk to anyone besides yourself, do not add an Alternate Contact.

9. Step 3: Demographic Information Page 2

10. Answer #2 even if you are male Answer both race AND ethnicity Choose the relationship status that best fits your situation Legally-married same-sex couples are now counted as “Married- State & Federally recognized” If your status is “Married- State & Federally Recognized” you must provide income documentation for both you and your spouse.

11. Step 4: Household Information Page 2

12. Husband43 Daughter 12/23/99 Carefully review the definition of “Household” at the beginning of the section. List every member of the household of any age and their age or date of birth. Relationship only Names not required You will need to include income documentation for every member of the household age 18 or older. Use the comment box in #3 if you need to explain anything else about your living situation to LA HAP.

13. Step 5: Applicant Employment Information Page 2

14. Let us know about your employment situation. Whether or not you are employed does NOT affect your eligibility. LA HAP will NOT contact your employer. Why does LA HAP need to know how often you are paid? When you provide your income documentation to LA HAP, they can add the amounts correctly to get your yearly income.

15. Step 6: Household Information Page 3

16. Client has income, one or more household members also have income: Documentation of client’s income and household members’ income Client has income, no other household members have any income: Documentation of client’s income only Client has no income, one or more household members have income: Documentation of household members’ income only No one in the household, including client, has income: Certification of No Income or legal affidavit for client only Documentation is required for all forms of income except for Food Stamps/SNAP (but benefit amount must be provided). Why does LA HAP need the SSDI start date? To assess when client was/will be eligible for Medicare (2 years after SSDI start date) Amount: Leave blankLeave blank What income documentation does LA HAP need?

17. Step 7: General Health Information Page 3

18. Insurance can be confusing. Many people may know they have Medicare or Medicaid, but don’t realize this is considered insurance. This is LA HAP’s way of asking, “Are you sure?” before the applicant skips the insurance section altogether. If the answer is “Yes,” you really can skip this section! More on Medicare in a moment… So why does LA HAP ask these questions?

19. Step 8: Primary Health Insurance Policy Information Page 4

20. Fill out this section once for EACH policy you have. The Plan Name is more specific than “Blue Cross Blue Shield” or “Humana.” It can’t be found on the card, but can usually be found by checking the SOB or calling the insurance company. Why does LA HAP need it? HRSA requires us to prove that the plans we work with are as good as or better than uninsured L-DAP coverage. Having the plan name allows us to find this information. Marketplace: effectuation date  end of calendar year Medicare Part D: calendar year Employer-sponsored /group: varies COBRA: varies AlwaysCare: effectuation date  12 months later The plan start and end date will vary based on which type of plan you have.

21. This section is only necessary if you are requesting premium assistance. Including a premium invoice only necessary if you are requesting premium assistance for a new plan. LA HAP cannot assist with past premiums for a time when the client was not LA HAP eligible. Make sure premium payments are up to date. Do you want LA HAP to cover premiums for an employer- sponsored plan? Click here for our Employer HR Form.Click here for our Employer HR Form.

22. Use these pages to fill out additional insurance policy information if you have secondary insurance, COBRA, and/or a standalone dental policy. Complete them exactly as you completed Step 8 on Page 4. If you leave any of these pages blank, return the blank pages to LA HAP anyway. This way we know that no pages are missing. Page 5, Step 9: Secondary Insurance Page 6, Step 10: COBRA Page 7, Step 11: Dental Insurance

23. Steps 13-18: Comments, Consent, Signature, Checklist Page 8

24. Examples of Additional Comments: why the residency documentation provided doesn’t match the address provided; client has just moved from another state; etc. Our checklist is slightly out of date. However, that is because our requirements have become less restrictive. So, no harm in following this checklist except extra work! Helpful but not required Only required if requested by LA HAP Only required if requesting premium assistance for first time on a new plan Please read this carefully. Call LA HAP and ask them to explain anything you don’t understand.

25. What do I need to attach to my application?

26. Proof of your income Attach ONE of the following: 2 pay stubs from the last 6 months A signed legal affidavit from the last 6 months The LA HAP Certification of No Income form from the last 6 monthsLA HAP Certification of No Income Benefit award letter from the current award year (SSDI, etc.) Benefit check from current award year Tax document from most recent award year

27. Proof of your Louisiana residency Attach ONE of the following: LA- issued ID card, not expired LA-issued Driver’s License, not expired Lease agreement, not expired 2 pay stubs from last 6 months with address visible Medical or utility bill from last 6 months Signed, legal affidavit from last 6 months Benefit award letter from current award year

28. Are you requesting premium help for the first time on a new plan? Include an invoice from the insurance company. If LA HAP is already paying your premiums, you do not need to include an invoice.

29. Are you requesting help with a Medicare Part D plan? You must also apply for Low Income Subsidy (LIS), also known as “Extra Help,” an assistance program offered by the Social Security Administration. You can apply for LIS here. With your LA HAP application, attach: a copy of your LIS application receipt (you can print this from the webpage after you apply), OR a copy of your LIS approval or denial letter

30. Submitting your application Fax : 504-568-3157 Mail : LA HAP 1450 Poydras St, Suite 2136 New Orleans, LA 70112

31. Tracking your application

32. When the application is received, LA HAP staff updates the client’s Ramsell profile. Only caseworkers have access to Ramsell Don’t have access? Return the Ramsell User Request form to info@lahap.org Ramsell User Request form info@lahap.org If you’re a client, you can call LA HAP at 504-568-7474 to verify that an application was received

33. 1)LA HAP staff : Will call client/case manager if the problem can be solved over the phone Sends “Application Incomplete” fax to case manager or letter to client if issue can’t be resolved on phone Updates “Other” tab of client Ramsell profile 2) Client/Case manager: Tracks down missing information Returns to LA HAP: missing information + “Application Incomplete” fax sent by LA HAP staff as reference 3) LA HAP staff: Logs follow-up information as received in “Other” tab; files for processing Application will be reviewed again by LA HAP staff What the caseworker will see in Ramsell: Incomplete applications

34. Questions? Please give us a call at 504-568-7474.