The Nevada Check Up Application form serves as the gateway for applying to the Children's Health Insurance Program (CHIP) in Nevada, a program designed to provide low-cost health coverage to uninsured children who meet certain eligibility criteria. It details the process for applying, including questions about household composition, citizenship, income, and health plan selections, while also outlining the steps for potential Medicaid eligibility review. This comprehensive document is a critical first step for families seeking affordable healthcare options for their children under the age of 19, emphasizing a straightforward process for submission and subsequent review.
In a significant move to ensure the well-being of its younger residents, the state of Nevada presents the Nevada Check Up (NCU) Application form, a key instrument for enrolling children in the Children’s Health Insurance Program (CHIP). Emphasizing the importance of prompt assistance, the document opens a pathway for low-cost health coverage for uninsured children up to the age of 18, who fit within the program's guidelines. Crucially, the application delves into detailed queries regarding household composition, including the necessity to list other adults and children living within the home, their employment status, and any other income sources, which contribute to a comprehensive assessment of eligibility. Furthermore, it cross-examines the applicants' eligibility for Medicaid, further ensuring that assistance is thoughtfully directed to those in need. In addition to demographic and financial data, the form requests information concerning health insurance status, highlighting a holistic approach to evaluating the health coverage needs of Nevada’s children. The application process is underscored by an explanation of potential premium costs, premised on family size and income, along with an insight into the selection of health plans, thereby providing families with the necessary tools to make informed decisions about their children’s healthcare coverage. With provisions for both English and Spanish-speaking applicants, the Nevada Check Up program aims to be widely accessible, underlining the state’s commitment to the health and well-being of all its children.
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)
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:
Male
Female
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
Lawful Permanent Resident (LPR) as of
(Date):
Relationship to applicant above
Spouse Sibling Child Parent Other Relative Other :
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NCU-0100 (06/10)
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.
Social Security # (REQUIRED)
(REQUIRED)
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?
Yes
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
Major Medical
Medicare A, B, or D
Step-Child
None
Niece/Nephew
Child Care Expenses - complete if applicable
Amount Paid:
How often paid:
disabled and
receiving SSI?
Yes, Name of Insurance:
Cancer Dental/Vision
Relationship of child to applicant:
(3) Last Name
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(4) Last Name
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
(2) Person Employed - Last, First
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
Amount
Child Support/Alimony
Social Security Payments - select
RSDI
SSI
Disability Payment Source
Unemployment Benefits
Pension Payment and Source
Interest or Dividends (Stocks, Bonds,
Trusts, Mutual Funds, Savings, etc.)
Other (such as cash assistance, etc)
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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
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:
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.
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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
Apr, May, Jun
4th Quarter
July 1
Jul, Aug, Sept
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PLEASE KEEP FOR YOUR RECORDS
NCU App Insert English (06/10)
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
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Filling out the Nevada Check Up Application form is the first step toward securing quality health insurance for children in need under the Children’s Health Insurance Program (CHIP). This guide is designed to help applicants navigate the form accurately to ensure a smooth application process. The steps below outline the necessary information and documents required, simplifying the application process.
After submitting your application, expect the eligibility determination process to take up to 45 days from when a complete application and all necessary documentation are received. You will be notified by mail regarding the outcome of your application, including details about the coverage start date and any applicable premium amount. Should you disagree with any decision made regarding your application or the handling of it, you have the right to request a hearing within 30 days of the decision. Accurate and complete applications ensure a smoother review process, potentially leading to an expedited determination.
Nev Free Coveragenada Check Up is the State of Nevada's Children's Health Insurance Program (CHIP). It's a program funded by both the federal and state government, designed to provide low-cost health care coverage to uninsured children who are under the age of 19. Eligibility is based on the family meeting certain program guidelines.
What health services does Nevada Check Up cover?
Most medically necessary services for children are covered under Nevada Check Up. This includes comprehensive medical care, dental care, and vision care. The program aims to ensure that enrolled children have access to essential healthcare services.
How does a family qualify for Nevada Check Up?
It's important to note that applying for Nevada Check Up does not affect a family’s immigration status.
Are there premium payments required for Nevada Check Up?
Yes, there is a quarterly premium for Nevada Check Up, determined by the family size and income. This premium is charged per family, not per child. Premium amounts vary depending on the family's income level relative to the Federal Poverty Level (FPL), with specific exemptions for American Indian families who are members of federally recognized tribes. In the event that families are enrolled partway through a quarter, premiums will be prorated accordingly.
What is the process if we're eligible for Medicaid instead?
During the review of your Nevada Check Up application, if it appears your children may be eligible for Medicaid, your Nevada Check Up enrollment will be denied, and your case may be referred to the Division of Welfare and Supportive Services (DWSS) for a Medicaid eligibility review. You have the option to decide if you want this application to be automatically referred to Nevada Medicaid if applicable.
How do we apply for Nevada Check Up?
To apply, you must complete the Nevada Check Up Application form. Ensure all required sections are filled out, including information about the head of the household, other adults in the household, children for whom you are applying, employment information of adults, and other income details. It is mandatory to sign the application for it to be processed. Completed applications can be sent to the Nevada Check Up Program office in Carson City, Nevada.
How long does the application process take?
The eligibility determination process for Nevada Check Up may take up to 45 days from the time a complete application, with all necessary documentation, is received. Once eligibility is confirmed, you will be notified by mail regarding the coverage start date and the amount of the premium.
What happens if there are changes in our family situation?
It is your responsibility to report to Nevada Check Up any changes in your children's status, such as a change of address or phone number, moving out of state, becoming eligible for Medicaid or other health insurance, death of a household member, or if the child becomes a resident in a public institution. Timely reporting ensures accurate determination of eligibility and helps avoid potential issues with coverage or financial responsibilities.
Applying for health insurance through the Nevada Check Up (NCU) program, many families look forward to securing affordable healthcare for their children. However, a few common mistakes can affect the application process. Understanding these could help streamline the process and avoid unnecessary delays or denials.
One common misstep is not providing complete and accurate information about every family member residing in the household. The NCU application requires details about each adult and child, including their full names, social security numbers, dates of birth, and citizenship status. Failure to disclose all household members or providing partial information can lead to processing delays or incorrect eligibility determination.
Another error often seen is applicants glossing over the section inquiring about current or previous health insurance coverage. This part of the application asks whether the children have been covered by health insurance within the last six months, a crucial criterion for NCU eligibility. Applicants mistakenly skipping this question or not providing truthful answers might find their application rejected or referred for further review.
A significant number of applicants also forget to indicate whether they'd like their application referred to Nevada Medicaid in case the children are found ineligible for NCU but may qualify for Medicaid. This oversight can result in missing an opportunity for health coverage under Medicaid, especially for families who unknowingly meet Medicaid's eligibility requirements.
Last but not least, another mistake involves the section on income and employment information. The NCU application requests detailed income information and verification for all income sources within the household. Some applicants either leave this section incomplete or do not attach the required income verification documents dated within the last 45 days. This oversight can prevent the application from being processed, as assessing financial eligibility is a critical step in determining qualification for the program.
To maximize the chances of a successful application, it's essential for families to thoroughly review the entire application form, ensure all sections are completed accurately, and attach all required documents before submission. By paying attention to these details, families can improve their likelihood of securing affordable healthcare coverage for their children through Nevada Check.C
Applying for the Nevada Check Up (NCU) involves more than filling out the application form. To ensure that all the necessary information is accurately captured and assessed, there are additional forms and documents often required to support an application. Below is a list of documents typically used alongside the Nevada Check Up Application form.
These documents play a crucial role in the application process by providing the necessary verification for eligibility determination. It's important for applicants to gather and submit all required documentation efficiently to avoid delays in processing their Nevada Check Up Application. Adequate preparation and attention to the details of these accompanying forms and documents can streamline the enrollment process, making it easier for families to receive the health care coverage they need.
The Nevada Check Up Application form is similar to other government assistance forms, such as the Medicaid application and the Supplemental Nutrition Assistance Program (SNAP) application. Just like these forms, the Nevada Check Up form collects detailed personal information, including household size, income, employment details, and citizenship status. This thorough data collection is essential to assess eligibility and ensure that assistance goes to those who truly need it.
Specifically, the form's structure and the nature of questions bear resemblance to the Medicaid application process. Both require applicants to disclose if their children have any existing health coverage and inquire about the desire to be referred to Medicaid if applicable. Furthermore, they share a focus on gathering detailed family and income information to determine eligibility. These similarities underline the close relationship between Medicaid and the Children's Health Insurance Program (CHIP), with Nevada Check Up serving as the state's CHIP implementation.
Another document the Nevada Check Up Application form closely aligns with is the SNAP application. Both applications inquire about household composition, including adults and children living in the home, and require detailed income information from all sources to calculate eligibility. Additionally, both forms prompt for information on other benefits the household might be receiving, which can affect the eligibility and benefit levels. This comparison highlights the comprehensive approach these programs take to understand applicants' financial situations and needs fully.
When filling out the Nevada Check Up Application form, it's important to pay attention to details and follow the guidelines closely. Below are things you should and shouldn't do during the application process:
By following these dos and don'ts, you can help ensure a smoother application process for Nevada Check Up, potentially avoiding delays or issues with enrollment.
When dealing with the Nevada Check Up (NCU) Application, which is essential for gaining access to the Children's Health Insurance Program (CHIP), there are several misconceptions that can lead to confusion. Understanding these can help families navigate the application process more effectively.
Misconception 1: Providing Citizenship Status Information Risks Deportation
One common misconception is the fear that providing information about citizenship status will lead to deportation or negative immigration consequences. The form clearly states that information regarding citizenship status is not reported to the Immigration and Naturalization Service (INS). This misunderstanding can deter families from applying, potentially leaving eligible children without health coverage.
Misconception 2: Only U.S. Citizens Are Eligible for NCU
It’s a common belief that only U.S. citizens are eligible for Nevada Check Up. However, the program is also open to Lawful Permanent Residents (LPRs) and certain other non-citizen categories as long as they've met specific residency requirements. Acknowledging this can encourage a broader group of families to apply, ensuring more children have access to healthcare.
Misconception 3: If Eligible for Medicaid, You Cannot Apply for NCU
Another misconception is the idea that if a child is eligible for Medicaid, they cannot apply for Nevada Check Up. In reality, the application includes questions to determine if the applicant should be referred to Medicaid. This means families should not hesitate to apply for NCU out of concern for Medicaid eligibility; the application process itself will sort out which program is more appropriate for the child’s circumstances.
Misconception 4: Application Information Isn’t Verified
Finally, it might be erroneously assumed that the information provided on the application isn't verified for accuracy. The application does state that Nevada Check Up and/or the Department of Health and Human Services reserves the right to contact any party necessary to verify the information presented. This emphasizes the importance of providing accurate and truthful information to avoid potential penalties including denial or termination of benefits, repayment of services, and possible legal action.
Understanding these misconceptions can alleviate concerns and encourage families who need health insurance for their children to apply for the Nevada Check Up program. The aim is to ensure that all eligible children have access to the healthcare services they need.
When completing the Nevada Check Up Application, it is essential to gather accurate information about every member of your household. This data will play a critical role in determining your children's eligibility for the Children's Health Insurance Program (CHIP) within Nevada. Here are six key takeaways to guide you through the application process:
Remember, the application process for Nevada Check Up can take up to 45 days once all required documents are submitted. It's crucial to fill out the application truthfully and accurately to avoid delays or penalties for misrepresentation. When in doubt, contact the Nevada Check Up program directly for assistance or clarification.
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