Completing the LA HAP Application

Download and print the application here.

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.

Step 1: Applicant Assistance InformationPage 1

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

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

Step 2: Applicant and Contact InformationPage 1

• 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.

Please answer

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.

Step 3: Demographic InformationPage 2

• 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.

Step 4: Household InformationPage 2

Husband 43Daughter 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.

Step 5: Applicant Employment InformationPage 2

• 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.

Step 6: Household Information Page 3

• 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 blank

What income documentation does LA HAP need?

Step 7: General Health Information Page 3

• 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?

Step 8: Primary Health Insurance Policy Information Page 4

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.

• 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.

• 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 InsurancePage 6, Step 10: COBRAPage 7, Step 11: Dental Insurance

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

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.

What do I need to attach to my application?

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

months• Benefit award letter from the current award year (SSDI, etc.)• Benefit check from current award year• Tax document from most recent award year

Proof of your Louisiana residencyAttach 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

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.

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

Submitting your application

Fax: 504-568-3157

Mail: LA HAP1450 Poydras St, Suite 2136New Orleans, LA 70112

Tracking your application

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

• If you’re a client, you can call LA HAP at 504-568-7474 to verify that an application was received

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

Questions?

Please give us a call at 504-568-7474.