S MOKE S IGNALS
NOVEMBER 15, 2014
7
Save Our Skookum survey
Date Rec’d____
Rec’d By ____
Entered by: __
Confidential Health Care Resource Survey
First Name:________________________ Last Name: ______________________________
Tribal roll #:________
Best Contact Number:________________________
1. Are you enrolled in the Skookum Health Plan? Yes _______ No _________
2. Do you have any other insurance (e.g. Medicaid, Medicare)? Yes______ No ______
If yes, what is the name of your insurance? _________________________________
3. Are you currently employed? Yes ________ No _________
Employers name & address if applicable:
Employer Name:_______________________________________________________
Address: _____________________________________________________________
City:_______________________ State:__________________ Zip:_______________
4. If employed, does your employer OFFER health care insurance to you?
Yes_______ No_____ Ineligible_______
If yes, is there a cost to you? Yes____ No ____ How much? _________/monthly
Can your immediate Skookum eligible family be enrolled? Yes____ No ____
Cost per month:_______________________________________________________
Is there an enrollment period and/or open enrollment? _______________________
Name of employers health care insurance:__________________________________
Please describe reason for ineligibility? (e.g. part time work only, temporary employee.)
_____________________________________________________________________
5. If you are married, does your spouse’s employer OFFER employee health care insurance?
Yes_______ No_____ Ineligible________
If yes, is there a cost to you? ______ How much? _______/monthly
Can your Skookum eligible immediate family be enrolled? Yes____ No ____
Cost per month:________________________________________________________
Is there an enrollment period and/or open enrollment?:______________________
Name of employers health care insurance:_________________________________
Please describe reason for spouse’s ineligibility? (e.g. part time work only, temporary employee.)
____________________________________________________________________
Spouse’s employers name & address if applicable:
Please circle the family size and annual household income that represents your family the closest in that line.
Employer Name:_______________________________________________________
Address: _____________________________________________________________
Please circle the family size and annual household income that represents your family the closest in that line.
Family City:_______________________
Size
ANNUAL HOUSEHOLD INCOME
State:__________________
Zip:_______________
1
$10,830.00 $12,996.00 $14,403.90
$14,620.50 $16,245.00 $18,952.50 $20,035.50 $21,660.00 OVER
Family Size 2
ANNUAL HOUSEHOLD
INCOME $25,497.50 $26,954.50 $29,140.00 OVER
$14,570.00 $17,484.00 $19,378.10 $19,669.50
$21,855.00
1
$10,830.00
$12,996.00
$14,403.90
$14,620.50
$16,245.00
$18,952.50 $33,873.50
$20,035.50 $36,620.00
$21,660.00 OVER
OVER
3
$18,310.00 $21,972.00 $24,352.30 $24,718.50 $27,465.00 $32,042.50
$14,570.00 $26,460.00
$17,484.00 $29,326.50
$19,378.10 $29,767.50
$19,669.50 $33,075.00
$21,855.00 $38,587.50
$25,497.50 $40,792.50
$26,954.50 $44,100.00
$29,140.00 OVER
OVER
4 2 $22,050.00
$18,310.00 $30,948.00
$21,972.00 $34,300.70
$24,352.30 $34,816.50
$24,718.50 $38,685.00
$27,465.00 $45,132.50
$32,042.50 $47,711.50
$33,873.50 $51,580.00
$36,620.00 OVER
OVER
5 3 $25,790.00
$22,050.00 $35,436.00
$26,460.00 $39,274.90
$29,326.50 $39,865.50
$29,767.50 $44,295.00
$33,075.00 $51,677.50
$38,587.50 $54,630.50
$40,792.50 $59,060.00
$44,100.00 OVER
OVER
6 4 $29,530.00
$25,790.00 $39,924.00
$30,948.00 $44,249.10
$34,300.70 $44,914.50
$34,816.50 $49,905.00
$38,685.00 $58,222.50
$45,132.50 $61,549.50
$47,711.50 $66,540.00
$51,580.00 OVER
OVER
7 5 $33,270.00
$29,530.00 $44,412.00
$35,436.00 $49,223.30
$39,274.90 $49,963.50
$39,865.50 $55,515.00
$44,295.00 $64,767.50
$51,677.50 $68,468.50
$54,630.50 $74,020.00
$59,060.00 OVER
OVER
8 6 $37,010.00
7
$33,270.00 $39,924.00 $44,249.10 $44,914.50 $49,905.00 $58,222.50 $61,549.50 $66,540.00 OVER
8
$37,010.00 $44,412.00 $49,223.30 $49,963.50 $55,515.00 $64,767.50 $68,468.50 $74,020.00 OVER
Please List All Tribally enrolled dependants in your household:
Please List All Tribally enrolled dependants in your household:
Last Name:____________________________ First name:___________________________
Age:_________ Tribal Roll #:________
Last Name:____________________________
name:___________________________
Enrolled
on Skookum Health Plan: Yes_______ First
No: __________
Age:_________
Tribal Roll #:________
Any
other insurance?___________________________________________________________
Enrolled on Skookum Health Plan: Yes_______ No: __________
Any other insurance?___________________________________________________________
Last Name:____________________________ First name:___________________________
Age:_________ Tribal Roll #:________
Last Name:____________________________
name:___________________________
Enrolled
on Skookum Health Plan: Yes_______ First
No: __________
Age:_________
Tribal Roll #:________
Any
other insurance?____________________________________________________________
Enrolled on Skookum Health Plan: Yes_______ No: __________
Any other insurance?____________________________________________________________
Last Name:____________________________ First name:___________________________
Age:_________ Tribal Roll #:________
Last Name:____________________________
Enrolled
on Skookum Health Plan: Yes_______ First
No: name:___________________________
__________
Age:_________
Tribal Roll #:________
Any
other insurance?____________________________________________________________
Enrolled on Skookum Health Plan: Yes_______ No: __________
Any other insurance?____________________________________________________________
Please add a separate sheet of paper if you have additional dependants.
Please add a separate sheet
of paper
if you have additional dependants.
*PLEASE
NOTE*
Please fill out and return only 1 survey per household (unless there is more than 1 family in your home).
*PLEASE
Please call one of the numbers
below NOTE*
for additional surveys if needed.
Please fill out and return only 1 survey per household (unless there is more than 1 family in your home).
For questions
regarding
this of survey,
please below
contact for Barbra
Steere
at 503-879-2487
Please
call one
the numbers
additional
surveys
if needed.
Or Melody Baker at 503-879-2011.
Toll survey,
free is please
1-800-775-0095.
For questions regarding this
contact Barbra Steere at 503-879-2487
Or Melody Baker at 503-879-2011.
Toll free is 1-800-775-0095.
Medicaid is health insurance that helps many people who can’t afford
medical care pay for some or all of their medical bills.
Good health is important to everyone. If you can’t afford to pay for
medical care right now, Medicaid can make it possible for you to get
the care that you need so that you can get healthy and stay healthy.
Medicaid is available only to people with limited income. You must
meet certain requirements in order to be eligible for Medicaid. Med-
icaid does not pay money to you; instead, it sends payments directly
Photo by Michelle Alaimo
From left, Sydney Clark, Certifi ed Applications assister, Tauni
McCammon, Contract Health specialist, Erica Mercier, Contract Health
specialist, Barbara Steere, Health Benefi ts specialist, Tresa Mercier,
Health & Wellness Business Offi ce manager, Loretta Meneley, Certifi ed
Application assister, and Melody Baker, Senior Contract Health
specialist, are the Tribe’s Save Our Skookum team.
to your health care providers. Depending on your state’s rules, you may
also be asked to pay a small part of the cost (co-payment) for some medical
services. (For more information, download “Medicaid At-A-Glance 2005”
from the bottom of the page.)
Many groups of people are covered by Medicaid. Even within these
groups, though, certain requirements must be met. These may include
your age, whether you are pregnant, disabled, blind, or aged; your income
and resources (like bank accounts, real property, or other items that can
be sold for cash); and whether you are a U.S. citizen or a lawfully admitted
immigrant. The rules for counting your income and resources vary from
state to state and from group to group. There are special rules for those
who live in nursing homes and for disabled children living at home.
Your child may be eligible for coverage if he or she is a U.S. citizen or
a lawfully admitted immigrant, even if you are not (however, there is a
5-year limit that applies to lawful permanent residents). Eligibility for
children is based on the child’s status, not the parent’s. Also, if someone
else’s child lives with you, the child may be eligible even if you are not
because your income and resources will not count for the child.
In general, you should apply for Medicaid if your income is limited and
you match one of the descriptions of the Eligibility Groups. (Even if you
are not sure whether you qualify, if you or someone in your family needs
health care, you should apply for Medicaid and have a qualifi ed caseworker
in your state evaluate your situation.)
For specifi c information about enrolling in Medicaid, eligibility,
coverage and services for your State, please contact your local
Medicaid offi ce. You can view your State’s Medicaid Offi ce contact
information by visiting the Benefi ts.gov website (see the link on
the CMS home page) or checking the contact information for State
Medicaid offi ces (see the link on the CMS home page.)
To learn about the Medicaid program in your state see Related Links
Inside CMS at the bottom of the page.
Screening Tools
To help you see if you may be eligible for a variety of governmental pro-
grams, you may access the GovBenefi ts and Benefi tsCheckUp websites.
(See related links on the CMS home page.)
When Eligibility Starts
Coverage may start retroactive to any or all of the three months prior to
application, if the individual would have been eligible during the retroac-
tive period. Coverage generally stops at the end of the month in which a
person’s circumstances change. Most states have additional “state-only”
programs to provide medical assistance for specifi ed people with limited
incomes and resources who do not qualify for the Medicaid program. No
federal funds are provided for state-only programs.
What is Not Covered
Medicaid does not provide medical assistance for all people with limited in-
comes and resources. Even under the broadest provisions of the federal statute
(except for emergency services for certain persons), the Medicaid program does
not provide health care services for everyone. You must qualify for Medicaid.
Low-income is only one test for Medicaid eligibility; assets and resources are
also tested against established thresholds. As noted earlier, categorically needy
persons who are eligible for Medicaid may or may not also receive cash assis-
tance from the Temporary Assistance for Needy Families (TANF) program
or from the Supplemental Security Income (SSI) program. Medically needy
persons who would be categorically eligible except for income or assets may
become eligible for Medicaid solely because of excessive medical expenses. n
www.cms.gov/MedicaidEligibility/downloads/ListStateMedicaidWebsites.pdf