Application Disclaimers

Written by Access Health CT | Published March 2nd, 2021 | Updated March 2nd, 2021

Application Disclaimers (1).pdf

Application Disclaimers

You must agree to the following disclaimers to complete your application. If you do not agree to the disclaimers, you will not be eligible to enroll in a Qualified Health Plan or Medicaid.

Medicaid Only Disclaimers: You may be eligible for programs offered through the Department of Social Services such as Medicaid (known as HUSKY A and Husky D) and the Children’s Health Insurance Program (known as CHIP or HUSKY B). The information listed on your application will be used to decide if you are eligible for these programs. ________________________________________________________________________________

  • I know that I must tell the program I’m enrolled in if information I listed on this application changes.
  • MEDICAID ONLY: I know that if Medicaid pays for a medical expense any money I get from other health insurance or legal settlements will go to Medicaid in an amount equal to what Medicaid pays for the expense.
  • MEDICAID ONLY: I know that if Medicaid pays for any of my medical expenses, any money I receive from a lawsuit will be assigned to the State to pay for any medical expenses paid by the State related to injuries that led to the lawsuit. If I have other insurance or a third party is liable to pay for my medical expenses, the State may recover the cost of my medical bills directly from the insurer or third party. The State may bill a legally liable relative to repay the State for the costs of my medical care. The State may recover money from the estates of those people who were 55 years old or older at the time that community medical benefits were paid and who do not have a living spouse or surviving child under age 21 or blind or disabled. The State may recover from an inheritance or other lump sum of money I receive to repay the State for the costs of my medical care. The State may place a lien, under certain conditions, on my home if I permanently enter a nursing facility.
  • I’m signing this application under penalty of perjury. This means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that if I’m not truthful, there may be a penalty.

Screenshot of Application disclaimers: