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YOUR RIGHTS AND RESPONSIBILITIES
• By signing and submitting this application, you state that you have permission from all of the people listed on the application to both submit their
information to the Louisiana Department of Health (LDH), and receive any information about their eligibility and health coverage.
• You understand that LDH is authorized to gather the information requested in this application and any supporting documentation, including
social security numbers, under the Patient Protection and Aordable Care Act (Public Law No. 111-148), as amended by the Health Care and
Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
• You understand that providing the requested information (including social security numbers) is voluntary. However, failing to provide it may
delay or prevent you from getting health coverage through Medicaid or any other insurance aordability program.
• You understand that LDH will check the information you give us to make sure it is correct. You give LDH permission to contact any outside
source(s) necessary to check this information, process your application, determine eligibility, and otherwise operate the Medicaid program. ese
outside sources may include:
– Federal agencies (such as the Internal Revenue Service, Social
Security Administration, and Department of Homeland Security),
other state agencies, and/or local government agencies.
– Banks, nancial institutions, and consumer reporting agencies.
– Employers identied on applications for eligibility determinations.
– Doctors or other medical providers.
– Applicants/enrollees, and authorized representatives of applicants/
enrollees.
– LDH contractors engaged to perform a function for the Medicaid
program.
– Anyone else as required or allowed by law.
• You give these outside sources permission to give LDH any information about you, or any person necessary for this application, that it may request.
You understand that this permission will end when this application is denied, when your Medicaid eligibility ends, or when you submit a written
statement to LDH canceling this permission, whichever comes rst. A cancellation may prevent you from being found to be eligible for Medicaid.
• You understand the social security numbers will only be used to get information from these outside sources to verify income, make eligibility
determinations, or for other purposes directly connected to the administration of the Medicaid program.
• You must tell Medicaid if anything changes or is dierent than what you’ve written on this application. Call 1-888-342-6207 to report any
changes. You also understand that a change in your information could aect the eligibility for member(s) of your household. You agree to tell
Medicaid within 10 days if any of the following change: mailing or home addresses, things you own, health insurance coverage or premiums,
income, if anyone moves in or out of your home, or if anyone moves out of state.
• You state that answers you gave on this application are true and correct. If you purposely gave information that is not true or if you withheld
information, you have committed fraud. If you commit fraud, you may have to pay back money that Medicaid pays for care that you receive.
• You state that the information given in this application about your citizenship and immigration status is true and correct.
• By signing and submitting this application, you understand that if anyone on this application enrolls in Medicaid, you are giving LDH your
rights to any money owed to you by any other health insurance, legal settlement, a spouse or parent, or other third party.
• You understand that Medicaid will only send case information to Child Support Enforcement for medical support if you ask them to. LDH will
only make a referral if parents of children under age 19 receive Medicaid. You can request that Medicaid not refer you if you feel you have good
cause not to cooperate with Child Support Enforcement.
• You understand that Estate Recovery rules require LDH to recover the cost of certain Medicaid payments from your estate in the event of your
death. ese costs include the total amount of payments for facility services, hospital care, waiver services, payments to Home and Community
Based Services (HCBS) or Program for All-Inclusive Care for the Elderly (PACE) providers, and prescription drugs received at age 55 or
older. LDH will not make a claim against the estate while you or your legal spouse is still living. LDH will also not make a claim if you have a
dependent child who is under age 21, blind, or disabled. Collection may not be made if it is not cost eective for LDH to do so, or if your heirs
apply for a hardship waiver after your death. A hardship may exist if the estate property is the only source of income for the heirs, if that income
is limited, or if there are other extenuating circumstances.
• You agree that by accepting Medicaid, the State of Louisiana or its assignee will be named as the remainder beneciary of all annuities purchased on
or after Feb. 8, 2006 for the total amount of medical assistance paid on your behalf, unless you have a spouse, minor child, or a child with a disability.
In these cases, the State of Louisiana must be named as beneciary after these individuals. You agree to tell Medicaid about any annuity you and your
spouse own or co-own regardless if the annuity is irrevocable (cannot be changed) or Medicaid counts it. You understand that you must tell Medicaid
about changes made to any annuity which may aect when payments begin, the amount paid, frequency of payments, and additions to the principal.
• You can ask for a Fair Hearing if you think any decision made on the case is unfair, incorrect, or made too late.
• LDH cannot treat you dierently because of race, color, sex, age, disability, religion, nationality, or political belief. If you think it has, you can
call the U.S. DHHS Regional Oce for Civil Rights in Dallas, TX at 1-800-368-1019 or write to the Louisiana Department of Health, Human
Resources at P. O. Box 4818, Baton Rouge, LA 70821-4818.
After reading, please continue to the next page to complete your application.