TX HHS Form 5020. Application for Texas Health Insurance Premium Payment (HIPP) Program

The Texas Health Insurance Premium Payment (HIPP) Program Application Form 5020 is a crucial document that helps individuals and families access affordable health insurance. This form is typically filled out by those who are eligible for Medicaid but have access to employer-sponsored health insurance or COBRA benefits.

This application requires key information about the individual's family, including their social security number, date of birth, email address, and phone number. Additionally, it asks about the health insurance or COBRA benefits available through the individual's employer or other place, including the name of the health insurance company, policy start date, and monthly premium. The form also requires the Medicaid case number for the family and a list of family members who receive Medicaid benefits.

To complete the application, individuals must provide required information and attach supporting documents, such as their employer's Summary of Benefits and Rate Sheet, if they already have insurance. The HIPP Program offers two options for submitting the form: faxing it to 866-409-1188 or mailing it to P.O. Box 201120, Austin, TX 78720-9774. For faster service, individuals can also call 800-440-0493.

• The application is used by individuals and families who are eligible for Medicaid but have access to employer-sponsored health insurance or COBRA benefits.
• The form requires key information about the individual's family, including their social security number, date of birth, email address, and phone number.
• The application must be completed with required information and supporting documents, such as an employer's Summary of Benefits and Rate Sheet.