STATE OF NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE OF HUMAN SERVICES
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STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
New Hampshire Health Protection Program
Health Insurance Premium Payment Services
Program Application
Thank you for your interest in the HIPP Program. If you have NOT received an application in the mail, then
you may utilize this form. If you HAVE received an application in the mail, please complete and return the
application that was sent in the mail, as it has requirements specific to your case.
In order to qualify for NH HIPP, you must meet the eligibility rules. If approved, your eligibility for NH HIPP
will be reviewed annually. Also, per RSA 126-A:5, XXIII(c)(3), NH HIPP is subject to cancellation upon
notice.
NH HIPP rules:
• You must be eligible for the New Hampshire Health Protection (Medicaid) Program at the time of
your NH HIPP application
• You must be currently enrolled in ESI or have access to ESI
• Health insurance coverage must not be court-ordered
• ESI must be cost effective based on Medicaid costs
You are not eligible for NH HIPP if you are eligible for or enrolled in any of the following:
• Medicare
• Medicare Advantage Plans (Medicare Part C)
• Medicare Supplement Policy plans
• Medicaid Spend Down program (In and Out medical assistance)
• COBRA
• School-based plan for students while at school
• Indemnity or catastrophic insurance plan that does not cover standard medical benefits
• Insurance plan through the Health Insurance Exchange (Marketplace)
To apply for NH HIPP, please do the following:
• Complete the enclosed application (both FORM ONE and FORM TWO); and
• Fax or mail it with a copy of:
1. Health insurance premium rate sheet from your employer that includes rates/costs for all levels of
plans offered (Employee Only, Employee and Spouse, Employee and Child, Family, etc.)
regardless of which option you chose
2. Health Insurance Summary of Benefits for the current benefit year (this typically describes what
services are covered and not covered, policy limits, co-payments, deductibles, etc.)
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 1 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comSTATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
3. Recent paystub or other verification to show proof of your employer health insurance premium
payment (if you are currently enrolled)
4. Front and back of your health insurance card (if you are currently enrolled)
Please complete FORM ONE and FORM TWO and return them with the copies listed above to the NH HIPP
office. FORM TWO may be completed by your employer, such as a Human Resources Representative or
Benefits Coordinator. Be sure to include the Employee contributions for ALL health insurance premiums
offered by your employer.
Fax or mail your application and documents to the address listed below.
Fax: 844-388-0648
Mailing Address: New Hampshire HIPP Program
75 South Main Street
Unit #7 PMB 279
Concord, NH 03301
If you have any questions or need help, please call the NH HIPP office at 844-696-4447.
Sincerely,
The NH HIPP Team
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 2 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comSTATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
Member Information:
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Telephone Number: _______________________
Medicaid ID Number: ______________________
Date: __________________
FORM ONE: New Hampshire Health Insurance Premium Payment Program (NH HIPP) Application
Please complete FORM ONE and FORM TWO and send it to the NH HIPP office. FORM TWO may be completed by
your employer, such as a Human Resources Representative or Benefits Coordinator. You must answer all questions.
Note that failure to fully complete and return this application could result in your Medicaid ending.
If you have any questions, please call an Eligibility Advisor at (844) 696-4447.
1. How do you have access to ESI? ❏ Yourself ❏ Spouse (Name):____________________________
2. Has employment terminated for the individual with ESI or with ESI access listed above? ❏ YES, Date: __ ❏ NO
3. Do you or anyone in your family have Medicare coverage? ❏ Yes ❏ No If so, who? ______________________
4. Do you or anyone in your family have private (commercial) health insurance? ❏ Yes ❏ No
IF YES, which type: ❏ Employer Sponsored ❏ COBRA ❏ Other _________________________
What is the premium for this policy? $ __
These premiums are paid/ deducted from your pay:
❏ Weekly ❏ Every other week ❏ Twice a month ❏ Monthly ❏ Quarterly ❏ Other
Type of Coverage: ❏ Individual ❏ Individual and child(ren) ❏ Individual and Spouse ❏ Family
IF NO, do you have access to health insurance through your employer (but not currently enrolled)? ❏ Yes ❏ No
5. Is your health insurance coverage court-ordered (part of a divorce/separation decree)? ❏ Yes ❏ No
6. If you are currently enrolled in health insurance through your employer, please complete this section with the insurance
policyholder’s information.
Name: ___________ Social Security#: Date of Birth: _____
Address: City/ State/ Zip: _________
Home Phone: Cell Phone: Email:
Signature: __________________________
❏ (Check box to sign up for email notifications.) Yes, NH HIPP can send information about the program and my
payments to my email address provided above.
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 3 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comSTATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
FORM ONE (continued): New Hampshire Health Insurance Premium Payment Program (NH HIPP) Application
7. Please complete the information below if you are currently enrolled in your employer sponsored insurance
Health Insurance Company:
Policy/Subscriber/Member Number:
Group Number:
Effective Date of Policy: _ End Date of Policy:
8. List everyone in your household, including Medicaid recipients. (Use extra paper if needed.)
Name Social Birth Date Medicaid ID Relationship to Gender Enrolled
Security Number Member in ESI
Number (Spouse, child, (yes/no)
(Last 4 digits) etc.)
/ /
/ /
/ /
/ /
9. Direct Deposit of Premiums: If accepted into the NH HIPP program, our preferred method of sending you
payments is through Direct Deposit into your bank account. By doing so, the NH HIPP office will deposit your
payments into your account and you will not receive a paper check. If you are not accepted into the program, the NH
HIPP office will properly discard your banking information. If you cannot receive direct deposit, please contact an
Eligibility Advisor at 844-696-4447 to arrange for an alternative payment method.
Bank Name: Account Routing #: _____________
Account #: (Please provide a copy of your voided check with this application)
To process your application fully, the NH HIPP program must receive a copy of your employer’s health insurance
premium rate sheet, policy Summary of Benefits, and a recent paystub or other verification to show proof of your
premium payment (if you are enrolled), and the front and back of your insurance card (if you are enrolled).
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 4 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comSTATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
Member Information:
Name: _______________________________________________________________________
Address: _____________________________________________________________________
City, State, Zip: ________________________________________________________________
Telephone Number: _______________________
Medicaid ID Number: ______________________
Date: __________________
FORM TWO: New Hampshire Health Insurance Premium Payment Program (NH HIPP) Application
Complete FORM ONE and FORM TWO and send it to the NH HIPP office. FORM TWO may be completed by your
employer, such as a Human Resource Representative or Benefits Coordinator.
1. Employer Information:
Employer Name: Employer Federal Tax ID:
Address: City: State: Zip:
Contact Phone Number: Fax Number:
2. Employer-sponsored health insurance information:
Do you offer health insurance to your employees? ❏ YES ❏ NO
Is there a minimum number of hours an employee must works to receive health insurance? ❏ YES ❏ NO
If so, how many hours _______ (per ❏ Week ❏ Every Other Week ❏ Month)
If you offer health insurance to your employees, please complete the table below.
Please complete the table below for each health insurance plan offered OR attach your company rate sheet
showing all rates offered. Also, please provide a Summary of Benefits for the health insurance plan
accessible to the applicant.
Plan Type Health Insurance Carrier Plan Name Number of Monthly Group #
Name Persons Employee
Covered Contribution
Individual $
Individual $
+ Spouse
Individual $
+ Child
Family $
Other $
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 5 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comSTATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH AND HUMAN SERVICES
OFFICE OF HUMAN SERVICES
FORM TWO (Cont.): The New Hampshire Health Insurance Premium Payment Program (NH HIPP) Application
3. Does this individual have access to purchasing dependent coverage? ❏ YES ❏ NO
4. When does your company's open enrollment period start and end? Start: / / End: / /
5. Employee's History:
Has the individual above dropped or reduced health insurance coverage within the last 6 months? ❏ YES ❏ NO
If YES, which plan?
Individuals for whom coverage terminated: Termination Date:
6. Your Information:
Name (Print): Signature:
Title: Date Signed:
Phone: Ext:
You can either fax or mail a copy of this form to the NH HIPP office.
Fax: 844-388-0648
Mailing Address: New Hampshire HIPP Program
75 South Main Street
Unit #7 PMB279
Concord, NH 03301
If you have any questions about this application, please contact our office at 844-696-4447.
Phone: 844-696-4447 | Monday to Friday, 8 a.m. to 5 p.m. Eastern Standard Time Page 6 of 6
Fax: 844-388-0648 | Email: CustomerService@MyNHHIPP.comYou can also read
