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Ten-Day Report of Change For Medicaid/Hawki: Iowa Department of Human Services

This document is a ten-day report form for reporting changes to Medicaid/Hawki coverage. It informs recipients that they must report any changes within ten days to avoid receiving improper coverage or having to pay back benefits received in error. The form collects information on household member changes, income changes, asset changes, medical coverage changes, and any other relevant changes.

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Neph
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300 views6 pages

Ten-Day Report of Change For Medicaid/Hawki: Iowa Department of Human Services

This document is a ten-day report form for reporting changes to Medicaid/Hawki coverage. It informs recipients that they must report any changes within ten days to avoid receiving improper coverage or having to pay back benefits received in error. The form collects information on household member changes, income changes, asset changes, medical coverage changes, and any other relevant changes.

Uploaded by

Neph
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Iowa Department of Human Services

Ten-Day Report of Change for Medicaid/Hawki


You must tell us when something changes. You will need to tell us within ten days of the change. If you
don’t tell us when changes happen, we may give you coverage you should not get. If so, you will have to
pay back what you got in error. Complete this form only when you have a change.
If you have proof of the change you reported, send it with this form. This may speed up processing of
your reported change.

Tell Us About Yourself

Name (First Last): Case Number or State ID:

Address Line 1: Last 4 Digits of SSN:

Address Line 2: Date of birth:

City and State: Phone:

Zip Code: Other phone:

Email:

Is this a new address? YES NO

Mailing Address (if different):

Who You Live With

Pregnancy
Is someone in your household pregnant? YES NO

If yes, are you requesting Medicaid for this person? YES NO

Do they need help paying for medical bills from the last three YES NO
calendar months?
Who Due Date: Number of expected babies:

470-5590 (Rev. 08/22)


Household Member Changes:
Did someone move in or move out (including a newborn baby)? Please provide details below.
Name

Date Moved

In or Out? In Out In Out In Out In Out


DOB

SSN

Relationship

Tax Filer? YES NO YES NO YES NO YES NO


If yes, what is the person’s Tax Filing Status?
Single Single Single Single
Head of Household Head of Household Head of Household Head of Household
Married jointly Married jointly Married jointly Married jointly
Married separately Married separately Married separately Married separately
Qualifying widow(er) Qualifying widow(er) Qualifying widow(er) Qualifying widow(er)
If you selected Married Filing Jointly or Married Filing Separately, list their spouse’s name:
Spouse’s Name

Is this person claiming anyone as a tax dependent?


YES NO YES NO YES NO YES NO
If yes, list the people that they are claiming as a dependent.

Dependents

Is this person a tax dependent of someone else?


YES NO YES NO YES NO YES NO
If yes, who claims the person as a tax dependent?

For Those Who Moved In


Are you requesting Medicaid for this person?
YES NO YES NO YES NO YES NO
If yes, do they need help for Medical bills from the last three calendar months?
YES NO YES NO YES NO YES NO
For Those Who Moved Out
Did the person who moved out move to a nursing home?
YES NO YES NO YES NO YES NO
Is the person who moved out expected to return?
YES NO YES NO YES NO YES NO
If yes, when are they expected to return?
Return Date

470-5590 (Rev. 08/22)


Money Your Household Gets

Income and Job Changes


If someone in your household got a new job or if one of the new household members that moved in has
a job list details below.

Job 1 Job 2 Job 3 Job 4


Who

Employer name

Start Date

Wages and tips (before


taxes) per pay period:

Date of First Paycheck

Pay Frequency

Is medical insurance
available? YES NO YES NO YES NO YES NO

If anyone ended a job list details below


Who

Employer name

Date of Last Paycheck

Last Date Worked

If someone in your household had a change in work hours or pay list details below
Who

Employer name

Pay Frequency

New wages and tips per


pay period (before taxes)
Date of first paycheck
reflecting this change:

470-5590 (Rev. 08/22)


Other Income Changes
(Self-Employment, Unemployment benefits, Social Security benefits, SSI, disability, child support, etc.)

If someone in your household had a change in other income explain below:


(If Self Employment, report the monthly net amount after expenses deducted)
Type of Income Person who Change Monthly
receives amount

Start Stop Increase Decrease

Start Stop Increase Decrease

Start Stop Increase Decrease

Start Stop Increase Decrease

Is anyone in your home expecting to get a one-time payment such as back child support, an inheritance, or an
insurance settlement? If yes, explain:

Income Deductions

If someone in your household has a change in income deductions that they pay, explain below:
(This includes alimony, student loan interest, or other item(s) that can be deducted from a federal income tax
return)
Who pays? How much? How often?
Medical expenses not
covered by insurance

Alimony paid to someone


else

Student loan interest

Other deductions

Type: _______________

470-5590 (Rev. 08/22)


Assets and Resources

You must report any changes in resources (checking/savings accounts, bonds, home/land, vehicles/boat, life
insurance, retirement account, etc.) Include specific information about the opening, closing, purchasing, selling
of, or changes to resources.

Asset Type Owned By Value Location/Company

Additional Information:

Medical Coverage

Did someone have a change in their health insurance premium, started or stopped paying premiums, including
Medicare, or stopped or started getting other medical insurance?

Explain:

470-5590 (Rev. 08/22)


Other Changes

Someone in my household:

Got a Social Security Number

Explain:

Who is under 18, has enrolled in school or dropped out of school

Explain:

Changed their federal income tax filing status, including change in claimed dependents

Explain:

Changed immigration status

Explain:

Any other change not already listed

Explain:

Signature Date

To report your change by phone, call 1-877-347-5678 between the hours of 7 am and 6 pm Monday
through Friday.

To report by mail, fax, or email, send the form to:


DHS, Income Maintenance Customer Service Center, Imaging Center 1
417 E Kanesville Blvd, Council Bluffs, IA, 51503
Fax: 877-238-0015
Email: [email protected]

470-5590 (Rev. 08/22)

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