Ingham Health Plan Application

Enrollment Application

Customer Service: 866-291-8691 or planmanagement@ihpmi.org
Please complete this brief screening to determine if you may be eligible for Ingham Health Plan (IHP).
1. Verify your home address is Ingham County. Complete a zip-code-lookup

(Click on the drop down arrow to view County information.)
I live in Ingham County

Yes No
2. Verify your HOUSEHOLD GROSS income (before taxes and deductions) falls within income eligibility guidelines for IHP. If income is at or below Medicaid eligibility, please apply for Medicaid health coverage first. IHP is for people who don't have or qualify for other health coverage such as Medicaid, Medicare or commerical.
- Family size includes yourself, spouse or other parent, children (19 and under), tax dependents living the household.
- Household income includes ALL wage earners in household. Include income such as wages, unemployment benefits, workers' comp, child support, SSI, RSDI, rental property, alimony, and self-employment income.
I appear to meet income eligibility guidelines for IHP AND don't have/qualify for Medicaid, Medicare or commercial insurance.

Yes No

Self Employment Verification Form
You are being asked to complete this form because you indicated one of the following:

1) You have not filed a Schedule C tax document, or

2) The Schedule C you filed is not an accurate representation of your current year's income.
Name of Applicant

First Name Last Name
Name of Business
Type of Business
Name of Other Business Owners
Business Address

Street Address

Street Address Line 2

City State

Zip Code

Report the Last 3 months

REPORTING MONTH

INCOME $

EXPENSES $

PROFIT $

Month #1

Month #2

Month #3

TOTAL for 3 months

Average Monthly Profit (3 month total divided by 3)
Yearly income from Self-Employment (Average monthly profit multiplied by 12)
I certify that I am self-employed and the information above is accurate. I give Ingham Health Plan (IHP) permission to verify this statement with the internal revenue Service or the State of Michigan. I understand that if IHP finds that I have misrepresented my income to qualify for the program, I will be disenrolled. I understand that if I have other sources of earned or unearned income, I must report those sources to IHP.

Signature of Applicant self- attesting for Self employment income Clear
Date of Self-Employment Verification

Month Day Year
Date

FINAL STEP:
To complete the application you will need to upload, in PDF or JPEG format, copies of the required supporting documents.

You can scan documents using an app or take a picture with a cell phone.

All documentation MUST be legible.

1. Picture Identification

2. Proof of you live in Ingham County (at least one of following)
- Valid Michigan driver’s license or ID card
- Other ID which provides a name and address
- Recent mortgage, lease, or rent receipt
- W2 or 1040 tax form
- Ingham County voter’s registration card
- Recent utility or home services bill with name and address printed on it
- Recent paycheck or other income documentation with name and address printed on stub
- A letter dated within the last 30 days stating applicant resides at address list on application
3. Proof of income must be recent (within the past 30 days) for ALL wage earners in household (at least one of following for ALL wage earners)
- Paycheck stubs within the last 30 days (2 biweekly or 4 weekly)
- Medicaid denial letter or other verification on income from DHHS
- Other statement of income from employer
- Unemployment statement
- Social Security benefit statement
- Account interest statement or other statement of unearned income
- Most recent tax form(s) for applicants who are self employed
4. Immigration Documents, if applicable (visa, green card, permanent residency card)

5. Medicaid status documents, if applicable
- Medicaid application completed within last 6 months
- Pending, Denial or appeal letter from Medicaid
Upload copies of supporting documents here by clicking on Browse Files. *

Browse Files
Your application can't be processed without REQUIRED documents Cancel of
Additional info to share?
Terms & Consent: Please check each box as you read it *

I understand that if I qualify, I will be enrolled in Ingham Health Plan and agree to pay the annual $20.00 administrative fee. An invoice will be sent separately. I understand that if I qualify, I MUST call Ingham Health Plan and inform Ingham Health Plan of my new address if I move. If I do not, I may be disenrolled. I understand that if I qualify and my income or household size changes, I MUST call Ingham Health Plan. If I do not, I may be disenrolled. If I am disenrolled, I understand I will be responsible to pay for any medical services I receive after my disenrollment date. I give permission for Ingham County Dept of Health & Human Services (DHHS) to release information about my DHHS benefits to Ingham Health Plan Corp if needed to determine IHP eligibility (ie Medicaid denial letter, proof of income, etc).
I agree to the terms and consent listed above. *
I certify that the above information is true and accurate account of my residency, income, and insurance status. I understand that providing false information may result in denial or termination of IHP benefits. I understand that IHP is not insurance and has limited coverage benefits.

Signature of Applicant or Legal Guardian Clear
Date of Application

Month Day Year
Date
Printed Name of Applicant

First Name Last Name
Name of person completing the application (If different than applicant)

First Name Last Name
Phone Number of person completing application (if different than applicant)
Email of person completing application (if different than applicant)
example@example.com
Should be Empty:

Enrollment Application

Enrollment Application

Self Employment Verification Form