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IMPORTANT NOTICES

NEW HAMPSHIRE – Medicaid SOUTH DAKOTA – Medicaid
https://www.dhhs.nh.gov/ombp/nhhpp/ http://dss.sd.gov
Phone: 603.271.5218 888.828.0059
Hotline: NH Medicaid Service Center at 888.901.4999 TEXAS – Medicaid
NEW JERSEY – Medicaid and CHIP http://gethipptexas.com
Medicaid: http://www.state.nj.us/humanservices/dmahs/clients/medicaid 800.440.0493
609.631.2392 UTAH – Medicaid and CHIP
CHIP: http://www.njfamilycare.org/index.html
800.701.0710 Medicaid: https://medicaid.utah.gov
CHIP: http://health.utah.gov/chip
NEW YORK – Medicaid 877.543.7669
https://www.health.ny.gov/health_care/medicaid/ VERMONT – Medicaid
800.541.2831 http://www.greenmountaincare.org
NORTH CAROLINA – Medicaid 800.250.8427
https://dma.ncdhhs.gov VIRGINIA – Medicaid and CHIP
919.855.4100 Medicaid: http://www.coverva.org/programs_premium_assistance.cfm
NORTH DAKOTA – Medicaid 800.432.5924
http://www.nd.gov/dhs/services/medicalserv/medicaid CHIP: http://www.coverva.org/programs_premium_assistance.cfm
844.854.4825 855.242.8282
OKLAHOMA – Medicaid and CHIP WASHINGTON – Medicaid
http://www.insureoklahoma.org http://www.hca.wa.gov/free-or-low-cost-health-care/
888.365.3742 program-administration/premium-payment-program
OREGON – Medicaid 800.562.3022, ext. 15473
http://healthcare.oregon.gov/Pages/index.aspx WEST VIRGINIA – Medicaid
http://www.oregonhealthcare.gov/index-es.html http://mywvhipp.com/
800.699.9075 855.MyWVHIPP 855.699.8447)
PENNSYLVANIA – Medicaid WISCONSIN – Medicaid and CHIP
http://www.dhs.pa.gov/provider/medicalassistance/healthinsurancepremi https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf
umpaymenthippprogram/index.htm 800.362.3002
800.692.7462 WYOMING – Medicaid
RHODE ISLAND – Medicaid https://wyequalitycare.acs-inc.com
http://www.eohhs.ri.gov 307.777.7531
855.697.4347
SOUTH CAROLINA – Medicaid
http://www.scdhhs.gov
888.549.0820

To see if any other states have added a premium assistance program since July 31, 2018, or for more
information on special enrollment rights, contact either:
U.S. Department of Labor U.S. Department of Health and Human Services
Employee Benefits Security Administration Centers for Medicare & Medicaid Services
www.dol.gov/agencies/ebsa www.cms.hhs.gov
866.444.EBSA (3272) 877.267.2323, Menu Option 4, Ext. 61565

OMB Control Number 1210-0137 (expires 12/31/19)

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