Renewal Forms (Archive)

The following forms are used during the renewal process:

l  Minnesota Health Care Programs Renewal (DHS-3418).

This is the annual renewal form sent to enrolled clients to gather eligibility information. Enrollees must complete and return it to continue eligibility.

n Enrollees provide data similar to what is requested on an application, including but not limited to the following information:

m List of household members.

m Income.

m Assets.

m Health insurance.

m Other changes.

n  The DHS-3418:

m includes a medical release, along with the client’s rights and responsibilities.

m may also be used to apply for household members not currently covered.

m may be used as an application.

n  Do not require a DHS-3418 if the following forms are received instead:

m Combined Application Form (CAF) (DHS-5223).

m Renewal for People Receiving Long-Term Care Services (DHS-2128).

m Health Care Application (HCAPP) (DHS-3417).

This form may be used as an application if received in the renewal month.

l  Combined Application Form (CAF) (DHS-5223)

The CAF is the annual renewal for people receiving cash assistance or Food Support (FS). A person who is also receiving health care with these programs will be sent the CAF if the renewal date corresponds with the recertification date for FS and cash.

Contact the enrollee to request additional information if the CAF does not provide enough information to renew health care coverage.  

l  Renewal for People Receiving Long-Term Care Services (DHS-2128).

This is the form used to renew eligibility, both annually and at six months, for people residing in long-term care (LTC) facilities or receiving Elderly Waiver (EW) services. This includes LTC residents who receive MSA for personal needs and EW enrollees residing in GRH facilities and receiving GRH payments.

Note:  This renewal form is also used when all MHCP household members receive services through a CAC, CADI, DD or BI waiver. The DHS-3418 is sent to the household if there is a household member who is not receiving services through one of these waiver programs.

The DHS-2128 may be used as an application if received in the renewal month.

l  Request for Signature (DHS-3555).

Use this form to collect signatures if the renewal or other form does not have all required signatures. It explains:

n  Who should sign the renewal.

n  What will happen if the renewal is returned without a signature.

See Renewal Signatures for information on who must sign the renewal.

l  Health Care Coverage Options in Minnesota brochure (DHS-3416).

Send this form to clients who have questions about the different public and private health care options available to residents of Minnesota.

l  MA-BC Application/Renewal (DHS-3525) and Certification of Further Treatment Required (DHS-3525A).

These two forms are used exclusively for MA Breast and Cervical Cancer enrollees to renew coverage. Do not require these forms if another renewal form is received.

l  Household Report Form (HRF) (DHS-2120).

This form is used when a client is required to renew eligibility monthly. See Monthly Renewal for more information on monthly reporters.

This form may not be used as an application or as an annual renewal. It may be used as a six-month renewal.

l  Notice of Late or Incomplete Household Report Form, Health Care Renewal Form or Combined Six-Month Report (DHS-2414).

Send this notice to clients when their benefits are being terminated because they failed to return the required report form or the form was not completed correctly. The back of the form lists the client appeal rights information.

l  Combined Six-Month Report (DHS-5576).

This form is sent to MA clients for their six-month renewal and MA clients for their income and asset six-month renewal.

This form may be used as an application if received in the renewal month.

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