Combined Application for Health Coverage Assistance

The Combined Application for Health Coverage Assistance, used primarily by hospitals and clinics, allows counties to pre-determine individuals for health coverage assistance, and county assistance programs. Follow the instructions below to submit a Combined Application for assistance.

1. Ensure a Medicaid eligibility determination has been completed by Health and Welfare prior to the application being submitted for county welfare eligibility consideration.
2. Download a Combined Application for Assistance form.
3. Ensure the Combined Application for Assistance is entirely completed and has a valid signature for consideration for either Medicaid eligibility or county assistance. Incomplete applications may be delayed or denied based on incomplete information.
4. Ensure the cover sheet is entirely completed (first page of the application). Without the contact information, Health and Welfare will not be able to send notifications of denials or route applications to the appropriate county office.
5. Hospitals or county offices may submit the Combined Application for Assistance. Submit the Combined Application for Assistance directly to Health and Welfare by mail or fax.
   1. Mail: PO Box 83720, Boise, ID 83720-0026
   2. Fax: 208-528-3771 (electronic transmissions may be available at a later date.)
6. Health and Welfare will complete a Medicaid eligibility determination according to the timelines outlined for Medicaid application processing. If Medicaid is denied for any reason, Health and Welfare will send a notice of denial to the requesting hospital. Health and Welfare will also send a notice of denial with the application to the identified county office for county eligibility determination.