Re-application for Primary Care Benefits
Examine the Completed Sample
Application for Primary Care Benefits.
month, the Enrollment Coordinator will receive a list of those CAP enrollees
whose re-enrollment is due.
- Determine that the CAP Enrollee still meets the CAP eligibility criteria:
||a) Federal Poverty Level (FPL) at or below
||b) Enrollee is 18 or more years of age and less
than 65 years of age, and |
||c) Enrollee is not insured & not eligible for
insurance (i.e., Medicaid,
- Complete or update your organization's Sliding Fee Application to
determine the current total household size and total monthly household income
and thereby the FPL.
- If the patient still meets the eligibility criteria in a, b and c, enter the Enrollee name (First, Middle Initial and
Last) and the Social Security Number onto the CAP Application for Primary Care
Benefits as shown in the completed sample.
- The Application form is
available in Microsoft Word format. Add your corporation's name at
the top of the Application form, before you make copies.
- Ask the CAP enrollee to read, sign and date the Enrollment, Authorization
or Release portion of this Application.
- Witness this signature by signing and dating the form yourself.
Check the form for completeness and legibility.
- Store the completed form in accordance with the policies of your organization.
- Complete a new Patient Financial Statement. Instructions have been
- Update the Health History screen on the CAP Data Entry web site
(alternatively complete a new Health History scan form
and send it to the CAP IS Coordinator). Instructions are provided.
- ONLY IN THE EVENT THAT THE SLIDING FEE OR HOSPITAL
ELIGIBILITY HAVE CHANGED, issue a NEW membership card to the
re-enrollee (Example, on re-enrollment, the CAP member's income has gone
down such that she now has Hospital Eligibility, whereas at initial enrollment
she did not qualify for Hospital Eligibility because of her income).
- Check the proper block Clinic "Eligible for SF (Sliding
Fee) Yes or No and write in the FPL determined by completing the Sliding Fee
Application on the back of the card, .
- Check the block " Hospital Eligibility" either Yes or No. If the
Patient Financial Statement indicates that the CAP Enrollee is eligible, the
correct response is "Y" for Yes. Write in the FPL you determined by completing
the Patient Financial Statement.
- Examine your work, laminate the CAP membership card and present it to the
- Complete a new CAP Health History data page by using the CAP Data Entry web
site or send the completed CAP Health History scan form to the CAP IS
- Provide re-enrolling CAP member an SF-8 CAP Health Survey Form (scan
form). Ask the member to complete each question and return the form in the
self-addressed and stamped envelope.
- IF THE MEMBER HAS ONE OR MORE CHRONIC CONDITIONS,
complete a new Chronic Conditions Data
page by using the CAP Data Entry web site or send the completed Chronic
Conditions Data scan sheet to the CAP IS Coordinator.
You have completed the CAP Re-enrollment