EIP & Evergreen Unify Application Form

One Form, Two Agencies

Clients can now apply to the Early Intervention Program (EIP) and to the Evergreen Health Insurance Program by filling out just one form.  Clients no longer have to provide the same information individually to each agency.  The combined EIP/Evergreen application form contains all the information needed to qualify for EIP eligibility and to arrange Evergreen's help with insurance premiums.  As with all new procedures, there are some important points clients should be aware of.

Beginning April 1st, 2014, the Early Intervention Program and the Evergreen Health Insurance Program created a combined application for both programs.  The reason behind this change is in answer to clients’ feedback with the aim of eliminating duplication of forms.  Since a person must be active with EIP in order to qualify for the EHIP program, the two programs have streamlined the application process to make it easier and quicker.

The New Form

The Early Intervention Program and the Evergreen Health Insurance Program both work closely together and gather much of the same information for enrollment thus making it possible to combine the two applications.  By completing the combined EIP/Evergreen application, a person who is not yet enrolled in the Early Intervention Program can apply to both programs at the same time.  To indicate in this application that a person would like EHIP assistance with an insurance premium, the person would need to complete Section 3 of the dual application.  Upon submitting this application only to the Early Intervention Program, EIP will then follow up with Evergreen and supply information needed to also enroll the person in Evergreen.  The Evergreen Insurance Advocates will then contact the person and/or case manager if further documentation or information is needed.

If a person is already enrolled in the Early Intervention Program and needs Evergreen assistance (either new to Evergreen or changing insurance coverage), they must complete the “New Enrollment/New Payable” application, which then is submitted directly to Evergreen only

The following is a list of required documentation based on each insurance type needed by Evergreen to process an application.  The corresponding documentation based upon what type of insurance a person has or is applying for needs to be submitted directly to Evergreen.

Documents Needed to Apply for EHIP Assistance
Insurance Type Documentation Required
COBRA Summary of Benefits, bill
Group Insurance policy Summary of Benefits and letter from employer stating Evergreen payments can be accepted for premium payment (which would be the employee’s portion), monthly amount due, who to make the check out to, and where to mail the payment. Letter must be on company letterhead.
HWD Bill
Individual policy Bill
Medicare Part D plan Bill
Qualified Health Plan in Health Benefit Exchange Person must link to Evergreen Insurance Advocate as “navigator” in the Health Benefit Exchange and select a plan. For more information on this process please refer to the “Qualified Health Plan” page.