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If you live in DC, you can use this form to apply
for benefits. If you need help with this form, just
ask your worker or another ESA employee. You
can also call (202) 727-5355. Free interpreters
are available.
Please bring this to your Service Center. To find
out which Center is closest to you, call (202)
727-5355. You may also mail this form to DHS/
CRMU, 645 H St., NE, Washington, DC 20002.
Sí, hablo ESPAÑOL (SPANISH)
Si usted vive en DC, puede usar este formulario
para solicitar beneficios. Si necesita ayuda con
este formulario, pídale ayuda a su trabajador u
otro empleado de ESA. También puede llamar
al (202) 727-5355. Intérpretes gratis están
disponibles.
Por favor, lleve este formulario al Centro de
Servicio de su área. Para saber cuál Centro le
queda más cerca, llame al (202) 727-5355.
También puede enviar este formulario por
correo a 645 H St., NE, Washington, DC 20002.
FOR AGENCY USE ONLY Application Recertification
Case Name _____________________ Case #_____________
Date Rec’d _________________ Prog. Approved __________
Date Disp. _________________ Prog. Denied ____________
ESA Combined Application: December 2015
Income Maintenance Administration
Department of Human Services
Government of the District of Columbia
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HUMAN SERVICES
ECONOMIC SECURITY ADMINISTRATION
(202) 727-5355
(202) 727-
5355
(202) 727-5355.
727- 5355
(202) 727-5355
(202) 727-5355
5355
645 H St., NE
Washington, DC 20002.”
645 H St., NE, Washington, DC 20002.
Washington, DC 20002.”
645 H St., NE
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Anacostia Service Center
2100 Martin Luther King Avenue, SE
Washington, DC 20020
Phone: (202) 645-4614
Fax: (202) 727-3527
Congress Heights Service Center
4049 South Capitol Street, SW
Washington, DC 20032
Phone: (202) 645-4525
Fax: (202) 645-4524
H Street Service Center
645 H Street, NE
Washington, DC 20002
Phone: (202) 698-4350
Fax: (202) 724-8964
Fort Davis Service Center
3851 Alabama Ave., SE
Washington, DC 20020
Phone: (202) 645-4500
Fax: (202) 645-6205
Taylor Street Service Center
1207 Taylor Street, NW
Washington, DC 20011
Phone: (202) 576-8000
Fax: (202) 576-8740
Customers may call ESA at (202) 727-5355
to learn which Service Center serves their address.
IMPORTANT NOTICE ABOUT APPLYING for MEDICAID
Unless you are 65 years or older or you are disabled you need to complete a DC Health
Link Application for Health Coverage to get Medicaid. If you are applying in person at
one of the offices listed above you can ask for a paper copy of the Health Link
Application. If you want to file an on-line application for Medicaid go to the DC Health
Link Website at DC HealthLink.com. You can also call the DC HealthLink Customer
Service Center toll-free at 1-855-532-5465 for help applying.
GOVERNMENT OF THE DISTRICT OF COLUMBIA
DEPARTMENT OF HUMAN SERVICES
December 2015
Your Information
Last Name
First Name
Middle Name
Date of Birth
Telephone
Current Address Apt.
Mailing Address (if different)
City, State ZIP
Are you Homeless? Yes No
Do you plan to stay in DC? Yes No
I am applying for: Medical Assistance/QMB Food Stamps IDA (Interim Disability Assistance)
TANF/GC (Temporary Assistance for Needy Families/General Assistance for Children)
Note: Your Food Stamp benefits start on the day that you apply. You can apply right away. Make
sure to write down your name and address above and then sign at the bottom of this page.
Expedited Food Stamps
You might be able to get Food Stamps in less than a week! To see if you qualify, please tell us:
1. Will your household income be more than $150 this month? Yes No
2. Do you have more than $100 in cash or in the bank? Yes No
3. Is your income & ready cash this month more than your rent and utilities? Yes No
If you answered NO to the questions above, then you may be eligible. Please tell us:
(a) What will be your total income this month? $__________; (b) How much do you have in cash or the
bank? $__________; and (c) What did you pay for housing (rent/ utilities) this month? $____________
4. Are you or anyone in your household a migrant or seasonal farm worker? Yes No
Authorized Representative
Do you want someone else to act for or represent you? Yes No If YES, please tell us:
Name of Your Authorized Representative: Address of Rep.: Telephone of Rep.:
___________________________ _________________________________ __________________
What do you want them to do? Do interviews Make Inquiries Report changes Use EBT card
Signature
By signing below, I give my permission to DHS to get information about me. DHS can get this from my employer, landlord,
bank, and utility company. I give all of these people my permission to give information about me to DHS. I have reviewed
the information in my application and I believe that all of my information on this entire eight-page form is true and correct. I
know that if I give any false information, I may be breaking the law and I could be at risk of criminal prosecution
and penalties. I know that state and federal officials will check this information. I agree to help with their
investigations.
I agree to follow the rules for DHS benefits. I have received a copy of these rules. I know that I will have to recertify for
my benefits. I also understand that my child may get free health care through "HealthCheck."
Authorized Representatives: If the applicant cannot sign this form, you may sign it for them. By signing, you certify that
this person wants to apply for benefits and agrees to the conditions above.
SIGNATURE: X ___________________________________ DATE: _________________
1 of 8
December 2015
Who Lives with You?
(Please list everyone in the household, even if you are not applying for them.)
Last Name
First Name
Middle
Name
Applying
for this
Person?
(Yes/No)
Sex
(M/F)
Date of
Birth
Age
Social Security
Number*
Relation
to you
(child, aunt,
friend, etc.)
Do you
eat
together
?
(Yes/No)
U.S.
Citizen?
(Yes/ No)**
1. (You)
(Self)
(n/a)
2.
3.
4.
5.
6.***
* You can leave this blank if this person does not have an SSN or does not want benefits. However, you may still have to report this person’s income and assets.
** Many immigrants are eligible for benefits. To see if you may qualify, please fill out all of page 6. *** Attach another sheet if more than six people live in your house.
General Questions
1. Are you: Single Married Divorced Separated
Widowed (Not needed for Food Stamps)
2. Is anyone in the military or a U.S. Veteran? Yes No
If YES, who?
3. Is anyone pregnant? Yes No (Not needed for Food Stamps)
If YES, who? When is the baby due?
4. Are you in a long-term care facility (nursing home, ICF-MR, CRF, etc.)?
Yes No If YES, where? Yes No If YES, who?
5. How much do you pay for child-care or elder-care (day care, babysitter, etc.)? $ How often do you pay this?
6. Are you or anyone in your household hiding or running from the law to avoid prosecution, being taken into custody, going to jail for a felony
crime or attempted felony, or violating a condition of parole or probation? Yes No If YES, who?
7. Have you gotten benefits from another State in the last three (3) months? Yes No If YES, where?
8. Does anyone age 16 or older go to school or a job-training program? Yes No If YES, who?
Name of the school or program? How many hours per week?
9. In the last two (2) months, did anyone stop working or cut back on their hours? Yes No If YES, who?
Reason? _____________________________ What was their last day at work ? _______________ Date of final paycheck: _______________
2 of 8
December 2015
Income
Income from Work (before taxes or other deductions: gross, not net amount)
Are you or is anyone in your house working? Yes No
Person who is
working
Employer’s
Name/Telephone
Start Date
How much
is each paycheck?
(before taxes)
How often do
you get paid?
(weekly, biweekly,
monthly, etc.)
$ (GROSS)
$ (GROSS)
Other Income
Do you or anyone else get any other income? Please check all that apply and list each payment below.
SSI
Unemployment/Workers Comp.
Child support
Social Security (not SSI)
Pensions and retirement
Help with expenses
Veterans benefits
Foster care/adoption subsidy
Other ______________
Type of Payment
Who gets this?
How much is
each payment?
(before taxes and deductions)
How often do
they get this?
(weekly, biweekly, monthly, etc.)
$ (GROSS)
$ (GROSS)
Does anyone pay your family for meals or to rent a room (for example, a roommate or boarder)?
Yes No If YES, who pays? ____________ How much do they pay each month? $ _____________
Assets
Cash
Does anyone have more than $1,000 in cash? If YES, how much $ _________
Yes No
Bank
Accounts
Does anyone have more than $1,000 in the bank?
If YES, please attach your most recent bank statement(s).
Yes No
Life
Insurance
Does anyone have life insurance that they can cash in?
If YES, how much money would you get if you cashed it in today? $ ____________
Yes No
Real
Property
Does anyone own property besides the home you live in?
(For example: boats, rental property, real estate)
Yes* No
Car
Does anyone own a car, truck or van? If YES, list Make, Model and Year below.
_________________________________ Is it used by someone who’s sick/disabled?
Yes No
Yes No
Other
Does anyone have any stock, bonds, etc.?
Yes* No
Transfers
Did anyone sell, trade, or give away anything worth more than $1,000 during the
last three (3) years?
Yes* No
* If YES, please attach a description to this form.
3 of 8
December 2015
For the Blind and Disabled
(Medical Assistance and IDA Only)
Is anyone in your house blind or severely disabled? Yes No If YES, who? ______________
To get DC Disability Medicaid and Interim Disability Assistance (IDA), you may need to show that
you are blind or disabled. Please get a Medical Form and have a doctor fill it out. If you do not have
a doctor, call the DC Department of Healthcare Finance’s Office of the Ombudsman on (202) 724-
7491. They can help you find a doctor. The doctor will fill out the Medical Form for you. DHS will
treat all of your information as confidential.
Note: You do not need to fill out a Medical Form (856) if you are age 65 or older or if a child under
19 lives with you. Also, you may not need to fill out the form if you get Social Security disability
benefits. If you have questions, please ask your worker or call (202) 727-5355.
Housing, Utilities, & Other Bills
(Food Stamps Only)
Your Food Stamps amount may depend on your housing, utility, and medical bills. Please tell us the current
amount of these bills. Do not include any past due amount. To qualify for more Food Stamps, you must
provide proof of these bills. If you do not, we will assume that you do not want this deduction.
Rent or Mortgage
Rent
Mortgage
Monthly
Property
Taxes*
Homeowners
Insurance*
Condo
Fee*
Other
(describe
below)
How
much?
$
$
$
$
$
$
Who pays?
* Do not list property tax, insurance, or condo fees separately, if they are already included in your rent /mortgage amount.
Do you pay for heating or air-conditioning separately from your rent? Yes No
Did you get LIHEAP (Low Income Home Energy Assistance Program) benefits during the past 12
months? Yes No If yes, how much did you get? $____________
Utility Bills (if separate from rent/mortgage)
Do you pay any money for the following utilities (separate from your rent)?
Electric Bill Gas Bill Fuel Oil Water Bill Phone Bill (including cell)
Other _________________________
Other Bills
1. Is there anyone who is disabled or age 60 or older who pays medical bills?
Yes No If YES, who pays? _______________ How much do they pay each month? $ ____________
2. Does anyone in your home pay child support?
Yes No If YES, who pays? _______________ How much do they pay each month? $ ____________
4 of 8
December 2015
Parents Not Living in the Home
(TANF and Medical Assistance Only)
We can help you get child support for the children for whom you are applying. Please tell us about any
absent parents (any parents not living with their child). However, you could have a good reason for not
telling us about an absent parent. If you are afraid that an absent parent might hurt you or someone in
your family, then you have a good reason. If you have a good reason, then you do not have to give any
information now.
Do you have a good reason for not telling us about an absent parent? Yes No
If NO, then you need to fill in the information below.
Child with Absent Parent: Child # 1
Child’s Name
Date of Birth
In what city and state was this child conceived?
City: State:
Was this child born at full term? Yes No
If no, at how many weeks was this child born?
Name of Alleged Absent Parent
I certify that Child #1 listed above was conceived as a result of sexual intercourse with the alleged parent l have listed at the
location I listed above.
Signature:
Paternity Established?
Voluntary Support
Court-Ordered Child Support
Has paternity been established?
Yes No
If so, by what means?
Date you last received money
from the Absent Parent
Court
City, State
Date ordered
Amount ordered
More Information about Absent Parent
Last Known Address
Telephone
Social Security Number
Alias or Nicknames
Birthdate
Race
Place of Birth (City, State)
Last Known Place of Employment
Dates of Employment:
Name of Absent Parent’s Father
Name of Absent Parent’s Mother
Child with Absent Parent: Child # 2
Child’s Name
Date of Birth
In what city and state was this child conceived?
City: State:
Was this child born at full term? Yes No
If no, at how many weeks was this child born?
Name of Alleged Absent Parent
I certify that Child #2 listed above was conceived as a result of sexual intercourse with the alleged parent l have listed at the
location I listed above.
Signature:
5 of 8
December 2015
Paternity Established?
Voluntary Support
Court-Ordered Child Support
Has paternity been established?
Yes No
If so, by what means?
Date you last received money
from the Absent Parent
Court
City, State
Date ordered
Amount ordered
More Information about Absent Parent (complete this if different from Child #1)
Last Known Address
Telephone
Social Security Number
Alias or Nicknames
Birthdate
Race
Place of Birth (City, State)
Last Known Place of Employment
Dates of Employment:
Name of Absent Parent’s Father
Name of Absent Parent’s Mother
Child with Absent Parent: Child #3
Child’s Name
Date of Birth
In what city and state was this child conceived?
City: State:
Was this child born at full term? Yes No
If no, at how many weeks was this child born?
Name of Alleged Absent Parent
I certify that Child #3 listed above was conceived as a result of sexual intercourse with the alleged parent l have listed at the
location I listed above.
Signature:
Paternity Established?
Voluntary Support
Court-Ordered Child Support
Has paternity been established?
Yes No
If so, by what means?
Date you last received money
from the Absent Parent
Court
City, State
Date ordered
Amount ordered
More Information about Absent Parent (complete this if different from Child #1 and #2)
Last Known Address
Telephone
Social Security Number
Alias or Nicknames
Birthdate
Race
Place of Birth (City, State)
Last Known Place of Employment
Dates of Employment:
Name of Absent Parent’s Father
Name of Absent Parent’s Mother
I solemnly swear or affirm under criminal penalties for the making of a false statement that I have read the
foregoing information regarding parents absent from the home and that the factual statements made in it
are true to the best of my personal knowledge, information and belief.
I understand and agree that the Child Support Services Division (CSSD) will collect all child support
payments. Since I am assigning support rights, I also agree to repay CSSD any payments that are made
to me.
SIGNATURE: X _______________________________ DATE: _________________
6 of 8
December 2015
Health Insurance and Medical Bills
(Medical Assistance Only)
You may still get Medical Assistance even if you have other health insurance. We can also pay your
Medicare premiums for you. Please tell us about your health insurance.
Medicare
Does anyone have Medicare (a red, white and blue card)?
If YES, who has Medicare? ______________________________
Yes No
Health Insurance
Does anyone have any other insurance?
If YES, please give us a copy of the insurance card.
Yes No
Retro Medicaid/
Medical Bills
Did anyone have any medical bills in the last three months?
If you get DC Medicaid, you can get paid back for some bills that you have
paid. We can also pay some unpaid bills. Call (202) 698-2009.
Were your address, income, and assets the same as now during
the last three months? If no, describe the change.
Yes No
Yes No
Voluntary Questions
Ethnicity: Hispanic/Latino Not Hispanic/Latino
Race: Black/African-American Asian American Indian or Alaskan Native
White Native Hawaiian or Other Pacific Islander
Note: You may check more than one race. Also, you do not have to provide this information. None of this information will affect
your benefits. We only ask for this information to make sure that we do not discriminate.
Language Preference
The DC Language Access Act requires that we provide services for persons who do not speak English or
cannot speak English well. The law also requires that we collect information on the languages that our
customers use. Please answer the following questions:
What is the Language that you usually speak?
English Spanish French Vietnamese Korean Amharic
Chinese (Mandarin) Chinese (Cantonese) Other __________________________
What Language do you want to use to get ESA services?
English Spanish French Vietnamese Korean Amharic
Chinese (Mandarin) Chinese (Cantonese) Other __________________________
If you do not want to use the language that you usually speak, you must sign the statement below:
I have been told that I have the right to receive ESA services in the language that I usually speak. By
signing below, I am saying that I do NOT want language services.
Sign here only if you do NOT want language services: ____________________________________
7 0f 8
December 2015
For Immigrants (Non-Citizens) Applying for Benefits
Many immigrants are eligible for benefits. For any non-citizen applying for benefits, please provide the immigration information below. If
your status is “OTHER,” then we will not ask you for any more information about your immigration status.
If you are only applying for your child, you do not have to give details about your immigration status. Instead, you can just give your
child’s immigration information. If you just want benefits for your child, you can mark “OTHER” for your own immigration status.
We may ask Immigration Services (USCIS) to verify the status of anyone who is NOT listed as “OTHER”. This may affect your eligibility
for benefits and the amount of your benefits
Please use these categories for "Current Status" in the table below:
Lawful permanent resident (LPR)
Refugee or Asylee
Cuban or Haitian Entrant
Person who has been granted
withholding of deportation (removal)
Parolee admitted for at least one year
Alien who has been present before April
1, 1980, as a “Conditional Entrant"
Person on active duty in U.S. Armed
Forces (or veteran)
Spouse, widow or dependent of
American soldier or veteran
A victim of domestic violence
A victim of a severe form of trafficking in
human persons
Native American/Inuit born outside of the
U.S.
Hmong/Laotian
Afghan/Iraqi Special Immigrant
Amerasians who came to the U.S. due to
the Vietnam War
OTHER: status does NOT match one of
those listed here.
Name
Alien ID #
(“A” number)
Current Status
Date that You
Moved to the U.S.
Was ever a
Refugee/
Asylee?
Cuban/
Haitian?
1.
Yes
Yes
2.
Yes
Yes
3.
Yes
Yes
4.
Yes
Yes
5.
Yes
Yes
Important: Did anyone above move to the United States before August 22, 1996? Yes No
If YES, who? __________________________________
For Lawful Permanent Residents (LPRs) only:
1. Do you have a sponsor? Yes No
2. Have you, your parents, your spouse, and/or your sponsor ever worked in the U.S.? Yes No
8 of 8
Note: Some immigrants who moved to the U.S. after August 22, 1996
do not have to wait five years before getting benefits.
December 2015
This Is Your Receipt
The date stamp at the right shows that DHS got your application. If you have any
questions, you can call the ESA Call Center on (202) 727-5355.
Your worker will give you a "checklist." This checklist tells you which documents
that you need to bring back to DHS. You can also mail copies to your Service
Center at the address recorded below. If you mail them, please write your name
and your date of birth on each document. DHS must help you get the documents
you need, when you are not able to get them. Let us know if you need help.
ESA Contact: ____________________________ Tel: _____________________
Service Center address: _____________________________________________
Documents That You May Need to Bring to DHS
Proof of:
Examples
Income
Recent paystubs; statement showing retirement income, disability income, or
Workers Compensation; pension statement; etc.
Assets
Recent bank and checking account statements, etc.
DC Residency
DC driver’s license, lease, rent receipt, written statement from your landlord, utility or
telephone bill, etc.
Social Security Number
Social Security card; tax or payroll documents with your SSN on it; DC driver’s
license with your SSN on it; etc. (Not required for Food Stamp-only applicants.)
Medical Exam Report/Disability
Recent medical report (or Form 856) and any supporting materials from your doctor.
Immigration Information
Employment Authorization card, I-94, visa, passport, or other documents from the
INS.
Rent/Mortgage (Food Stamps only)
Lease, rent receipt, cancelled check, mortgage statement, etc.
Utility Bills (Food Stamps only)
Recent bills for electric, gas, fuel, phone, water, telephone, etc. (if you pay these
separately from your rent).
Relationship (TANF only)
Birth certificate (full copy) for your child(ren) or official records from a school, court,
hospital, etc.
“Living with” (TANF only)
Statements from two non-relatives or school records.
Also bring your Medicare card or other health insurance card, if you have one.
Referrals
HealthCheck provides free check-ups for children on Medicaid. It also pays for other services that a child needs.
HealthCheck can also get you free rides to the doctor. To find out more, call (202) 639-4030.
WIC is a program for children under five. With WIC, you can save up to $140 each month on food. Also, WIC staff can
talk with you about breast-feeding. To find out more, call 1-800-345-1WIC (1-800-345-1942).
If you are eligible for DC Medicaid, you can get money back for recent medical bills that you have paid. To find out
more, call (202) 698-2009.
The District has a special program for seniors and the disabled who need in-home nursing and other home care. This
program has a higher income limit than regular Medical Assistance. To find out more, call 1-877-919-2372.
HIV/AIDS testing and services
(202) 671-4900
Medicare
1-800-633-4227
Alcohol and drugs
1-888-7WE-HELP
Social Security Administration
1-800-772-1213
Depression and mental health
1-888-7WE-HELP
Energy Assistance
(202) 673-6700
Breast/cervical cancer screening
(202) 442-5900
Public Housing and Section 8
(202) 535-1000
ESA DATE
STAMP
Case Name ____________________
December 2015
Free Legal Help
Neighborhood Legal Services
680 Rhode Island Ave., NE
(202) 832-6577
4609 Polk St., NE (Ward 7)
(202) 832-6577
2811 Pennsylvania Ave., SE (Ward 8)
(202) 832-6577
Bread for the City Legal Clinics
1640 Good Hope Rd., SE
(202) 561-8587
1525 Seventh St., NW
(202) 265-2400
Legal Aid Society
666 11
th
St., NW, Suite 800
(202) 628-1161
Legal Clinic for the Homeless
1200 U St., NW
(202) 328-5500
Legal Counsel for the Elderly
(for people age 60 and older)
601 E St., NW
(202) 434-2120
Your Rights and the Program Rules
Recertification
We will send you a recertification notice in the mail. If you
get Medical Assistance, just complete the form and send it
back to DHS. If you get Food Stamps or cash assistance
(TANF, GC or IDA), then you will need to come to DHS for
an interview. If you do not recertify, then you will lose your
benefits. Also, please let us know if you move. Just call
(202) 727-5355 to report your new address
General Rules
You must give true and complete information. If you lie or
give false information, you may lose your benefits. You
could also be fined and go to prison. We may verify your
information to make sure it is correct. We may check on
your income, your Social Security information, and your
immigration information. We verify this information
through computer matching programs. We may also
interview you and do a home visit.
Your case may be chosen for a Quality Control review.
This is a detailed review of all of your information. It may
include personal interviews and a review of your medical
records. By applying, you agree to cooperate with the
state or federal reviewers. If you refuse to cooperate, you
may lose all or part of your benefits. If you are under
investigation or are fleeing to avoid the law, we may share
your information with federal and local agencies. If a food
stamp claim arises against you, the information on this
form, including SSNs, may be sent to Federal and State
offices, or private claims collection agencies for claims
collection action against all adults in the household.
Under federal and District law, you must provide your
Social Security Number (if you have one) if you are in the
assistance unit. (See 42 CFR 435.910, 7 CFR 273.6, DC
Code §4-204.07, §4-205.05a, and §4-217.07) Your SSN
will be used to verify your identity, prevent receipt of
duplicate benefits, and make required program changes.
The DHS computer system uses your SSN to verify your
income by using records from federal and local sources,
including the Internal Revenue Service, the Social
Security Administration, DC Department of Employment
Services, and the DC Child Support Services Division
(CSSD). DHS also reserves the right to check your
information with income verification services and other
local agencies.
Unless you receive a notice of simplified reporting, you
must report changes in your income, assets, shelter and
childcare costs, and who lives with you. To report a
change, call (202) 727-5355. You must call us before the
10th day of the month after the change.
Fair Hearings
If you think that DHS has made a mistake, then you can
get a Fair Hearing. Call (202) 698-4650 to find out more.
You can also call (202) 727-8280. At a Fair Hearing, you
can ask someone else to speak for you. This could be an
attorney, a friend, a relative, or someone else. You can
also bring witnesses. We will pay for transportation to the
Fair Hearing for you and your witnesses. We may also
pay for some of your other costs. You can also get free
legal help for a Fair Hearing. Call one of the agencies
above to talk to a lawyer or counselor.
Medical Assistance Rules
The Medicaid rules have changed. If you are not aged
(over 65), blind, or disabled, you must complete the new
DC Health Link application for medical insurance.
However, if you are over 65, blind or disabled or if you
want us to review your application for Interim Disability
Assistance, then you must complete this form. After you
apply, you will get a decision about your Medical
Assistance within 45 days (or 90 days if DHS must
determine if you are disabled). If you do not get a notice
within this period, please call (202) 727-5355.
If you get Medical Assistance, then you must recertify
each year when we send you a recertification notice.
There is no time limit for getting Medical Assistance. Also,
if you lose TANF, you may still get Medical Assistance.
Child Support: You agree to cooperate fully with the DC
Child Support Services Division (CSSD) in establishing
paternity and getting child and medical support as
required by law. You can apply for an exception to this if
you have a good reason. However, you can lose your
benefits if you do not cooperate without a good reason.
Estate Recovery: The District will seek recovery for the
bills we pay if you are in a nursing home or other medical
institution. Also, if you are age 55 or older, the District will
seek recovery for services that you get. This means that
we may put a lien or claim on your property or estate. If
you have questions, call (202) 698-2000.
December 2015
Lawsuits: If you sue or enter into settlement negotiations
with a third party for a medical claim or injury, you must
provide written notice of the action (either by personal
service or certified mail) within 20 calendar days to the
Medical Assistance Administration, Third Party Liability
Section, 441 4
th
Street, NW, Suite 1000- South ,
Washington, DC 20001. If you have questions, call (202)
698-2000.
Out of Pocket Reimbursement Information:
If you paid for drug prescriptions, doctor visits, or
hospitalizations during a time that you were eligible for
Medicaid, you may be able to be reimbursed for the
expenses.
REQUIREMENTS: You may be eligible for reimbursement
if during a period of time you or a family member were
eligible for Medicaid, and
a. You paid for drug prescriptions, doctor visits, or
hospitalizations; or
b. You are still paying a bill or are being asked to pay a bill
by a pharmacy, clinic, doctor, or hospital for drug
prescriptions, doctor visits, or hospitalizations.
If you believe that you are entitled to reimbursement, you
must request reimbursement within six (6) months of the
date you went to the pharmacy, clinic, doctor, or hospital,
or within six (6) months of the date you learned you were
eligible for Medicaid, whichever is later.
You must complete and submit a Medicaid
Reimbursement Request Form to the DC Department of
Health Care Finance. You can get a copy of the form at
any ESA office, or you can download a copy at
https://www.dc-
medicaid.com/dcwebportal/nonsecure/recipientForms.
IF YOU HAVE QUESTIONS OR IF YOU NEED HELP
COMPLETING THE FORM OR OBTAINING
REQUESTED INFORMATION CONTACT:
a. The Medicaid Recipient Claims Research Team of the
D.C. Department of Health Care Finance (DHCF) at (202)
698-2009.
b. Terris Pravlik & Millian, LLP, 1121 12th Street, NW,
Washington, DC 20005, (202) 682-0578, who will provide
you with free legal assistance.
A DECISION ON YOUR REIMBURSEMENT CLAIM
MUST BE MADE WITHIN 90 DAYS:
a. The Medicaid Recipient Claims Research Team must
make a decision on your reimbursement claim within 90
days from the time you file your claim. If no decision is
made within those 90 days, your claim will be treated as
valid, and you will be paid within 15 days after the end of
the 90 day period.
b. If you are not satisfied with the decision of the Medicaid
Recipient Claims Research team, you have a right to a fair
hearing. You may request a fair hearing by calling the
Office of Administrative Hearings at (202) 442-9094. The
Office of Administrative Hearings is located at 441 4th
Street, NW; Washington, DC 20001-2714.
c. If you are not satisfied with the result of the fair hearing,
you may appeal to the United States District Court of the
District of Columbia within 30 days. You may obtain free
legal assistance to help you present your case at the fair
hearing or at the appeal by contacting Terris Pravlik &
Millian, LLP at 1121 12th Street, NW; Washington, DC
20005 or (202) 682-0578.
TANF Rules
There are new requirements in the TANF program. After
you apply, you must complete an orientation, assessment
and develop an initial self sufficiency plan as a condition of
eligibility for TANF benefits. This requirement does not
apply to you if you are receiving SSI or if you are
caretaker of child(ren) that are not yours and you are only
applying for the child(ren). To schedule an appointment for
an assessment, you can call the Family Resource Center
at (202) 698-1860. You will get a decision about your
TANF within 45 days. If you do not get a notice within 45
days, you can get a Fair Hearing. Also, if you think your
benefit amount is incorrect, then you can get a Fair
Hearing.
If you are able to work, then you must comply with the
work requirements to receive TANF benefits. You could
lose your benefits if you do not comply. If you have a
physical or mental condition that keeps you from working,
let DHS case coordinator know at any time. You can be
excused from working if you have a good reason. This is
called a work exemption.
You are excused from working if:
You are a minor parent and you are in school
You have a child under 6 and cannot find child care
You are incapacitated, injured or have a disability
You are required to take care of someone in your
house who is ill or disabled
You are 60 years of age or older
You need treatment for substance abuse and you
cannot work
You are a victim of domestic violence and you are
afraid for your safety
You have a child under one (1) years old
We may ask for proof of your need to be excused,
including a report from your doctor where appropriate. If
you are eligible for the exemption, you may also be
eligible for a temporary transfer to POWER.
POWER: You can apply for a temporary transfer to
POWER at any time if you are eligible for TANF benefits
but cannot work. You can apply for POWER by letting us
know that you have a physical or mental condition that
prevents you from working. You can also be eligible for
POWER if you are:
A minor parent enrolled in school
You are required to take care of someone in your
house who is ill or disabled
Your are 60 years of age or older
You need treatment of substance abuse and you
cannot work
You are a victim of domestic violence and you are
afraid for your safety
December 2015
Child Support: There are new rules for Child Support. You
can receive both TANF and a portion of your child support
at the same time. The Child Support Services Division can
help you get child support from the other parent. You are
required by law to cooperate with the CSSD. Contact
(202) 442-9900 to set up an appointment with them. By
signing this application, you agree to cooperate fully with
the CSSD in establishing paternity and getting child and
medical support as required by law. You can ask for an
exemption if you have a good reason for not cooperating.
You have a good reason if:
You are afraid that you, your children, or a close
family member could be harmed if you help CCSD
Your child was conceived because of rape by a
stranger , someone you know, or a relative
Your child is going to be adopted or you are deciding
whether to give up your child for adoption
You may have other reasons for not wanting to help
CSSD. Discuss them with your Child Support Worker. If
you have a good reason, tell your DHS and Child Support
Worker and provide proof within 20 days of the request for
exemption. After you provide proof to CSSD, they will let
you know of their decision. If you do not cooperate with
CSSD, and you do not have an exemption, then you will
lose 25% of your TANF benefit.
TANF Time Limits: Most people can only get TANF for 60
months. We count every month that you received a TANF
benefit until you get to 60 months. If you are subject to the
time limits, your TANF benefit will be reduced or
eliminated at the beginning of 61 months.
You are not subject to the time limits if you are receiving
SSI or if you are receiving TANF because you are caring
for someone else’s child. In addition, the months do not
count if you are receiving POWER benefits. It is important
that you let us know if you are having trouble working
because of illness or disability. You may qualify for
POWER for other reasons. Please see the section on
POWER for more information.
Work Pays While on TANF: When you report that you got
a job, you may be eligible to receive up to $1,250 in TANF
bonuses while you work! We also discount your income so
that you can keep more of your TANF while you are
bringing home a paycheck. How much of your TANF
money you keep depends on how much you are earning.
Sanctions: If you do not follow your plan or work
requirements, your TANF benefits will be cut, unless you
have a good reason. This is called a work sanction. We
want you to put yourself in the best situation to be
successful for you and your children. DHS offers services
to assist you with preparing for and getting a job, address
problems that are preventing you from being successful at
a job, and help with getting a better job. If you are at risk
of a sanction, we will notify you in advance. You can
avoid sanctions. Contact your case manager or DHS
Family Resource Center to learn how.
There are three levels of work sanctions. The first level
sanction will reduce your grant by reducing your
household size and moving you from the grant. The
second level sanction will reduce your benefits in half.
The third level you will lose your entire grant. You must
comply for four consecutive weeks to get your benefits
back. If you do not comply right away, the sanction could
last longer. For more information ask for a TANF: Your
Guide to Putting the Pieces Together booklet or go to
www.dhs.dc.gov or call (202) 698-1860.
Electronic Benefit Transfer rule changes: Recently
Congress passed a law that changes how and where you
can use your TANF benefits on your EBT card. Your EBT
card is the card you use to access your TANF benefits.
You are not permitted to use your EBT card in liquor
stores, casinos, or strip clubs. If you use the card at any of
these locations, the transaction will be blocked. DHS is
monitoring the use of the card at these locations. If you
repeatedly use the card at prohibited locations you may be
in violation of the program rules and disqualified from the
program.
Food Stamp Rules
You may file an application for Food Stamps separately
from other benefits. You will get Expedited Food Stamps
within seven (7) days if you are eligible. After you apply,
you will get a decision about your Food Stamps within 30
days. If you do not get a notice within this period you can
get a Fair Hearing. Also, if you do not think your benefit
amount is correct, then you can get a Fair Hearing.
You must have an interview with DHS to get Food
Stamps. If you need to do an interview by telephone,
please let your worker know. We can do phone interviews
if you cannot come to DHS because of work. We can also
do phone interviews if you are sick or have a sick relative
for whom you are caring.
You will have to come to DHS to recertify when we send
you a notice. Note: some elderly and disabled customers
only have to recertify every two years. However, there is
no time limit for getting Food Stamps. In fact, even if you
lose TANF, you may still get Food Stamps.
If you get Food Stamps, you must follow these rules.
Do not lie or hide information to get Food Stamps.
Do not trade or sell your Food Stamps;
Do not use someone else’s Food Stamps; and
Do not buy alcohol or tobacco with Food Stamps.
If you break the rules, then you could be fined and go
to prison for up to 20 years. You may also lose your
benefits for one year for the first violation, two years
for the second
violation, and permanently for the third
violation. If you lie about living in the District or your
identity, then you cannot get Food Stamps for 10
years. If you sell or trade your Food Stamps for any
purpose (e.g., to get drugs, firearms, ammunition, or
explosives) or traffic in $500 or more in benefits, then
you may lose your benefits permanently.
December 2015
IDA Rules
After you apply, you will get a decision about your IDA
within 60 days. If you do not get a notice within 60 days,
you can get a Fair Hearing. Also, if you do not think your
benefit amount is correct, then you can get a Fair Hearing.
If you get IDA, then you must cooperate with your IDA
case manager. This means:
Give us medical reports and other materials;
Keep your appointments with the doctor and with the
Social Security Administration;
Keep your appointments with your case manager; and
Go to treatment programs, as required.
If you do not follow these rules, then you may lose part or
all of your IDA benefits. Also, DHS will take out the
amount of IDA that you got from your first “lump sum” SSI
check; DHS will send the rest of your first SSI check to
you.
Rights of Support
You must turn over to the District Government any
payments that you get from an insurance company for
medical care. You must turn over part or all of your child
support to the DC Child Support Services Division (CSSD)
after you get your first TANF payment. If you do not agree
to these conditions, then you cannot get Medicaid or
TANF. Once you are off TANF, then you can keep any
current child support payments. If you use a Medicaid
card or the TANF benefit, then you are telling us that you
agree to these conditions.
Confidentiality
By applying, you give DHS permission to talk with your
employer, your landlord, your bank, your doctor, and other
people who have information about you. You also give
these people your permission to give information about
you to DHS. In addition, you also give DHS permission to
look at your motor vehicle records, wage data, tax
information, and other government records. Of course,
DHS keeps all of your information confidential. DHS does
not release your records without your permission (except
when required by law).
Equality and Non-Discrimination
This institution is prohibited from discriminating on the
basis of race, color, national origin, disability, age, sex and
in some cases religion or political beliefs.
The U.S. Department of Agriculture also prohibits
discrimination based on race, color, national origin, sex,
religious creed, disability, age, political beliefs or reprisal
or retaliation for prior civil rights activity in any program or
activity conducted or funded by USDA.
Persons with disabilities who require alternative means of
communication for program information (e.g. Braille, large
print, audiotape, American Sign Language, etc.), should
contact the Agency (State or local) where they applied for
benefits.
Individuals who are deaf, hard of hearing or have speech
disabilities may contact USDA through the Federal Relay
Service at (800) 877-8339. Additionally, program
information may be made available in languages other
than English.
To file a program complaint of discrimination, complete the
USDA Program Discrimination Complaint Form, (AD-
3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and
at any USDA office, or write a letter addressed to USDA
and provide in the letter all of the information requested in
the form. To request a copy of the complaint form, call
(866) 632-9992. Submit your completed form or letter to
USDA by:
(1) mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, D.C. 20250-9410
(2) fax: (202) 690-7442; or
(3) email: program[email protected].
For any other information dealing with Supplemental
Nutrition Assistance Program (SNAP) issues, persons
should either contact the USDA SNAP Hotline Number at
(800) 221-5689, which is also in Spanish or call the State
Information/Hotline Numbers (click the link for a listing of
hotline numbers by State); found online at:
http://www.fns.usda.gov/snap/contact_info/hotlines.htm.
To file a complaint of discrimination regarding a program
receiving Federal financial assistance through the U.S.
Department of Health and Human Services (HHS), write:
HHS Director, Office for Civil Rights, Room 515-F, 200
Independence Avenue, S.W., Washington, D.C. 20201 or
call (202) 619-0403 (voice) or (800) 537-7697 (TTY).
This institution is an equal opportunity provider.
In accordance with the DC Human Rights Act of 1977, as
amended, DC Official Code § 2-1401.01 et seq., (Act) the
District of Columbia does not discriminate on the basis of
actual or perceived: race, color, religion, national origin,
sex (gender or sexual harassment), age, marital status,
gender identity or expression, personal appearance,
sexual orientation, familial status, family responsibilities,
matriculation, political affiliation, genetic information,
disability, source of income, status as a victim of an intra-
family offense, and place of residence or business.
Sexual harassment is a form of sex discrimination, which
is prohibited by the Act. In addition, harassment based on
any of the above protected categories is prohibited by the
Act. Discrimination in violation of the Act will not be
tolerated. Violators will be subject to disciplinary action.
These prohibitions also apply to the denial of credit or
insurance. COMPLAINTS OF POSSIBLE VIOLATIONS
OF THIS LAW MAY BE FILED WITH:
Government of the District of Columbia
Office of Human Rights
441 4th Street, N.W., 570N
Washington, D.C. 20001
Telephone (202) 727-4559 • Fax (202) 727-9589
December 2015
DC Economic Security Administration
645 H Street, NE
Washington, DC 20002
ESA Combined Application
December 2015