Hawaii medicaid application form

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    Apply for Medicaid

    The Med-QUEST Division accepts applications for medical assistance coverage online, over the phone, by mail or Fax. Fill out the application as completely as possible. Completed applications ensure more timely determination. If additional information is needed, the Med-QUEST Division will contact you.

    You have three ways to apply for a health plan:

    DHS 1100 “Application for Health Coverage and Help Paying Costs”
    DHS 1100 Instructions

    Additional forms are needed for applicants with the following conditions.
    Please include these forms when you apply for Medicaid.

    • Applicant needs Long Term Care Services – DHS 1100, DHS 1100B, DHS 1167, DHS 1169, DHS 1169A, DHS 8003 and DHS 8004.
    • Applicants with disability – DHS 1100, DHS 1100B, DHS 1127 and DHS 1128

    Health Plan Enrollment

    An eligible individual will receive an enrollment choice packet by mail to select a plan from the available plans in their area.
    

    If you’re pregnant and enrolled in a QUEST Integration Health Plan on the date you deliver your child, your newborn will automatically be enrolled in your health plan for a minimum of 30 days from the date of birth. Med-QUEST will mail you an enrollment packet and give the option to change your newborn’s health plan after the first 30 days.

    If your Medicaid eligibility ends for any reason, your QUEST Integration health plan enrollment will also end. You may reapply at any time. If you become eligible within six months from when you last had Medicaid benefits, Med-QUEST will assign you to your former health plan.