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LOUISANA—Medicaid ®JERSEY—Medicaid and CHIP Website:www.medicaid.la.gov or www.ldh.la.gov/lahipp Medicaid Website:http://www.state.nj.us/humanservices/dmahs/ Phone: 1-888-342-6207(Medicaid hotline)or 1-855-618-5488 clients/medicaid/ (LaHIPP) Medicaid Phone:609-631-2392 CHIP Website:http://www.njfamilycare.org/index.html CHIP Phone: 1-800-701-0710 l MAINE—Medicaid NEW YORK—Medicaid Website:http://www.maine.gov/dhhs/ofi/public-assistance/index.html ▪ Website:https://www.health.ny.gov/health_care/medicaid/ Phone: 1-800-442-6003 Phone: 1-800-541-2831 TTY:Maine relay 711 MASSACHUSETTS—Medicaid and CHIP NORTH CAROLINA—Medicaid Website:http://www.mass.gov/eohhs/gov/departments/masshealth/ • Website:https://medicaid.ncdhhs.gov/ Phone: 1-800-862-4840 Phone:919-855-4100 1. MINNESOTA—Medicaid NORTH DAKOTA—Medicaid Website:https://mn.gov/dhs/people-we-serve/children-and-families/ Website:http://www.nd.gov/dhs/services/medicalserv/medicaid/ health-care/health-care-programs/programs-and-services/medical- Phone: 1-844-854-4825 assistance.jsp[Under ELIGIBILITY tab,see"what if I have other health insurance?"] Phone: 1-800-657-3739 MISSOURI—Medicaid OKLAHOMA—Medicaid and CHIP Website:http://www.dss.mo.gov/mhd/participants/pages/hipp.htm Website:http://www.insureoklahoma.org Phone:573-751-2005 Phone: 1-888-365-3742 MONTANA—Medicaid OREGON—Medicaid • L � Website:http://dphhs.mt.gov/MontanaHealthcarePrograms/ Website:http://healthcare.oregon.gov/Pages/index.aspxhttp:// HIPPPhone: 1-800-694-3084 www.oregonhealthcare.gov/index-es.html Phone: 1-800-699-9075 PENNSYLVANIA—Medicaid RHODE ISLAND—Medicaid and CHIP Website:https://www.dhs.pa.gov/providers/Providers/Pages/Medical/ Website:http://www.eohhs.ri.gov/ HIPP-Program.aspx Phone: 1-855-697-4347,or 401-462-0311(Direct Rite Share Line) Phone: 1-800-692-7462 SOUTH CAROLINA—Medicaid VIRGINIA—Medicaid and CHIP Website:https://www.scdhhs.gov Website:haps://www.coverva.org/hipp/ Phone: 1-888-549-0820 Medicaid Phone: 1-800-432-5924 CHIP Phone: 1-855-242-8282 SOUTH DAKOTA—Medicaid WASHINGTON—Medicaid Website:http://dss.sd.gov Website:https://www.hca.wa.gov/ Phone: 1-888-828-0059 Phone: 1-800-562-3022 TEXAS—Medicaid T WEST VIRGINIA—Medicaid Website:http://gethipptexas.com/ Website:http://mywvhipp.com/Toll-free Phone: 1-800-440-0493 phone: 1-855-MyWVHIPP(1-855-699-8447) UTAH—Medicaid and CHIP WISCONSIN—Medicaid and CHIP Medicaid Website:https://medicaid.utah.gov/ Website:https://www.dhs.wisconsin.gov/publications/pl/p10095.pdf CHIP Website:http://health.utah.gov/chip Phone: 1-800-362-3002 Phone: 1-877-543-7669 IVERMONT—Medicaid WYOMING—Medicaid Website:http://www.greenmountaincare.org/ Website:https://wyequalitycare.acs-inc.com/ Phone: 1-800-250-8427 Phone:307-777-7531 To see if any other states have added a premium assistance program since January 31,2020,or for more information on special enrollment rights,contact either:U.S.Department of Labor Employee Benefits Security Administrationwww.dol.gov/agencies/ebsal-866-444-EBSA (3272)or U.S.Department of Health and Human Services Centers for Medicare&Medicaid Serviceswww.cms.hhs.govl-877-267-2323, Menu Option 4,Ext.61565 Paperwork Reduction Act Statement According to the Paperwork Reduction Act of 1995(Pub.L.104-13)(PRA),no persons are required to respond to a collection of information unless such collection displays a valid Office of Management and Budget(OMB)control number.The Department notes that.a Federal agency cannot conduct or sponsor a collection of information unless it is approved by OMB under the PRA,and displays a currently valid OMB control number,and the public is not required to respond to a collection of information unless it displays a currently valid OMB control number.See 44 U.S.G.3507.Also,notwithstanding any other provisions of law,no person shall be subject to penalty for failing to comply with a collection of information if the collection of information does not display a currently valid OMB control number.See 44 U.S.C.3512.The public reporting burden for this collection of information is estimated to average approximately seven minutes per respondent.Interested parties are encouraged to send comments regarding the burden estimate or any other aspect of this collection of information,including suggestions for reducing this burden,to the U.S.Department of Labor,Employee Benefits Security Administration,Office of Policy and Research,Attention:PRA Clearance Officer,200 Constitution Avenue,N.W.,Room N-5718,Washington,DC 20210 or email ebsa.opr@dol.gov and reference the OMB Control Number 1210-0137. OMB Control Number 1210-0137(expires 1/31/2023) 72 37