Eligibility & Registration

Is your health insurance a Medicaid managed care plan? *

Check your insurance card. We can only accept Medicaid managed care plans.

Answer "Yes" if your plan is one of these

A Medicaid HMO plan through an insurer such as Fidelis, Healthfirst, MetroPlus, UnitedHealthcare Community Plan, or Anthem/Empire
A HARP plan (e.g., Healthfirst HARP, Fidelis HealthierLife)
An HIV Special Needs Plan (e.g., Amida Care, MetroPlus Partnership in Care)

Answer "No" if you have any of these

Straight (fee-for-service) Medicaid with no plan
Essential Plan or Child Health Plus
Medicare, including Medicare Advantage or a dual plan
MLTC, MAP, PACE, or FIDA
Private or employer insurance in addition to Medicaid

Yes, I have a Medicaid managed care plan and none of the "No" items apply No, I have one of the "No" items Unsure, I don't know what kind of plan I have

Name of your plan * As it appears on your insurance card

01

Eligibility

These answers help us confirm whether this program may be a fit.

Medically enhanced category *

02

Eligible member

Enter the eligible member's details as they appear on the insurance card.

Date of birth *

First name * Last name *

Other household members on Medicaid

Add each household member enrolled in a regular Medicaid insurance plan. Include their details exactly as they appear on their insurance card.

03

Contact and address

Tell us where you live and how we can reach you.

Street address * Apt / unit City * State * ZIP code * Email * Primary phone * 10-digit number. Please use your cell number if possible.

Do you consent to, and can your primary phone receive, SMS text messages? *

Yes No

Secondary phone 10-digit number. Preferred language * The language you would like your screening to be conducted in.

04

Support preferences

Tell us about the food support and related benefits you may need.

Are you concerned about food security and would like to enroll in the Medicaid waiver nutrition program? *

Switching between groceries and meals later requires reauthorization, wait time, and a possible lapse of service.

Ready-prepared meals Raw grocery items (I cook my own)

Allergies or dietary restrictions

Are you or anyone in your household currently employed? *

Yes No

Are you currently receiving WIC? *

Yes No

Are you currently receiving SNAP? *

Yes No

05

Final details

Share anything else that can help our team follow up.

How did you hear about this program? Anything else you'd like us to know?