If you’re looking for the DHCS 7096 form to apply for California’s Health Insurance Premium Payment (HIPP) program, the number no longer matches the current paperwork. The Department of Health Care Services now uses Form DHCS-6172 as the main HIPP application, and it must be submitted together with several supplementary forms. Download the packet from the DHCS website, complete every required form, and mail or fax it to the HIPP Program office in Sacramento. DHCS processes complete applications within 30 days.
Before You Start: Who HIPP Is For
HIPP reimburses the employee share of private health insurance premiums for certain Medi-Cal beneficiaries when paying those premiums costs the state less than covering the person’s care directly through Medi-Cal. To apply, you need to meet all of the following:1County of Santa Clara Social Services Agency. Health Insurance Premium Payment (HIPP) Program
- Full-scope Medi-Cal coverage on a fee-for-service basis, not a Medi-Cal managed care plan.
- Not eligible for Medicare.
- A high-cost medical condition for you or a covered family member, such as cancer, kidney dialysis, or a high-risk pregnancy.
- Access to private health insurance through an employer group plan, COBRA continuation, or a conversion policy.
- Private coverage that actually covers the high-cost condition.
- No past-due or retroactive premium balances on the policy.
- A DHCS determination that paying the premium is cost-effective for the state.
If you’re applying based on COBRA coverage, submit the packet within 30 days of the insurance termination date so DHCS has time to process it before coverage lapses.1County of Santa Clara Social Services Agency. Health Insurance Premium Payment (HIPP) Program
HIPP applies to employer-sponsored group plans and COBRA. It is not designed for individual Marketplace plans purchased through Covered California.
The Forms You Need to Complete
A HIPP application is a packet, not a single form. DHCS requires all of the following:2California Department of Health Care Services. Health Insurance Premium Payment Web Forms
- HIPP Application Form (DHCS-6172) — the main application.
- HIPP Disclosure Statement (DHCS-9121).
- Release of Information (DHCS-9119).
- Medical Statement of Diagnosis (DHCS-9120), completed by your treating physician.
- Payee Data Record (STD 204).
- Notice to Terminating Employees.
The Appointment of Representative (DHCS-9113) is optional and only needed if you want someone else to communicate with DHCS on your behalf.2California Department of Health Care Services. Health Insurance Premium Payment Web Forms
All forms are available for download from the DHCS website in English, Spanish, and more than a dozen additional languages including Armenian, Chinese, Korean, Russian, Tagalog, and Vietnamese.2California Department of Health Care Services. Health Insurance Premium Payment Web Forms
How to Fill Out Each Form
Before you start, gather your Medi-Cal Benefits Identification Card, your private insurance card, and a recent pay stub showing the premium deduction. Having these in front of you prevents the back-and-forth that slows most applicants down.
The Main Application (DHCS-6172)
Enter your Medi-Cal Beneficiary Identification Number (BIC) from your Medi-Cal card. Then provide the insurance company name, group number, and your individual policy number. If the coverage is through an employer, the form asks for the employer’s name, address, phone number, and the HR department contact. DHCS uses that information to verify your enrollment and premium amount.
List the exact monthly premium shown on your pay stub, not a rounded figure. The form also asks for the policy’s effective date and the employer’s Federal Employer Identification Number (FEIN), which HR can provide. The FEIN matters because DHCS uses it to route reimbursement payments.
Medical Statement of Diagnosis (DHCS-9120)
Your treating physician fills this out, not you. The doctor documents the high-cost condition, the treatment plan, and confirms that your private insurance covers the needed services. DHCS bases its cost-effectiveness analysis on projected medical expenses, so a vague or incomplete medical statement is one of the fastest ways to stall an application. Ask your doctor to be specific about diagnosis and anticipated treatment.
Release of Information (DHCS-9119)
Sign and date this one carefully. Without it, DHCS cannot contact your insurer or employer to verify anything, and your packet will sit untouched until you provide a valid release.
Disclosure Statement and Payee Data Record
The DHCS-9121 acknowledges your understanding of the program terms. The STD 204 is a standard state payee form that allows DHCS to set up premium reimbursement payments. Both need signatures where indicated.
Where to Send the Packet
Send all required forms together to:
Third Party Liability and Recovery Division
HIPP Program – MS 4719
P.O. Box 997425
Sacramento, CA 95899-7425
For faster delivery, fax the packet to (916) 440-5676. You can email questions in advance to HIPP@dhcs.ca.gov.3California Department of Health Care Services. Health Insurance Premium Payment Program/Cost Avoidance
DHCS does not accept incomplete packets. Before sending, confirm you have DHCS-6172, DHCS-9121, DHCS-9119, DHCS-9120, STD 204, and the Notice to Terminating Employees, each signed and dated. If you mail the packet, use a service with delivery tracking.
What Happens After You Submit
DHCS processes new HIPP applications within 30 days of receiving all required documentation.4California Department of Health Care Services. HIPP Frequently Asked Questions That clock starts when the packet is complete, not when you drop it in the mail. If anything is missing or unclear, DHCS will contact you, and the 30-day window resets once they have everything they need.
If approved, DHCS reimburses the employee’s share of the premium. The employer’s share is not reimbursed. You keep both your private insurance and your Medi-Cal coverage, and services the private plan does not cover remain available through Medi-Cal.3California Department of Health Care Services. Health Insurance Premium Payment Program/Cost Avoidance
If Your Application Is Denied
The most common denial reason is that the private coverage is not cost-effective: the premiums and related costs exceed what Medi-Cal would spend covering your care directly. Incomplete paperwork and failing the fee-for-service Medi-Cal requirement also come up often.
HIPP denials do not go through the standard Medi-Cal state hearing process administered by the Department of Social Services.1County of Santa Clara Social Services Agency. Health Insurance Premium Payment (HIPP) Program If you are denied, contact the HIPP office at HIPP@dhcs.ca.gov or by fax at (916) 440-5676 to ask about your options. Reapplying with stronger medical documentation or updated cost information is often the most practical path.
Once enrolled, report changes right away. If you lose access to employer coverage, switch to a managed care plan, or your Medi-Cal eligibility changes, notify the HIPP office. Maintaining both Medi-Cal and your private plan is a condition of continued participation, and failing to report changes can end your enrollment.