United Health Care Grant

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Your total family income, CANNOT exceed $20,000 per family member (ex: 3

family members-Adj. Gross Inc. for 2007-$60,000)

Grant Application - Criteria

Please carefully read the criteria. Applications submitted that do not meet

the criteria will not be considered.

In evaluating applications, the Regional Board will consider applications

based on the following criteria:

1.. Grant applications requesting assistance for dental or orthodontic

treatment unrelated to a serious medical condition are excluded from grant

consideration.

2.. The applicant must be 16 years old or younger and live in the United

States and receive and pay for care/items in the United States.

3.. The applicant must be covered by a commercial health benefit plan and

limits for the requested service are either exceeded, or no coverage is

available and/or the copayments are a serious financial burden on the

family. The UnitedHealthcare Children's Foundation requires a commercial

health benefit plan. A commercial health benefit plan is defined below:

Included Excluded

a.. Your commercial health benefit plan is offered through:

a.. Your commercial (private) employer. Example: most grant

applicants whose parent works for a commercial entity will have this type of

health insurance.

b.. Your health benefit plan is offered through a commercial

health plan that you individually purchased. Example: small business owners,

sole-proprietors, etc.

c.. Your health benefit plan is offered through your employment

with a town, city, state or federal government. Example: teachers, police

officers, active duty or civilian military duty, etc.

a.. Medicaid, Medicare, SCHIP (which may be called various names by

each state), HIS or other state or federally subsidized health insurance

programs given to those without insurance or with low incomes.

4.. The potential of the intervention to significantly enhance either the

clinical condition or the quality of life for the child, the financial

status of the family and the severity of the child's illness. If a grant is

approved, services must be provided by a trained, and if appropriate,

licensed professional.

5.. Financial need of the child's family will be evaluated and documented

through information provided on the application and by submission of a

photocopy of the most recently filed Federal tax return (Internal Revenue

Service 1040, 1040-A, or 1040-EZ). Awards will NOT be granted to individuals

in families whose Adjusted Gross Income (AGI) exceeds $20,000 per family

member. For example, if you are a family of three and your most recently

filed IRS 1040 indicates that your AGI is $60,001 or more, you are not

eligible.

6.. Other financial resources to meet the health care need are not

available.

7.. The amount awarded to an individual within a 12-month period is

limited to either $5,000 or 85% of the fund balance, whichever amount is

less. Awards to any one individual are limited to a lifetime maximum of

$7,500.

8.. An application must be submitted prior to the child's 17th birthday.

9.. The health care professional is to be paid directly; exceptions can be

made to reimburse the family if adequate documentation is submitted showing

the health care professional has been paid.

10.. Applications are to be reviewed by a health care professional

appointed by the Foundation to determine the medical appropriateness of the

treatment.

11.. An application must be submitted to the Foundation prior to the

receipt of services. The Foundation does not pay for past medical expenses.

12.. Applicants who are not approved by the Regional Board must wait a

period of twelve months before re-applying, unless the medical condition and

requested items have significantly changed from the original request.

13.. In order to apply for your child, the child must live with you 51% or

more and be listed as a dependent on your most recently filed IRS 1040. If

the child is not listed on your most recently filed IRS 1040, then we need a

copy of both your most recently filed IRS 1040 and the most recently filed

IRS 1040 on which the child is listed as a dependent.

14.. If a grant is approved, you can not re-apply for another grant until

30 days before your current grant expires. Yearly and lifetime maximum grant

limits apply.

Shortcut to: http://www.uhccf.org/apply_applicant.html