Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 20
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343
StEP
American indian or Alaska Native (Ai/AN) Household Member(s)
1. Are you or is anyone in your household an American Indian or Alaska Native?
Yes
No
If no, skip to Step 4.
If yes, complete the rest of this application, including
Supplement B: American indian or Alaska Native Household
Member.
Names(s) of person(s)
American Indians and Alaska Natives who enroll in health coverage can also get services from the Indian Health Service,
tribal health programs, or Urban Indian Health Programs. If you or any household members are American Indians or Alaska
Natives, you may not have to pay premiums or copayments, and may get special monthly enrollment periods.
4
StEP
your Household's Health Coverage
Complete Question 1 about health coverage that any person in the household has now. Complete Question 2 about health
insurance available to a household member from a job, whether or not the employed person lives in the household.
1. Is anyone enrolled now in any of the following types of health coverage?
Yes
No
If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
tRiCARE (Do not check if you have direct care or Line of Duty.) . . . . Start date
Name(s) of person(s) covered
Veterans Affairs (VA) health programs . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
Peace Corps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
Employer insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
Name of health insurance
Policy number
CoBRA coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
Retiree health plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
other coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Start date
Name(s) of person(s) covered
Name(s) of health insurance
Policy number
Is this a limited-benefit plan (like a school accident policy)?
Yes
No
2. Is anyone listed on this application offered health coverage from a job but not enrolled in it?
Yes
No
This includes a job for a household member or an individual who is not in the household, such as a noncustodial parent. This
question is about coverage that is available but in which eligible household members are not enrolled.
If yes, you will need to complete and include
Supplement A: Health Coverage from
Jobs, and the rest of this application.
Is this a state employee benefit plan?
Yes
No
If no, continue to Step 5.
Page 18
ACA-3 (Rev. 10/16)
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