Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 14
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32Person 3 (continued)
STEP 2
|
12. Is this person living in Massachusetts, and does this person either intend to reside here, even if he or she does not have a fixed
address, or has this person entered Massachusetts with a job commitment or seeking employment?
Yes
No
If this person is visiting in Massachusetts for personal pleasure or for the purposes of receiving medical care in a setting other
than a nursing facility, you must answer no to this question.
13. Does this person have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is
expected to last for at least 12 months? If legally blind, answer yes.
Yes
No
14. Does this person need reasonable accommodation because of a disability or an injury?
Yes
No
If yes, complete the rest of this application, including Supplement C: Accommodation.
15. Is this person pregnant?
Yes
No
If yes, how many babies is she expecting?
What is the expected due date?
16. Does this person have breast or cervical cancer? (Optional)
Yes
No
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
17. Is this person HIV positive? (Optional)
Yes
No
MassHealth has special coverage rules for people who are HIV positive.
18. Was this person ever in foster care?
Yes
No
a. If yes, in what state was this person in foster care?
b. Was this person getting health care through a state Medicaid program?
Yes
No
INCOME INFORMATION
Does this person have any income?
Yes
No
If yes, go to Current Job 1 for job income. Go to Self-Employment for self-employment income. For all other income, go to
Other Income. If any income is not steady from month to month, please provide the average income for the time period (per
week, per month, etc.).
If no, skip to questions 32 and 33.
CURRENT JOB 1
19. Employer name and address
Federal Tax ID#
20. a. Wages/tips (before taxes) $
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly ( Subtract any pre-tax deductions, such as nontaxable health insurance premiums.)
b. Income effective date
21. Average number of hours worked each WEEK
22. Is this job a sheltered workshop?
Yes
No
23. Is this person seasonally employed?
Yes
No. If yes, which months does this person work in a calendar year?
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
CURRENT JOB 2
| if you have more jobs and need more space, attach another sheet of paper.
24. Employer name and address
Federal Tax ID#
25. a. Wages/tips (before taxes) $
Weekly
Every 2 weeks
Twice a month
Monthly
Quarterly
Yearly ( Subtract any pre-tax deductions, such as nontaxable health insurance premiums.)
b. Income effective date
26. Average number of hours worked each WEEK
27. Is this job a sheltered workshop?
Yes
No
28. Is this person seasonally employed?
Yes
No. If yes, which months does this person work in a calendar year?
Jan.
Feb.
March
April
May
June
July
August
Sept.
Oct.
Nov.
Dec.
Page 12
ACA-3 (Rev. 07/17)
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