Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 20
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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
MassHealth regulations require members to obtain and maintain available health insurance, including health insurance available
through an employer. In order to determine continued MassHealth eligibility for you and members of your household, we may
request additional information from you and your employer about your access to employer sponsored health insurance coverage.
You must cooperate in providing information necessary to maintain eligibility, including evidence of obtaining or maintaining
available health insurance, or your MassHealth benefits may be terminated. See the Member Booklet for more information.
1. Is anyone listed on this application offered health coverage from a job but NOT ENROLLED in it?
Yes
No
Answer yes, even if this insurance is from another person’s job, like a spouse, even if the person does not live in the household.
If yes, you will need to complete and include
Supplement A: Health Coverage from
Jobs, and the rest of this application.
Name(s) of person(s) offered insurance
Is this a state employee benefit plan?
Yes
No
2. Does anyone qualify or is anyone enrolled 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.
Answer yes, even if this insurance is from another person, like spouse, even if the person does not live in the household.
Enrolled in Medicare or qualifies for a Medicare Part A plan with no premium.
Name(s) of person(s) covered
Start date
End date
Medicare ID #
Qualifies for Peace Corps health benefits . . . . . . . . . . . . . . . . . Start date
End date
Name(s) of person(s) covered
Qualifies for TRICARE or a Federal Employees health benefit program. Start date
End date
Name(s) of person(s) covered
Enrolled in a Veterans Affairs (VA) health program . . . . . . . . . . . Start date
End date
Name(s) of person(s) covered
MassHealth
Name(s) of person(s) covered
Enrolled in employer coverage. If anyone on this application is enrolled in employer coverage, you must complete and
include
Supplement A: Health Coverage from
Jobs.
Name of employer
Plan name
Names of covered household members
Policy # or Member ID
. . . . . . . . . . . Start date
End date
Other coverage (including COBRA or Retiree health plans) . . . . . . . Start date
End date
Name(s) of person(s) covered
Policy # or Member ID
Page 18
ACA-3 (Rev. 07/17)
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