Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 26
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32American Indian or Alaska Native
SUPPLEMENT
B
Household Member (AI/AN)
Complete this supplement if you or a household member are an American Indian or Alaska Native.
TELL US ABOUT YOUR AMERICAN INDIAN OR ALASKA NATIVE HOUSEHOLD MEMBER(S).
American Indians and Alaska Natives can get services from the Indian Health Service, tribal health programs, or urban Indian health
programs. They also may not have to pay premiums or copayments and may get special monthly enrollment periods. Answer the
following questions to make sure your household gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach it.
AI/AN PERSON 1
AI/AN PERSON 2
1. Name (first, middle, last)
1. Name (first, middle, last)
2. Member of a federally recognized tribe?
2. Member of a federally recognized tribe?
Yes
No
Yes
No
If yes, tribe name
If yes, tribe name
3. Member of a Massachusetts-recognized tribe?
3. Member of a Massachusetts-recognized tribe?
Yes
No
Yes
No
If yes, tribe name
If yes, tribe name
4. Has this person ever gotten a service from the Indian
4. Has this person ever gotten a service from the Indian
Health Service, a tribal health program, or Urban Indian
Health Service, a tribal health program, or Urban Indian
Health Program, or through a referral from one of these
Health Program, or through a referral from one of these
programs?
programs?
Yes
No
Yes
No
If no, is this person eligible to get services from the
If no, is this person eligible to get services from the
Indian Health Service, tribal health programs, or Urban
Indian Health Service, tribal health programs, or Urban
Indian Health Program, or through a referral from one of
Indian Health Program, or through a referral from one of
these programs?
these programs?
Yes
No
Yes
No
5. Certain money received may not be counted for
5. Certain money received may not be counted for
MassHealth. List any income (amount and how often)
MassHealth. List any income (amount and how often)
reported on your application that includes money from
reported on your application that includes money from
• Per capita payments from a tribe that come from
• Per capita payments from a tribe that come from
natural resources, usage rights, leases, or royalties;
natural resources, usage rights, leases, or royalties;
• Payments from natural resources, farming, ranching,
• Payments from natural resources, farming, ranching,
fishing, leases, or royalties from land designated as
fishing, leases, or royalties from land designated as
Indian trust land by the Department of the Interior
Indian trust land by the Department of the Interior
(including reservations and former reservations); or
(including reservations and former reservations); or
• Money from selling things that have cultural
• Money from selling things that have cultural
significance.
significance.
$
How often?
$
How often?
Page 24
ACA-3 (Rev. 07/17)
SUPPLEMENT B
American Indian or Alaska Native Household Member (AI/AN)
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