Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 6
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32Person 1 (continued)
STEP 2
|
Immigration status
Immigration document type
Choose one or more document status and types from the list on page 22.
Document ID number
Alien number
Passport or document expiration date (mm/dd/yyyy)
Country
b. Did you use the same name on this application that you did to get your immigration status?
Yes
No
If no, what name did you use? First, middle, last and suffix
c. Did you arrive in the U.S. after August 22, 1996?
Yes
No
d. Are you an honorably discharged veteran or active duty member of the U.S. military, or the spouse or child of an honorably
discharged veteran or an active-duty member of the U.S. military?
Yes
No
10. Do you live with at least one child younger than age 19, and are you the main person taking care of this child(ren)?
Yes
No
Name(s) and date(s) of birth of child(ren)
11. Race (optional—check all that apply.)
Hispanic, Latino, or Spanish origin
American Indian or Alaska Native
Korean
(complete Step 3 and Supplement B)
Cuban
Native Hawaiian
Asian Indian
Mexican, Mexican-American, or
Other Asian
Chicano
Black or African American
Other Pacific Islander
Puerto Rican
Chinese
Samoan
Other Hispanic/Latino/Spanish
Filipino
Vietnamese
Guamanian or Chamorro
White or Caucasian
Japanese
Other
12. Are you living in Massachusetts, and you either intend to reside here, even if you do not have a fixed address, or you have
entered Massachusetts with a job commitment or seeking employment?
Yes
No
If you are 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. Do you 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. Do you 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. Are you pregnant?
Yes
No
If yes, how many babies are you expecting?
What is your expected due date?
16. Do you have breast or cervical cancer? (Optional)
Yes
No
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
17. Are you HIV positive? (Optional)
Yes
No
MassHealth has special coverage rules for people who are HIV positive.
18. Were you ever in foster care?
Yes
No
a. If yes, in what state were you in foster care?
b. Were you getting health care through a state Medicaid program?
Yes
No
INCOME INFORMATION
Do you 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.
Page 4
ACA-3 (Rev. 07/17)
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