Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 12
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16STEP 2
American Indian or Alaska Native (AI/AN) family member(s)
Are you or is anyone in your family American Indian or Alaska Native?
1.
If NO, skip to Step 3.
YES. If YES, ask for and complete SCDHHS Form 3400-Appendix B (American Indian or Alaska Native Family Member).
STEP 3
Your family’s health coverage
Answer these questions for anyone who needs health coverage.
1. Is anyone enrolled in health coverage now from the following? If available, please provide a copy of the insurance card.
YES. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.
NO.
Medicaid
Employer insurance
CHIP
Name of health insurance:
Medicare
Policy number:
Start Date:
Claim number:
Is this COBRA coverage?
Yes
No
Date Medicare coverage started:
Is this a retiree health plan?
Yes
No
TRICARE (Don’t check if you have direct care of Line Of Duty)
Other health insurance
Name of health insurance:
VA health care programs:
Policy number:
Start Date:
Peace Corps:
Is this a limited-time benefit plan (ex: a school accident policy)?
Y
N
2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, such
as a parent or spouse.
YES. If YES, you’ll need to complete and include Appendix A. Is this a state employee benefit plan?
Yes
No
NO. If NO, continue to Step 4.
STEP 4
Read and
Sign. Please read the following rights and responsibilities. If you disagree with a statement,
your eligibility for programs may be impacted. A signature is required to complete the application
process and submit your application to the agency.
1. I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, or disability.
I can file a complaint of discrimination by calling (888) 808-4238 or writing to the Civil Rights Division, SCDHHS, P.O. Box 8206,
Columbia, SC 29202-8206.
2. I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that
cooperating to collect medical support will harm me or my children, I can tell the agency and may not have to cooperate.
3. I assign and give my rights to any payments from a liable third party to the SCDHHS up to the payment amount that Healthy
Connections has made for my medical care. This assignment applies to any of my minor children who may be injured. These
payments may include payments from health insurance, legal settlements, or other third parties. I also understand that I have
a duty to cooperate in identifying and providing information to assist Healthy Connections in pursuing third parties who may
be liable to pay for care and services.
4. I understand that I must cooperate fully with state and federal workers if my case is reviewed. I also understand that, as a
condition of eligibility, I must apply for and take steps to obtain any other benefits, including but not limited to annuities,
pensions, retirement, disability and other benefits.
5. As an applicant/beneficiary for Medicaid services, I understand that there are two groups of people that are affected by
estate recovery:
•
A person of any age who was a patient in a nursing facility, intermediate care facility for the intellectually disabled, or other
medical institution at the time of death, and who was required to pay most of his/her income for the cost of care; or
•
A person who was 55 years of age or older when he/she received medical assistance consisting of nursing facility
services, home and community based services, and hospital and prescription drug services provided to individuals in
nursing facilities or receiving home community-based services.
I understand that upon receiving any of these services, the Department of Health and Human Services will file a claim
against my estate (all personal and real property owned by me at my death) for the amount Medicaid has paid for my
services.
NEED HELP WITH YOUR APPLICATION?
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este formulario
Visit
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (June 2016)
Application for Medicaid and Affordable Health Coverage
Page 12 of 13
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