Form Fa-001 - Application For Benefits Page 23
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31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Answer the following questions if anyone in your household is applying for help with
Health Insurance Coverage:
health insurance costs, help with Medicare costs, and/or Cash Assistance.
Do any applicants have health insurance other than AHCCCS or Medicare?
Yes
No
If ‘Yes,’ give the following information:
Name of Insured
Name of Insurance Provider
Policy Number
Coverage Effective Date
Does any child under age 19 in this application qualify for health benefits (even if
Yes
No If Yes, who?__________________
they choose not to enroll) through the State of Arizona because:
A parent or step parent (in or out of the home) works for an employer
(State or other public agency) that offers health insurance coverage
through the State of Arizona and is eligible to get health insurance
coverage; or
The child or child’s spouse works for an employer (State or other public
agency) that offers health insurance coverage through the State of Arizona
and is eligible to get health insurance coverage?
Yes
No
Have any children under the age of 19 lost health insurance coverage in the last 90
days? If ‘Yes,’ give the following information:
If YES, name of child(ren) who lost health insurance coverage:
Name of Policy Holder
Name of Insurance Company
Group Number
Policy Number
Insurance Company Phone Number
Coverage End Date
Why did the health insurance coverage stop?
Cost too much
Coverage was through Medicaid/CHIP, or through Advance Premium Tax Credits (APTC), or Cost Sharing Reductions
Divorce or death of parent
Employer stopped offering coverage for dependents
Job changed or ended
Other: ___________________________________
If the health insurance cost too much:
The monthly premium to cover one person is: $_____________________
The monthly premium to cover the family is:
$_____________________
Was approved for APTC because employer-sponsored insurance was determined to be unaffordable.
Do any children under the age of 19 you are applying for have a
chronic illness? (Medical condition that requires frequent and
ongoing treatment and that if not properly treated will seriously
Yes
No
If Yes, who? __________________________________
affect the person’s overall health).
Please see page I for enrollment plan choices for everyone applying for Medical Assistance.
Health Plan Choice:
Name
Health Plan Choice
Person 1
Person 2
Person 3
Person 4
Person 5
Person 6
FA-001 (12-17)
Page 14
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