New York State Health Insurance Application

Arkansas Department of Human Services - Application for Health Coverage

Use this application to see what coverage you qualify for through DHS.

• Medicaid, ARKids First or the Health Care Independence Program

• If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan.

Who can use this application? Use this application to apply for you or anyone in your family.

Apply even if you or your child already has health coverage. You could be eligible for lower cost or free coverage.

Families that include immigrants can apply. You can apply for your children even if you are not eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen.

If someone is helping you fill out this application, you may need to complete a DCO-153, Consent for an Authorized Representative.

Apply faster online at: Access.Arkansas.gov

What you may need to apply: Social Security number, employer and income information, health insurance information, and policy numbers for current insurance.

Why do we ask for this information? We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it.

What happens next? Send your complete, signed application to the address on page 8.

Step 1 Tell Us About Yourself

(We need one adult in the family to be the contact person for your application.)

1. First Name, Middle Name, Last Name & Suffix

2. Home Address

3. Apartment or Suite Number

4. City

5. State

6. ZIP Code

7. County

8. Mailing Address (If different from home address)

9. Apartment or Suite Number

10. City

11. State

12. ZIP Code

13. County

14. Phone Number

15. Other Phone Number

16. Do you want to receive information about this application by email? Yes No

Email Address:

17. Preferred spoken or written language (if not English)

Step 2 Tell Us About Your Family

Tell us about all the family members that live with you. If you file taxes, we need to know about everyone on your tax return.

Do include: yourself, your spouse, your unmarried partner who needs health coverage, children under 21 who live with you, and anyone you include on your tax return.

You don’t have to include: your unmarried partner who does not need health coverage, their children, parents who file their own return, and other adult relatives who file their own return.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children.

Step 2: Person 1 (Start with yourself)

1. First Name, Middle Name, Last Name & Suffix

2. Relationship to you?

3. Date of Birth

4. Sex Male Female

5. Social Security Number (SSN)

6. Do you plan to file a federal income tax return NEXT YEAR? Yes No

6a. If yes, name of spouse:

6b. Will you claim any dependents on your tax return? Yes No

If yes, list name(s) of dependents:

6c. Will you be claimed as a dependent on someone’s tax return? Yes No

If yes, name of tax filer:

How are you related to the tax filer?

7. Are you pregnant? Yes No If yes, how many babies are you expecting?

8. Do you need health coverage? Yes No

9. Do you have a physical, mental or emotional health condition that causes limitations in activities or live in a medical facility or nursing home? Yes No

10. Are you a U.S. citizen or U.S. national? Yes No

11. If you are not a U.S. citizen or U.S national, do you have eligible immigration status? Yes

11a. Immigration document type

11b. Document ID number

11c. Have you lived in the U.S. since 1996? Yes No

11d. Are you or your spouse or parent a veteran or an active duty member of the U.S. military? Yes No

12. Do you want help paying for medical bills from the last three months? Yes No

13. Do you live with at least one child under the age of 19 and are you the main person taking care of this child? Yes No

14. Are you a full time student? Yes No

15. Were you in foster care in Arkansas at age 18 or older? Yes No

16. If Hispanic/Latino, what is your ethnicity? (Optional) Mexican Mexican American Chicano/a Puerto Rican Cuban Other:

17. Race (Optional) White American Indian or Alaska Native Filipino Vietnamese Guamanian or Chamorro Black or African American Asian Indian Japanese Other Asian Samoan Chinese Korean Native Hawaiian Other Pacific Islander Other:

Step 2: Person 1 (Continue with yourself)

Current Job & Income Information

Employed Not employed Self-employed

18. Employer Name and Address

19. Employer Phone Number

20. Wages/tips (before taxes) $

How often? Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly

21. Average hours worked each week

22. Employer Name and Address

23. Employer Phone Number

24. Wages/tips (before taxes) $

How often? Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly

25. Average hours worked each week

26. In the past year, did you: Change jobs? Stop working? Start working fewer hours? None of these?

27a. Type of work

27b. Net income from self-employment this month

28. Other income this month

None

Unemployment $ How often?

Pensions $ How often?

Net farming/fishing $ How often?

Net rental/royalty $ How often?

Social Security $ How often?

Alimony $ How often?

Retirement Accounts $ How often?

Other income $ How often? Type:

29. Deductions

Alimony paid $ How often?

Student Loan interest $ How often?

Other Deductions $ How often? Type:

30. Yearly Income

Your total income this year

Your total income next year (if different)

Step 2: Person 2

1. First Name, Middle Name, Last Name & Suffix

2. Relationship to you?

3. Date of Birth

4. Sex Male Female

5. Social Security Number (SSN)

6. Does PERSON 2 live at the same address as you? Yes No

If no, list address:

7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? Yes No

7a. If yes, name of spouse:

7b. Will PERSON 2 claim any dependents? Yes No

If yes, list name(s) of dependents:

7c. Will PERSON 2 be claimed as a dependent on someone’s tax return? Yes No

If yes, name of tax filer:

How is PERSON 2 related to the tax filer?

8. Is PERSON 2 pregnant? Yes No If yes, how many babies are expected?

9. Does PERSON 2 need health coverage? Yes No

10. Does PERSON 2 have a physical, mental or emotional health condition that causes limitations in activities or live in a medical facility or nursing home? Yes No

11. Is PERSON 2 a U.S. citizen or U.S. national? Yes No

12. If PERSON 2 is not a U.S. citizen or U.S national, do they have eligible immigration status? Yes

12a. Immigration document type

12b. Document ID number

12c. Has PERSON 2 lived in the U.S. since 1996? Yes No

12d. Is PERSON 2 or their spouse or parent a veteran or an active duty member of the U.S. military? Yes No

13. Does PERSON 2 want help paying for medical bills from the last 3 months? Yes No

14. Does PERSON 2 live with at least one child under the age of 19 and are they the main person taking care of this child? Yes No

15. Was PERSON 2 in foster care at age 18 or older? Yes No

16. Did PERSON 2 have insurance through a job and lose it within the past 3 months? Yes No

16a. Insurance end date

16b. Reason insurance ended

17. Is PERSON 2 a full time student? Yes No

18. If Hispanic/Latino, what is your ethnicity? (Optional) Mexican Mexican American Chicano/a Puerto Rican Cuban Other:

19. Race (Optional) White American Indian or Alaska Native Filipino Vietnamese Guamanian or Chamorro Black or African American Asian Indian Japanese Other Asian Samoan Chinese Korean Native Hawaiian Other Pacific Islander Other:

Step 2: Person 2 (Continue with Person 2)

Current Job & Income Information

Employed Not employed Self-employed

20. Employer Name and Address

21. Employer Phone Number

22. Wages/tips (before taxes) $

How often? Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly

23. Average hours worked each week

24. Employer Name and Address

25. Employer Phone Number

26. Wages/tips (before taxes) $

How often? Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly

27. Average hours worked each week

28. In the past year, did PERSON 2: Change jobs? Stop working? Start working fewer hours? None of these?

29a. Type of work

29b. Net income from self-employment this month

30. Other income this month

None

Unemployment $ How often?

Pensions $ How often?

Net farming/fishing $ How often?

Net rental/royalty $ How often?

Social Security $ How often?

Alimony $ How often?

Retirement Accounts $ How often?

Other income $ How often? Type:

31. Deductions

Alimony paid $ How often?

Student Loan interest $ How often?

Other deductions $ How often? Type:

30. Yearly Income

PERSON 2’s total income this year

PERSON 2’s total income next year (if different)

Step 3 American Indian or Alaskan Native (AI/AN) Family Members

Are you or is anyone in your family an American Indian or an Alaskan Native?

No Yes

Step 4 Your Family’s Health Coverage

1. Is anyone enrolled in health coverage now from the following?

Yes No

Medicaid

ARKids First/CHIP

Medicare

TRICARE Is this COBRA coverage? Yes No

VA Health Care Programs

Peace Corps

Employer insurance

Other

2. Is anyone listed on this application offered health coverage from a job? Yes No

Step 5 Read & Sign This Application

I am signing this application under penalty of perjury...

I know that I must tell DHS if anything changes...

I know that under federal law, discrimination is not permitted...

I confirm that no one applying for health insurance on this application is incarcerated.

Signature

Date

Step 6 Mail Completed Application

Mail your signed application to: DHS Jefferson County, 1222 West 6th Street, P.O. Box 5670, Pine Bluff, AR 71611

Or email the application to: 351Jefferson@arkansas.gov

Or you can fax the application to: 1-870-534-3421.

What happens next? We will process your application and send you a notice telling you if your application has been approved or denied.