BFA Form 800MA "Application for Health Coverage & Help Paying Costs" - New Hampshire

What Is BFA Form 800MA?

This is a legal form that was released by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance - a government authority operating within New Hampshire. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2018;
  • The latest edition provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of BFA Form 800MA by clicking the link below or browse more documents and templates provided by the New Hampshire Department of Health and Human Services - Bureau of Family Assistance.

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Download BFA Form 800MA "Application for Health Coverage & Help Paying Costs" - New Hampshire

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NH Department of Health and Human Services (DHHS)
BFA Form 800MA
Bureau of Family Assistance (BFA)
01/16 rev 5/16 rev2 3/18 rev3 8/18
Application for Health Coverage & Help Paying Costs
Affordable private health insurance plans that offer comprehensive coverage to help you stay well
Use this application
to see what coverage
A new tax credit that can immediately help pay your premiums for health coverage
Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP)
choices you qualify
for
You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a
family of 4)
Use this application to apply for anyone in your family
Who can use this
Apply even if you or your child already has health coverage. You could be eligible for lower-cost or
application?
free coverage
If you’re single, you may be able to use a short form. Visit HealthCare.gov
Families that include immigrants can apply. You can apply for your child even if you aren’t 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 Appendix C
Apply faster online
Go to HealthCare.gov or nheasy.nh.gov.
Social Security numbers (or document numbers for any legal immigrants who need insurance)
What you may need
Employer and income information for everyone in your family (for example, from paystubs, W -2
to apply
forms, or wage and tax statements)
Policy numbers for any current health insurance
Information about any job-related health insurance available to your family
We ask about income and other information to let you know what coverage you qualify for and if you can
Why do we ask for
get any help paying for it. We’ll keep all the information you provide private and secure, as required
this information?
by law.
 Send your complete, signed application to:
What happens
Central Medicaid Unit, 129 Pleasant Street, Concord, NH 03301.
next?
 If you don’t have all the information we ask for, sign and submit your application anyway. We’ll
follow-up with you within 1–2 weeks
 You’ll get instructions on the next steps to complete your health coverage. If you don’t hear from us,
visit HealthCare.gov or call 1-844-275-3447 (1-844-ASK-DHHS). Filling out this application doesn’t
mean you have to buy health coverage
Online: HealthCare.gov
Get help with this
Phone: Call the DHHS Customer Service Center at 1-844-275-3447 (1-844-ASK-DHHS)
application.
In person: There may be counselors in your area who can help. Call 1-844-275-3447 (1-844-ASK-
DHHS) for more information
En Espanol: Llame a nuestro centro de ayuda gratis al 1-844-275-3447 (1-844-ASK-DHHS)
You can apply for these additional programs by filling out BFA Form 800MA Insert, included with this
You can apply for
application. To apply for these programs, you must return all pages of this application, including the
additional programs
insert, to your local District Office.
by completing a few
 State Supplement Program (SSP) Medical Assistance: Aid to the Needy Blind (ANB), Aid to the
more questions
Permanently and Totally Disabled (APTD), and Old Age Assistance (OAA)
 Long Term Care Services: If you are living in a Nursing Facility, or you require Home Care services,
we may be able to help pay for some of those costs
 Medicaid for Employed Adults with Disabilities, otherwise known as the MEAD program
 Medicare Savings Programs (MSP) to help with your Medicare premiums
You may be able to get the following help from us:
Did you know that
 Supplemental Nutrition Assistance Program (SNAP): SNAP (formerly known as Food Stamps)helps
we offer other forms
thousands of people buy healthy food.
of assistance?
 Cash: If you are having trouble paying your bills, we offer cash assistance for qualifying adults and
families.
 Child Care: If you are having trouble paying for child care while you are working, looking for work, or
going to school, we may be able to help pay for some of your child care costs.
YOU CANNOT USE THIS APPLICATION TO APPLY FOR THESE OTHER FORMS OF ASSISTANCE. If you want to apply for any of these
other forms of assistance, go to
www.nheasy.nh.gov
to apply online, visit our website at
www.dhhs.nh.gov/dfa/apply.htm
to download an
application, or call us at 1-844-275-3447 (1-844-ASK-DHHS).
If you ONLY want to apply for Medicaid or federal payment assistance to help buy health coverage fill out all pages as best you can. Do not fill out
any questions you do not understand. If you have questions, call Client Services at 1-844-275-3447 OR ask the person helping you with this application.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-844-275-3447 (1-844-ASK-DHHS). Para obtener una copia de
?
este formulario en Español, llame 1-844-275-3447. If you need help in a language other than English, call 1-844-275-3447 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY/TDD users should call 1-800-735-2964 or 711.
DFA SR 16-03
(NA)
NH Department of Health and Human Services (DHHS)
BFA Form 800MA
Bureau of Family Assistance (BFA)
01/16 rev 5/16 rev2 3/18 rev3 8/18
Application for Health Coverage & Help Paying Costs
Affordable private health insurance plans that offer comprehensive coverage to help you stay well
Use this application
to see what coverage
A new tax credit that can immediately help pay your premiums for health coverage
Free or low-cost insurance from Medicaid or the Children’s Health Insurance Program (CHIP)
choices you qualify
for
You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a
family of 4)
Use this application to apply for anyone in your family
Who can use this
Apply even if you or your child already has health coverage. You could be eligible for lower-cost or
application?
free coverage
If you’re single, you may be able to use a short form. Visit HealthCare.gov
Families that include immigrants can apply. You can apply for your child even if you aren’t 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 Appendix C
Apply faster online
Go to HealthCare.gov or nheasy.nh.gov.
Social Security numbers (or document numbers for any legal immigrants who need insurance)
What you may need
Employer and income information for everyone in your family (for example, from paystubs, W -2
to apply
forms, or wage and tax statements)
Policy numbers for any current health insurance
Information about any job-related health insurance available to your family
We ask about income and other information to let you know what coverage you qualify for and if you can
Why do we ask for
get any help paying for it. We’ll keep all the information you provide private and secure, as required
this information?
by law.
 Send your complete, signed application to:
What happens
Central Medicaid Unit, 129 Pleasant Street, Concord, NH 03301.
next?
 If you don’t have all the information we ask for, sign and submit your application anyway. We’ll
follow-up with you within 1–2 weeks
 You’ll get instructions on the next steps to complete your health coverage. If you don’t hear from us,
visit HealthCare.gov or call 1-844-275-3447 (1-844-ASK-DHHS). Filling out this application doesn’t
mean you have to buy health coverage
Online: HealthCare.gov
Get help with this
Phone: Call the DHHS Customer Service Center at 1-844-275-3447 (1-844-ASK-DHHS)
application.
In person: There may be counselors in your area who can help. Call 1-844-275-3447 (1-844-ASK-
DHHS) for more information
En Espanol: Llame a nuestro centro de ayuda gratis al 1-844-275-3447 (1-844-ASK-DHHS)
You can apply for these additional programs by filling out BFA Form 800MA Insert, included with this
You can apply for
application. To apply for these programs, you must return all pages of this application, including the
additional programs
insert, to your local District Office.
by completing a few
 State Supplement Program (SSP) Medical Assistance: Aid to the Needy Blind (ANB), Aid to the
more questions
Permanently and Totally Disabled (APTD), and Old Age Assistance (OAA)
 Long Term Care Services: If you are living in a Nursing Facility, or you require Home Care services,
we may be able to help pay for some of those costs
 Medicaid for Employed Adults with Disabilities, otherwise known as the MEAD program
 Medicare Savings Programs (MSP) to help with your Medicare premiums
You may be able to get the following help from us:
Did you know that
 Supplemental Nutrition Assistance Program (SNAP): SNAP (formerly known as Food Stamps)helps
we offer other forms
thousands of people buy healthy food.
of assistance?
 Cash: If you are having trouble paying your bills, we offer cash assistance for qualifying adults and
families.
 Child Care: If you are having trouble paying for child care while you are working, looking for work, or
going to school, we may be able to help pay for some of your child care costs.
YOU CANNOT USE THIS APPLICATION TO APPLY FOR THESE OTHER FORMS OF ASSISTANCE. If you want to apply for any of these
other forms of assistance, go to
www.nheasy.nh.gov
to apply online, visit our website at
www.dhhs.nh.gov/dfa/apply.htm
to download an
application, or call us at 1-844-275-3447 (1-844-ASK-DHHS).
If you ONLY want to apply for Medicaid or federal payment assistance to help buy health coverage fill out all pages as best you can. Do not fill out
any questions you do not understand. If you have questions, call Client Services at 1-844-275-3447 OR ask the person helping you with this application.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-844-275-3447 (1-844-ASK-DHHS). Para obtener una copia de
?
este formulario en Español, llame 1-844-275-3447. If you need help in a language other than English, call 1-844-275-3447 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY/TDD users should call 1-800-735-2964 or 711.
DFA SR 16-03
(NA)
NH Department of Health and Human Services (DHHS)
BFA Form 800MA
Bureau of Family Assistance (BFA)
01/16 rev 5/16 rev2 3/18 rev3 8/18
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 (Leave blank if you don’t have one.):
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 have an email address?
Yes
No
If so, what is your Email address:
17. Would you like to get your notices online instead of getting them in the mail?
Yes
No
If you select “yes” above, a letter will be sent to you in the mail. This letter will contain the following:
information about New Hampshire’s online eligibility web portal, NH EASY;
steps on how to establish a NH EASY account; and
a time-sensitive PIN, which is needed to create a NH EASY account.
You must create a NH EASY account to receive your notices online. You can also check your application status and report
changes through NH EASY!
18. Preferred spoken or written language (if not English).
STEP 2
Tell us about your family.
Who do you need to include on this application?
Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax return.
(You don’t need to file taxes to get health coverage.)
You DON’T have to include:
DO Include:
Yourself
Your unmarried partner who doesn’t need health
Your spouse
coverage if you have no children in common
Your unmarried partner’s children
Your children under 21 who live with you
Your unmarried partner if you have children in common or if
Your parents who live with you, but file their own
tax return (if you’re over 21)
he or she needs health coverage
Anyone you include on your tax return, even if they don’t live
Other adult relatives who file their own tax return
with you
Anyone else under 21 who you take care of and lives with you
The amount of assistance or type of program you qualify for depends on the number of people in your family and their
incomes. This information helps us make sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more
than 2 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration
status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information
you provide private and secure as required by law. We’ll use personal information only to check if you’re eligible for health
coverage.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-844-275-3447 (1-844-ASK-DHHS). Para obtener una copia de
?
este formulario en Español, llame 1-844-275-3447. If you need help in a language other than English, call 1-844-275-3447 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY/TDD users should call 1-800-735-2964 or 711.
Page 1 of 9
DFA SR 16-03
(3YC)
STEP 2: PERSON 1
(Start with yourself)
Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one.
See page 1 for more information about who to include. If you don’t file a tax return, remember to still add family members who live with you.
1. First name, Middle name, Last name, & suffix:
2. Relationship to you?
SELF
3. Date of birth (mm/dd/yyyy)
4. Sex:
Male
Female
---------------
---------------
5. Social Security number (SSN):
We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can
speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If
socialsecurity.gov
someone wants help getting an SSN, call 1-800-772-1213 or visit
. TTY users should call 1-800-325-0778.
6. Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, please answer questions a–e.
NO. If no, skip to question d.
a. Will you file jointly with a spouse?
Yes
No
If yes, name of spouse:
b. Will you claim any dependents on your tax return?
Yes
No
If yes, list name(s) of dependents:
c. Do any of these dependents live with someone else?
Yes
No
If yes, list name(s) of dependents:
d. Are you required to file a federal income tax return next year?
Yes
No
e. Will you be claimed as a dependent on someone’s tax return?
Yes
No
If yes, please list the name of the tax filer:
How are you related to the tax filer?
7. Are you pregnant?
Yes
No If yes, a. how many babies are expected during this pregnancy?
b. due date:
8. Do you need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
Yes. If yes, answer all the questions below
No. If no, skip to the income questions on page 3.
Leave the rest of this page blank.
9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores,
etc) 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 aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Yes. Fill in your document type and ID number below.
a. Immigration document type
b. Document ID number
c. Have you lived in the U.S. since 1996?
Yes
No
d. 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 3 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 at age 18 or older?
Yes
No
16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other
17. Race (OPTIONAL—check all that apply.)
White
Korean
Japanese
Native Hawaiian
Guamanian or Chamorro
Vietnamese
Asian Indian
Filipino
Black or African American
Other Pacific Islander
Chinese
Other Asian
Samoan
American Indian or Alaska native
Other
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-844-275-3447 (1-844-ASK-DHHS). Para obtener una copia de
?
este formulario en Español, llame 1-844-275-3447. If you need help in a language other than English, call 1-844-275-3447 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY/TDD users should call 1-800-735-2964 or 711.
Page 2 of 9
NH Department of Health and Human Services (DHHS)
BFA Form 800MA
Bureau of Family Assistance (BFA)
01/16 rev 5/16 rev2 3/18 rev3 8/18
STEP 2: PERSON 1
(Continue with yourself)
Current Job & Income Information
Employed
Not employed
Self-employed
If you’re currently employed, tell us about
Skip to question 28.
Skip to question 27.
your income. Start with question 18.
CURRENT JOB 1:
18. Employer name and address
19. Employer phone number
(
)
--
20. Wages/tips (before taxes)
Hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
$
21. Average hours worked each WEEK
CURRENT JOB 2:
(If you have more jobs and need more space, attach another sheet of paper.)
22. Employer name and address
23. Employer phone number
(
)
--
24. Wages/tips (before taxes)
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
27. If self-employed, answer the following questions:
a. Type of work
b. How much net income (profits once business expenses are paid)
will you get from this self-employment this month?
$
OTHER INCOME THIS MONTH:
28.
Check all that apply, and give the amount and how often you get it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or supplemental security income (SSI).
None
$
$
Unemployment
How Often?
Net farming/fishing
How Often?
$
$
Pensions
How Often?
Rental/royalty
How Often?
$
$
Social security
How Often?
Annuity/trust
How Often?
$
$
Retirement
How Often?
Other income
How Often?
$
Alimony
How Often?
Type:
DEDUCTIONS:
29.
Check all that apply, and give the amount and how often you get it.
If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health
coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).
$
$
Alimony paid
How Often?
Other deductions
How Often?
$
Student loan interest
How Often?
Type:
30. YEARLY Income: Complete only if your income changes from month to month.
If you don’t expect changes to your monthly income, skip to the next person.
Your total income this year
Your total income next year (if you think it will be different)
$
$
THANKS! This is all we need to know about you.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-844-275-3447 (1-844-ASK-DHHS). Para obtener una copia de
?
este formulario en Español, llame 1-844-275-3447. If you need help in a language other than English, call 1-844-275-3447 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY/TDD users should call 1-800-735-2964 or 711.
Page 3 of 9
DFA SR 16-03
(3YC)
Page of 18