MDHHS-1171-HC (1-27) ADA final.pdf

Caretaker

Child

State

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Additional Group Details Fill out the following details along with the Assistance Application if seeking Healthcare Assistance.

Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc), or nursing home?

Was anyone in foster care in Michigan when they turned 18? Only required for applicants.

Is anyone applying for health insurance currently incarcerated (detained or jailed)?

If yes, who?

If yes, who?

If yes, who?

If yes, who?

No

No

No

No

Is anyone the primary caretaker for a child (under age of 19) in the home?

Was anyone in foster care in another state when they turned 18 on or after January 1, 2023?

If yes, who?

No

Tribe

MO/YR - MO/YR

MO/YR - MO/YR

Flint Water System For individuals under age 21 or pregnant women. By checking “yes” you are requesting Healthcare.

Did anyone in your home consume water from the Flint Water System and live, work, or receive childcare or education at an address that was served by the Flint Water System from April 2014 through September 30, 2025.

Home

Home

Work

Work

School

School

Childcare Facility

Childcare Facility

Names Dates

(MM/YY-MM/YY)

Address Served by Flint Water (Street, City, Zip code)

If yes, list below. No

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

American Indian or Alaska Native AI/AN family members may not have to pay cost sharing and may get special monthly enrollment periods. AI/AN family members do not have to meet Healthy Michigan work requirements.

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

Has anyone ever received a service or referral from the Indian Health Service, a tribal health program, or urban Indian health program?

If yes, are they a member of a federally recognized tribe?

If no, is anyone eligible to get these services?

If yes

If yes, who?

If yes, who?

If yes, who?

No

No

Name of Primary Tax Filer

Name of Spouse

Name of Dependent(s)

Tax Filers Fill out the following details along with the Assistance Application if seeking Healthcare Assistance.

Does anyone applying plan to file a federal tax return next year? You do not need to file a tax return to receive Healthcare.

Are they filing jointly with a spouse?

Are they filing jointly with a spouse?

Are they claiming dependents?

Are they claiming dependents?

If yes, who?

If yes, who?

If yes, who?

If yes, who?

If yes, who?

No

No

No

No

No

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Name

Yearly Income Does anyone’s income change from month to month?

Who?

Total Estimated Income This Year

Total Estimated Income Next Year If you think it will be different.

If yes, list below. No

Do you or anyone in your household have a job that is considered seasonal (school bus driver, harvesting, snow removal, ski resort work, lifeguard, etc)?

If yes, who? No

Name Name

Dependents Will anyone applying be claimed as a dependent on someone else’s tax return?

Dependent Tax Filer Relationship to Tax Filer

If yes, list below. No

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Education Are you or anyone in your household enrolled as a student (college, vocational, trade or technical training, high school, or a GED program)?

If yes, list below. No

Who

Name of School

Type of Institution (college, vocational, trade, technical, high school, GED)

Enrollment Status?

(check one)

# Credit Hours (college) if less than half time

# Contact Hours (vocational) if less than half time

Full time Half time Less than half time

Full time Half time Less than half time

Full time Half time Less than half time

Full time Half time Less than half time

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthy Michigan Plan Work Requirements Exemptions Skip the Exemptions, Qualifying Activities, and Temporary Hardship sections for people under age 19, over age 64, receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), who have Medicare, are in Foster Care Transition Medicaid (FCTMA), or who are American Indian or Alaska Native (AI/AN).

Answer the questions in this section to see if you or anyone applying may need to meet work requirements. Some questions may be similar to questions earlier in the application. Please make sure you complete this section. If you skip this section or leave answers blank, you may have to complete work requirements.

Have you or anyone in your household been pregnant in the last 12 months? (This question doesn’t apply to individuals who are CURRENTLY pregnant.)

If yes, who? No

End Date

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Do you or anyone in your household regularly and consistently provide care for a child under age 14 or a person with a disability?

If yes, list below. No

A disability is a physical or mental condition that makes it much harder for a person to do major everyday activities.

Who

Name person receiving care

Is the person receiving care a child under age 14 or a person with a disability?

child under 14 person with a disability child under 14 person with a disability child under 14 person with a disability child under 14 person with a disability

Date of Birth for child under 14 only

MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY MM/DD/YYYY

Are you related to this person?

Do you live with this person?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

If you answered “No” to both questions in the purple rows for all people listed in the table above, did you provide at least 80 hours of care in any one month?

Yes No

If No, report the time you spend providing care in the Qualifying Activities section of this application. These caregiving hours (and any other qualifying activity hours) may count toward meeting Healthy Michigan Plan work requirements.

Healthy Michigan Plan Work Requirements Exemptions (Continued)

A drug or alcohol disorder (including people who have been in recovery for less than 5 years).

If yes, who? No

A serious vision impairment or blindness.

If yes, who? No

A serious physical, intellectual, or developmental disability.

If yes, who? No

A serious mental health condition.

If yes, who? No

A serious or complex medical condition.

If yes, who? No

Are you or anyone in your household participating in treatment for a substance use disorder?

If yes, who? No

Are you or anyone in your household a veteran with a disability rated as total?

If yes, who? No

Note: You must submit a VA Summary Benefit letter with this form to qualify for this exclusion.

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthy Michigan Plan Work Requirements Exemptions (Continued) Do you or anyone in your household have one or more of the following health issues that make it hard to work, go to school, or do community service?

Were you or anyone in your household in foster care in another state when they turned 18 on or before December 31, 2022?

If yes, who? No

Have you or anyone in your household been released from jail or prison in the last 3 months?

(This question doesn’t apply to individuals who are CURRENTLY in jail or prison.)

If yes, who? No

Healthcare Coverage

MDHHS-1171-HC (Rev. 1-27) Previous edition obsolete.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthy Michigan Plan Work Requirements Exemptions (Continued)

Healthy Michigan Plan Work Requirements Qualifying Activities Use this section to report your unpaid work activities.

To meet the work requirement, you must have completed at least 80 hours of qualifying activities in at least one month of your review period. You may combine hours from different activities completed during the same month to reach 80 hours. Qualifying activities include:

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthy Michigan Plan Work Requirements Qualifying Activities (continued) Do you or anyone in your household participate in any type(s) of unpaid work or activities (caregiving, volunteering, community service, Michigan Works! program, etc.)?

If yes, list below. No

Who

Type of Activity

Organization

Application Month Completed

Application Month Hours Completed

Month Prior Completed

Month Prior Hours Completed

Do not report paid work hours or education hours here. These hours count toward Healthy Michigan Plan work requirements. Report your income in the Income section and education hours in the Education section of the application.

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Healthy Michigan Plan Temporary Hardship Some short-term situations may make it hard to work or complete other qualifying work activities.

In these cases, you may not need to meet work requirements for a limited period of time.

Complete this section to request a short-term hardship. If a question applies to you or anyone in your household, complete all parts of the question and provide all requested information.

Missing information may prevent approval of the short-term hardship. If approved, you or the applicable member of your household will not have to meet work requirements during the approved hardship period.

If you do not wish to request a short-term hardship, skip this section Have you or anyone in your household traveled outside your community of residence to get medical care for yourself or someone you care for?

If yes, who needs medical care?

No

Date RangeDates of travel?

City, StateLocation of travel?

Have you or anyone in your household recently received inpatient hospital care for more than 24 hours, or received serious medical care in another setting (such as, a nursing facility, psychiatric hospital, clinic, or the VA)?

If yes, who? No

“Outside of your community of residence” means traveling beyond the area you normally rely on for daily living and health care services. Because communities vary across Michigan, you should determine what “outside of your community” means based on where you usually receive care and the health care services available in your area.

Date RangeWhen did you receive care?

Me My dependent

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Name(s)

Name MM/YYYY

Health Coverage Info Fill out the following details along with the Assistance Application if seeking Healthcare Assistance.

Does anyone need help paying for medical bills from the past 2 months?

If yes, who?

Which months?

No

Did anyone have insurance through a job and lose it in the last 3 months?

If yes, list below. No

Who lost coverage? Reason Insurance EndedEnd Date

JAN FEB MAR APR MAY JUN

JUL AUG SEP OCT NOV DEC

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Name

If yes, list below. No

Type + Name of Coverage Person Covered Policy #

If Medicare, do you want help paying Medicare premiums?

If employer insurance: Is this COBRA coverage?

Is this a retiree health plan?

If other, is this a limited benefit plan (such as a school accident policy)?

Y N

Y N

Y N

Y N

Health Coverage Info (continued) Is anyone currently enrolled in health coverage (even if not applying)?

Including Medicaid, CHIP/MIChild, Medicare, VA Healthcare Programs, Peace Corps, Employer Insurance, TRICARE (unless you have direct care or Line of Duty), and Other.

To make it easier to determine your Healthcare eligibility in future years, do you agree to the use of IRS data for automatic renewals?

This allows the Marketplace and the State of Michigan to use income data (including information from tax returns). See Info Booklet (Pg 7) for more details.

Yes

If yes, for how many years?

No

5 4 3 2 1

If you need assistance, take a copy of this page to your employer and have them help you fill it out.

Information on this page won’t impact your application. It will be passed on to the federal government to determine your eligibility for APTC (Advanced Premium Tax Credits).

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Name

Name

Name

Health Coverage From Jobs Complete this page if someone in the household is eligible for health coverage from a job.

Attach a copy of this page for each job that offers coverage.

Is anyone in the household offered health insurance from a job?

(This includes coverage from someone else’s’ job, such as a parent of a spouse)

(This should be the person or department who manages employee benefits)

If yes, list below. If no, skip this page.

Phone # of Employer Contact

Employer Contact

Employer Address of Employer

Employee Employee Social Security #

Employer Identification #

(EIN)

Email of Employer Contact

Name(s)

If yes, when? No

Can the employee get coverage now or sometime in the next 3 months?

List everyone who is eligible for coverage from this job

Michigan Department of Health and Human Services Your Name:

Individual ID #:

Health Coverage From Jobs (continued)

If yes, list below.

Employer won’t offer health coverage

The premium amount will change for the lowest cost plan that meets the minimum value standard

No

Will the employer make any changes for the new plan year (if you know)?

Date of change

Date of change

Employee would pay this premium

If yes, how much would the employee have to pay for the lowest cost plan that meets the minimum value standard? Don’t include family plans. If the employer offers wellness programs, enter the premium that the employee would pay if they got the maximum discount for a tobacco cessation program.

Does the employer offer a health plan that pays at least 60% of the total costs of benefits (the minimum value standard for health plans)?

Yes No

$ per Wk 2Wks 2x/Mo Mo Qr Yr

$ per Wk 2Wks 2x/Mo Mo Qr Yr