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Dependent #1
Dependent #2
Dependent #3
Dependent #4
Dependent #5
Dependent #6
Dependent #1
Dependent #2
Dependent #3
Dependent #4
Dependent #5
Dependent #6
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Other BeneÀts , Incom e, and Ex penses
Aged, B l ind, Di sabled, Nurs ing Hom e, Wa iver, orSpenddow n Medic aid, Medic are Cost Shar ing,
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Renew al of Coverage in Fut ure Years
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You and your household must also fol low the medical assistance program rules.
You Have the Right t o :
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YOU WITHIN 10 DAYS
I f you r ec eive CHIP, PCN, UPP, or Medi ca id B eneÀt s, you m ust repor t :
Change in Mar i ta l Status or L iv ing Arrangem ents
Change in Insurance Coverage
I f you rec e ive Med ica id , you mus t a lso repor t :
Change in the Lega l Obl igat ion to Pay Chi ld Suppor t
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A lask a Nat ive Fa m i ly Mem ber (A I /AN)
Tel l us about your Am er ican Ind ian or A laska Nat ive fami ly m ember(s).
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Not L iv ing With You
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* An employer-sponsored health plan meets the “minimum value standard” if t he plan’s share of the total al lowed beneÀt costs
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Employer’s Least Ex pensive Plan or Avenue H Defaul t Plan
Employee’s Heal th Plan Choic e
$
$
$
$
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You c an choose an author ized representat ive .
