Form 3400: Application for Medicaid and Affordable Health Coverage

Include all the family members who live with you. If you file taxes, include everyone on your tax return. (You don't need to file taxes to get health coverage.)

DO include: yourself, your spouse, your children under 21 who live with you, your unmarried partner who needs health coverage, anyone you include on your tax return, even if they don't live with you, and anyone else under 21 who you take care of and lives with you.

If anyone applying for coverage meets the following criteria, check all boxes that apply. Have a physical or intellectual disability. Need to live in a medical facility or nursing home or need nursing services at home. Age 65 or older. Applying for PCSC Waiver. Receiving treatment for Breast cancer, Cervical cancer, Atypical Breast Hyperplasia or Precancerous Cervical Lesion (CIN 2/3). Receive Medicare. Applying for TEFRA. Have a disability and continuing to work.

Even if you or your household members do not meet any of these criteria, you may still qualify for Medicaid. If none apply, do not check anything; you will be evaluated for all available coverage types.

Presumptive Disability: this box for pilot use only.

One adult in the family is the contact person for your application. Enter First name, Middle name, Last name and Suffix (Please provide full legal name), Home address (Leave blank if you don't have one.), Apartment or suite number, City, State, ZIP code, County, Mailing address (if different from home address), Phone number, Other phone number, Email address and preferred spoken or written language (if not English).

Start with yourself, then add other adults and children. Complete Step 1 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.

STEP 1: PERSON 1. Enter First name, Middle name, Last name, & Suffix (Please provide full legal name), Relationship to you (SELF), Date of birth (mm/dd/yyyy), Sex (Male or Female) and Social Security number (SSN).

If you don't have a SSN, have you applied for one? Check Yes or No; if no, indicate the reason at question 15. The SSN is needed if you want health coverage and have an SSN.

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.)

7. Are you pregnant or recently pregnant? Check Yes or No; if yes, a. How many babies are expected? b. What is your due date?

8. Do you need health coverage (Medicaid)? (Even if you have insurance, there might be a program with better coverage or lower costs. If you already have Medicaid, check Yes.) If yes, answer all the questions before the income questions. If no, SKIP to the income questions.

9. Do you have a disabling physical, mental, or emotional health condition that causes limitations in activities? 11. Have you been diagnosed with and are receiving treatment for any of the following: Breast Cancer, Cervical Cancer, Atypical Breast Hyperplasia, Precancerous Cervical Lesion (CIN 2/3)? Check Yes or No for each.

12. Do you want to apply for Family Planning benefits? Family Planning is not full Medicaid coverage. If you leave this question blank, you will not be assessed for Family Planning.

13. a. Are you a U.S. citizen? b. Are you a U.S. national? If you aren't a U.S. citizen or U.S. national, do you have eligible immigration status? If YES, fill in your document type and ID number.

Employed: If you're currently employed, start with question 24 about your income. Not Employed: SKIP to question 36. Self-Employed: SKIP to question 35.

36. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often you get it. NOTE: You don't need to tell about child support, veteran's payments or Supplemental Security Income (SSI).

1. Are you or is anyone in your family American Indian or Alaska Native? If NO, skip to Step 3. If YES, ask for and complete SCDHHS Form 3400-Appendix B (American Indian or Alaska Native Family Member).

STEP 3 Your family's health coverage. Answer these questions for anyone who needs health coverage. 1. Is anyone enrolled in health coverage now? If available, please provide a copy of the insurance card. If yes, check the type of coverage and write the person(s)' name(s) next to the coverage they have.

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. If YES, you'll need to complete and include Appendix A. If NO, continue to Step 4.

STEP 4 Read and Sign. Please read the rights and responsibilities. If you disagree with a statement, your eligibility for programs may be impacted. A signature is required to complete the application process and submit your application to the agency.

You must tell SCDHHS within 10 days if any information you listed on this application changes and is different than what you wrote on this application.

Does any child on this application have a parent living outside of the home? Check Yes or No.

Confirm that no one applying for health insurance on this application is incarcerated (detained or jailed); if not, write who is incarcerated.

Renewal of coverage in future years: you agree to allow Medicaid or the Health Insurance Marketplace to use income data, including information from tax returns. Check Yes, renew my eligibility automatically for the next 5 years (the maximum number of years allowed), 4 years, 3 years, 2 years or 1 year, or check Don't use information from tax returns to renew my coverage.

The person who filled out Step 1 should sign this application. If you're an authorized representative, you may sign here, as long as the information required on DHHS Form 1282 - Authorized Representative has been provided.

By signing, you state that you have read and agree to the rights and responsibilities stated on this application. You are signing this application under penalty of perjury. This means you have provided true answers to all the questions on this form to the best of your knowledge. If you are not truthful, there may be a penalty under federal law.

Sign and enter the Date (mm/dd/yyyy). Please print this form, then sign it on the Signature line before submitting.

STEP 5: Mail your signed application to SCDHHS - Central Mail, PO Box 100101, Columbia, SC 29202-3101.

If you don't have all the information, sign and submit your application anyway. SCDHHS will follow-up with you within 1-2 weeks. If you don't hear from SCDHHS, visit SCDHHS.gov or call 1-888-549-0820.

APPENDIX A: You DON'T need to answer these questions unless someone in the household is eligible for health coverage from a job. Attach a copy of the Appendix A page for each job that offers coverage. You only need to include the Appendix A page when you send in your application, not the Employer Coverage Tool.

Scan the QR code to apply online for Medicaid at apply.scdhhs.gov.