Effective Date: 
7/2018

Documents

 

Instructions

Updated: 7/2018

 

Purpose

Form 3030 is used by applicants as a worksheet to apply for the Primary Health Care (PHC) Services Program, the Title V Fee-For-Service Program and the Epilepsy Program. 

Transmittal

Send completed Form 3030 to the Office of Primary and Specialty Health.

Detailed Instructions

Section I, Applicant Information — Complete all fields and check the appropriate boxes.

Other benefits or health care coverage — Document other benefits received or denied. Note: An applicant or family member eligible for Medicare Part A/B must be referred to the Medicare Prescription Drug Plan (Part D) for prescription drug benefits.

Special Circumstances — Enter any special circumstances.

Section II, Household Information — Enter the names of the members of the household. Include a person living alone or two or more persons living together where legal responsibility for support exists. Legal responsibility for support exists between persons who are legally married (including common-law marriage), a legal parent and a minor child (including unborn children), or a legal guardian and a minor child. Note: Title V contractors may add whether household members are U.S. citizens, eligible immigrants or non-U.S. citizens.

Section III, Income Information — Fill in the Income Type table with the name(s) of the household member(s) and income amounts. Income may be either earned or unearned. If actual or projected income is not received monthly, convert it to a monthly amount using one of the following methods:

  • Weekly income is multiplied by 4.33;
  • Income received every two weeks is multiplied by 2.17;
  • Income received twice a month is multiplied by 2.

Calculate the Total countable income.

Subtract the Deductions to determine net countable income, which may include:

  • child support payments;
  • dependent  child care, up to $200 per child per month for children under age 2;
  • dependent child care, up to $175 per child per month for children age 2 and older; or
  • adults with disabilities, up to $175 per adult per month.

Total the Net countable income.

Enter any notes in the Documentation of income box.

Refer to the table below to determine the household federal poverty level (FPL) and enter the correct percentage in the Household FPL box.

Program Eligibility by 2018 Federal Poverty Level (FPL) Effective April 1, 2018


Size

185% FPL

200% FPL

250% FPL

1

$1,872

$2,024

$2,530

2

$2,538

$2,744

$3,430

3

$3,204

$3,464

$4,330

4

$3,870

$4,184

$5,230

5

$4,536

$4,904

$6,130

6

$5,202

$5,624

$7,030

7

$5,868

$6,344

$7,930

8

$6,534

$7,064

$8,830

9

$7,200

$7,784

$9,730

10

$7,866

$8,504

$10,630

11

$8,532

$9,224

$11,530

12

$9,198

$9,944

$12,430

13

$9,864

$10,664

$13,330

14

$10,530

$11,384

$14,230

15

$11,196

$12,104

$15,130

Section IV, Program Eligibility — Determine program eligibility for each household member, using the corresponding numbers from the Household Information section.

BCCS = Breast and Cervical Cancer Services
FP = Family Planning
PHC = Primary Home Care
Title V/MCH = Title V Maternal and Child Health

Document the applicable copayments and fees by program in the Copay/Fees box.

Name of Agency, Signature of Agency/Staff Member and Date — The agency staff member enters the agency name, signs and dates the form.

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