Healthcare Cost Assistance Eligibility Questionnaire

1

Have you worked 40 hours or more per month for 2 months in a row?* This field is required.

Yes

No

Unsure

2

Have you been turning in your timesheets and/or payroll vouchers at the end of each pay period?* This field is required.You must submit your hours to your State agency (such as APD or ODDS) using Oregon Provider Time Capture and/or eXPRS.

Yes

No

Unsure

3

Are you in the Independent Choices Program?* This field is required.If you haven't heard of the program, it probably doesn't apply to you.

Yes

No

4

Are you paid through Acumen?* This field is required.

Yes

No

5

Are you currently enrolled in or eligible to enroll in medical insurance?* This field is required.

Yes, I am enrolled in medical insurance OR I am uninsured but eligible to enroll in some form of coverage (other than through Medicare, VA, CHAMPVA, or TRICARE).

No, I am uninsured and do not have access to any medical coverage.

Unsure

7

Click "submit" to see Healthcare Cost Assistance eligibility results.