| VHAP and
Catamount Health -
Eligibility Worksheet
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Monthly Income
|
|
|
|
| Inputs
|
|
Wages
|
Other
|
|
|
|
|
|
|
| Adult 1
|
|
|
|
|
Other income includes rents,
dividends, etc.
|
|
| Adult 2
|
|
|
|
|
Change Y to N if no other
adult.
|
0 if second adult has no income
|
|
|
|
|
|
|
|
|
|
|
|
| Number of
children
|
|
|
|
|
| Monthly
spending on child care
|
|
maximum of $175 per child
|
|
|
|
|
|
|
|
|
|
Premiums
|
|
|
| Eligibility
|
Adults
|
|
|
<per adult
|
|
|
|
Children
|
|
|
|
<per family
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| Please
note:
|
Dr. Dynasaur premium is per
family. If two figures are shown, the
first is for children with other insurance
|
|
|
and the second is for children
with NO other insurance.
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
This sheet only tests
financial eligibility. Programs have
additional eligibility
|
|
|
|
requirements such as duration
without insurance or reason for loss of previous coverage.
|
|
|
|
|
|
|
|
|
|
|
|
|
| For
additional information or to apply, call
1-800-250-8427 or visit http://www.greenmountaincare.org/
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Developed by Policy Integrity
LLC
|
|
|
|
Click here to visit our home
page
|
|
|
|