AmeriCorps programs must provide, or make available, healthcare insurance to those members serving a 1700-hour full-time term or half time 900 hours, who are not otherwise covered by a healthcare policy at the time the member begins his/her term of service.
The recipient must also provide, or make available, healthcare insurance to members serving a 1700-hour full-time or 900 hour half time term who lose coverage during their term of service as a result of service or through no deliberate act of their own. CNCS will not cover healthcare costs for dependent coverage.
Please select one:
_____ I am accepting the healthcare insurance provided through Cigna. I verify that I am not otherwise covered by a healthcare policy at the time I begin my term of service.
| Healthcare Insurance Effective Date: | |
| Healthcare Insurance End Date: |
_____ I am declining the healthcare insurance provided through CIGNA, effective the signature date. I verify that I am covered by a Minimum Essential Coverage compliant healthcare policy through one of the following options: staying on parents’ or spouse plan; insurance obtained through the Federal Health Insurance Marketplace of at least the Bronze level plan; insurance obtained through private insurance broker; Medicaid, Medicare or military benefits.
I have provided Project CHANGE with documentation of my healthcare insurance. I understand I am required to maintain healthcare insurance, and if I lose my current coverage during my term of service as a result of service or through no deliberate act of my own, I must notify Project CHANGE. I understand that if I decline healthcare coverage, I am not entitled to receive that portion of the health care benefit that I elected to forego during the waiver period.
| Member Name | Date | ||
| Member Signature |