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Application for certain populations

Dhs 3876 eng-2026

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The document DHS-3876-ENG is an application form for the Minnesota Health Care Programs (MHCP) aimed at specific populations seeking health care coverage. It outlines eligibility criteria, including age, disability status, and income requirements. The document provides instructions on how to complete the application, necessary attachments, and where to submit it. It also details different types of assistance available, such as Medical Assistance and Medicare Savings Programs, along with information on privacy practices and rights related to personal data. Additionally, it includes contact information for county or tribal agencies for further assistance.

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Click ‘Get Form’ to open the DHS-3876 ENG application in the editor.
Begin by reading the Notice of Privacy Practices and Notice of Rights and Responsibilities included in the form. Tear off and keep these notices for your records.
Fill out all required fields, starting with personal information such as your first name, last name, date of birth, and Social Security number if applicable. If you need more space for any answers, write them on a separate piece of paper and attach it.
Complete sections regarding household members applying for health care coverage. Include their names, dates of birth, and relationships to you. Ensure to indicate if they want health care coverage.
Provide details about your income, assets, and any other relevant financial information as prompted in the form. Attach copies of necessary proofs but do not send original documents.
Sign and date the application at the designated section before submitting it through mail or in person to your county or tribal agency.

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Versions	Form popularity	Fillable & printable
2019	4.8 Satisfied (219 Votes)
2018	4.3 Satisfied (128 Votes)

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the difference between medical assistance and MinnesotaCare?

It is online at .applymn.dhs.mn.gov. ApplyMN is a smart application that only asks questions based on the program(s) requested, the household composition and an applicants response to previous questions.

What is the Medical Assistance program in Minnesota?

MA is Minnesotas largest health care program and serves children and families, pregnant women, adults without children, seniors and people who are blind or have a disability. Most people who have MA get health care through health plans. You can choose a health plan from those serving MA members in your county.

Is MinnesotaCare the same as Blue Plus?

MinnesotaCare from Blue Plus is a healthcare plan for people who need affordable healthcare but dont qualify for Medical Assistance, Minnesotas Medicaid program. MinnesotaCare from Blue Plus is available in all Minnesota counties.

What is the income limit for MinnesotaCare?

MinnesotaCare is for families with income at or below 200% of the Federal Poverty Guidelines (FPG) ($30,120 per year for an individual; $62,400 for a family of four), but above 138% of FPG ($20,783 for an individual; $43,056 for a family of four).

Is MN Care considered Medical Assistance?

Medical Assistance (MA) is Minnesotas Medicaid program for people with low income. MA does not require you to pay a monthly premium. MA members have small co-pays for some services, usually $1 - $3. MinnesotaCare is a program for Minnesotans with low incomes who do not have access to affordable health care coverage.

Dhs 3876 eng-2026

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