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4Section 1How to get MassHealth,Children’s Medical Security Plan(CMSP), ConnectorCare Plansand Premium Tax Credits, or theHealth Safety NetApply faster online!Go to: MAhealthconnector.org. You willget results quickly. You can create a secureonline account where you can see copiesof notices and get important news fast.To apply in person, you can go to any oneof the four following enrollment centerslisted below. Do not send an application toany of these enrollment centers.MassHealth Enrollment Center45-47 Spruce StreetChelsea, MA 02150MassHealth Enrollment Center333 Bridge StreetSpringfield, MA 01103MassHealth Enrollment Center21 Spring Street, Suite 4Taunton, MA 02780MassHealth Enrollment Center367 East StreetTewksbury, MA 01876 How to apply for MassHealth, CMSP,ConnectorCare Plans and premium tax credits,or the Health Safety Net1. You can apply for benefits in several ways: online,by filling out a paper application, in person ata MassHealth Enrollment Center or authorizedhospital, or by telephone. To apply by telephone, callMassHealth Customer Service at 1-800-841-2900(TTY: 1-800-497-4648 for people who are deaf, hardof hearing, or speech disabled). By applying online,you can submit your application immediately, havemuch of your information proved electronicallythrough data matches, thus eliminating the need tosubmit paper documents, and have your eligibilitydetermined much faster. If you fill out a paperapplication, be sure to read the instructions. When itis filled out, send or fax it to:Health Insurance Processing Center Fax:P.O. Box 4405617-887-8770Taunton, MA 02780.We use all information collected on the onlineand paper applications, as well as proof of thisinformation, to determine your eligibility forbenefits, and if eligible, to make sure you get themost complete coverage you qualify for.2. We will perform information matches withother agencies and information sources when anapplication is submitted, at annual review, andperiodically to update or prove eligibility. Theseagencies and information sources may include, butare not limited to: the Internal Revenue Service,the Department of Homeland Security, the SocialSecurity Administration, the Department of Revenue,and the Division of Unemployment Assistance.Income information will be obtained through anelectronic data match. Income is considered provedif the income data received through an electronicdata match is reasonably compatible with theincome amount you stated on your application(the “attested” income amount). To be reasonablycompatible: both the attested income and the income fromthe data sources must be above the applicableincome standard for the individual; or both the attested income and the income fromthe data sources must be below the applicableincome standard for the individual; or the attested income and the income from thedata sources must be within a 10 percent rangeof each other.

Visit us online at MAhealthconnector.org3.4.5.6.7.If electronic data sources are unable to proveattested information or are not reasonablycompatible with attested information, additionaldocumentation will be required from the applicant.We need the Modified Adjusted Gross Income(MAGI) for every person in your household. In mostcases, this income can be proved through electronicdata matches. If electronic data sources are not ableto prove your income information, we will ask youfor additional documentation. You will get a Requestfor Information notice that will list all the requiredproofs and the deadline for submitting them. (Seepages 26-27 for information about MAGI.)You must give us a social security number (SSN)or proof that one has been applied for for everyhousehold member who is applying, unless one ofthe following exceptions applies. You or any household member has a religiousexemption as described in federal law. You or any household member is eligible only fora nonwork SSN. You or any household member is not eligible foran SSN.To get the type of health care that gives the bestcoverage, we need to prove the U.S. citizenship/national status or immigration status of everyhousehold member who is applying. (See pages38-40 for complete information about acceptableproofs.) We will conduct a data match withfederal and state agencies to try to prove your U.S.citizenship/national status or immigration status.If electronic data sources are unable to prove yourdeclared information, we will ask you for additionaldocumentation. You will receive a Request forInformation notice that will list all the requiredproofs and the deadline for submitting them.(See pages 40-41 for complete information aboutacceptable proofs.) See pages 36-39 for informationabout immigration status and eligibility for benefits.As soon as we get the information we need, we willdecide what benefits you are eligible for. We base ourdecision on state and federal law.An individual’s residency will be consideredproven if the individual has self-declared to beinga Massachusetts resident, and the residency hasbeen confirmed by electronic data matching withfederal or state agencies, or information services,or the individual has provided any of the followingdocuments. A copy of the deed and record of the most recentmortgage payment (if the mortgage was paid in full, a copy of the property tax bill from the mostrecent year)A current utility bill or work order dated withinthe past 60 daysA statement from a homeless shelter or homelessservice providerSchool records (if school is private, additionaldocumentation may be requested)Nursery school or day care records (if schoolis private, additional documentation may berequested)A Section 8 agreementA homeowners’ insurance agreementProof of enrollment of custodial dependent inpublic schoolA copy of the lease AND record of the mostrecent rent paymentIf you cannot give us any of the documents listedabove, you may submit an affidavit supportingresidency signed under the pains and penalties ofperjury.More specific information about MassHealth can be found in theMassHealth regulations at 130 CMR 502.000.The application (in English, English large print,and Spanish) is also available online atwww.mass.gov/masshealth.To get interpreter services or a MassHealth MemberBooklet in another language, call MassHealth CustomerService at 1-800-841-2900 (TTY: 1-800-497-4648 for peoplewho are deaf, hard of hearing, or speech disabled). Provisional eligibilityMassHealth provides benefits to eligible applicants basedon self-attestation (except for disability, citizenship,and immigration status) during the provisional period.*Applicants must provide all outstanding eligibility proofswithin 90 days of receipt of MassHealth’s Request forInformation Notice. Each applicant can only get oneprovisional eligibility approval in a 12-month period.MassHealth members will be required to enroll in amanaged care plan during the provisional period, ifotherwise mandatory to enroll. MassHealth memberswho have been assessed a premium will have to paythe premium during the provisional period. PremiumAssistance will not be provided during the initialprovisional period until all proofs have been submitted,and the health insurance investigation is complete.* You can also get benefits during a reasonable opportunity period,while you provide any required proofs of U.S. citizenship and identityor immigration status.5

6 Hospital determined presumptive eligibility The MassHealth cardA qualified hospital may make presumptive eligibilitydeterminations for its patients. Presumptive eligibilitywill be determined based on self-declared information.Qualified hospitals may determine presumptiveeligibility for the following.1. MassHealth Standard for children under age 19, for young adults aged 19 or 20, pregnant women, parents or caretaker relatives, individuals with breast or cervical cancer, individuals who are HIV positive, or independent foster care children up to age 262. MassHealth CarePlus for adults aged 21-643. MassHealth Family Assistance, if the individualsmeet the categorical and financial requirements ofMassHealth Family Assistance and are: HIV positive, or children with incomes up to 150% of the federalpoverty level (FPL) who have a nonqualifiedPRUCOL immigration status (See pages 14-15.)Only one hospital determined presumptive eligibilityperiod per member is permitted within a 12-monthtimeframe, starting with the effective date of the initialpresumptive eligibility period. An individual whohas been eligible for MassHealth, Health Connector,or Health Safety Net benefits within the previous 12months may not be determined presumptively eligibleby a hospital.Benefits provided through the hospital presumptiveeligibility process will begin on the date that thehospital determined presumptive eligibility and willcontinue until: the end of the month following the month ofthe presumptive eligibility determination, ifthe individual has not submitted a completeapplication by that date, or an eligibility determination is made basedupon the individual’s submission of a completeapplication, if the complete application wassubmitted before the end of the month followingthe month of the presumptive eligibilitydetermination.Each eligible household member will get a MassHealthcard and/or a CMSP card. You must show yourcard or cards to your doctor or other health careprovider whenever you get medical care. If you havea MassHealth card and have other health insurance,be sure to show all cards. If you are eligible only forpayment of health insurance premiums ( for example,some MassHealth Family Assistance members who onlyget premium assistance), you will not get a MassHealthcard. People who get health insurance through aConnectorCare plan will get a health insurance cardfrom the health plan they choose. Those determinedto be low-income for the purposes of the Health SafetyNet (HSN) will not get a card. If you are eligible for HSNservices, hospitals and community health centers willcheck to determine if they can get reimbursement forservices provided to you and your household.Note: MassHealth will not charge a premium during the hospitalpresumptive period.For more information about hospital determined presumptiveeligibility, see 130 CMR 502.000. Our decision and your right to appealWe will send you a notice to let you know if you canor cannot get one of the MassHealth coverage types orprograms, or ConnectorCare Plans and premium taxcredits, or the Health Safety Net. If you think that ourdecision is wrong, you have the right to ask for a fairhearing to appeal our decision.Notices have information that explains how to ask for afair hearing and how much time you have to ask for one.See page 42 to find out where to send your fair hearingrequest.If you have questions about a MassHealth notice orhow to ask for an appeal, call a MassHealth EnrollmentCenter at 1-888-665-9993 (TTY: 1-888-665-9997 forpeople who are deaf, hard of hearing, or speechdisabled). If you have questions about a HealthConnector appeal that is about services or premiums,call the Health Connector at 1-877-623-6765.If you have questions about a Health Safety Netgrievance, call the Health Safety Net CustomerService Center at 1-877-910-2100. Health Safety Netdeterminations are conducted through MassHealth.More specific information about MassHealth can be found in theMassHealth regulations at 130 CMR 450.000, 501.000 through508.000, 522.000, and 610.000.This booklet reflects the income standards in effect on March 1,2013, and the rules that are effective on January 1, 2014.

Visit us online at MAhealthconnector.org What U.S. citizens/nationals need toknow about applying for MassHealth andConnectorCare Plans and premium tax creditsVerification of U.S. citizenship/national status andidentity is required for all U.S. citizens/nationalsapplying for MassHealth and ConnectorCare plansand premium tax credits. See pages 40-41 for moreinformation about proof of U.S. citizenship/nationalstatus and identity.If you need to provide proofs, the most common formsof proofs for both U.S. citizenship/national statusand identity are a U.S. passport, a Certificate of U.S.Citizenship, a Certificate of U.S. Naturalization, or adocument issued by a federally recognized AmericanIndian tribe showing membership or enrollment in,or affiliation with, this tribe. U.S. citizenship/nationalstatus may also be proved with a U.S. public birthcertificate or a Report of Birth Abroad of a U.S. Citizen.Identity may also be proved with a state driver’s licensecontaining the individual’s photo, a government issuedidentity card containing the individual’s photo, or aU.S. military ID card. For more detailed informationabout proving citizenship and identity, see pages 40-41.We may be able to prove your identity through theMassachusetts Registry of Motor Vehicles records if youhave a Massachusetts driver’s license or a MassachusettsID card. Once you give us proof of your U.S. citizenship/national status and identity, you will not have to giveus this proof again. You must give us proof of identityfor all household members who are applying. Seniorsand disabled persons who get or can get Medicareor Supplemental Security Income (SSI), or disabledpersons who get Social Security Disability (SSDI) donot have to give proof of their U.S. citizenship/nationalstatus and identity. A child born to a mother who wasgetting MassHealth on the date of the child’s birth doesnot have to give proof of U.S. citizenship/national statusand identity. (See pages 40-41 for complete informationabout acceptable proofs.)For help getting proofs, like a Massachusetts birth recordor information about how to get a birth record fromanother state, please call MassHealth Customer Serviceat 1-800-841-2900 (TTY: 1-800-497-4648 for people whoare deaf, hard of hearing, or speech disabled). What non U.S. citizens need to know aboutapplying for MassHealth or ConnectorCarePlans and premium tax creditsTo get the type of health care that gives the bestcoverage, or to get a ConnectorCare plan and premiumtax credits, satisfactory immigration status for eachhousehold member who is applying must be proved.We will perform information matches with federaland state agencies to prove immigration status. Ifelectronic data sources are not able to prove anindividual’s declared information, we will ask foradditional documentation. We will send a Request forInformation notice that will list all the required proofsand the deadline for submitting them. Immigrationstatus information is listed on pages 36-39, or go to theMassHealth Web site at www.mass.gov/masshealth. What non U.S. citizens need to know aboutapplying for MassHealth Limited, MassHealthcoverage for pregnant women, CMSP, and theHealth Safety NetNon U.S. citizens who are not eligible for an SSN or donot have documentation of their immigration statusmay still qualify for MassHealth Limited, MassHealthcoverage for pregnant women, CMSP, or the HealthSafety Net. However, they do have to give us: proof of their income; and proof of identity to be eligible for the Health SafetyNet.Non U.S. citizens do not have to submit theirimmigration documents with the application if they areapplying only for their children, but are not applying forany health coverage for themselves.If individuals do not have pay stubs or tax records, theycan prove what their income is in other ways, like givingus a signed statement from their employer containingthe gross (before taxes and deductions) pay and hoursworked.Applications and the information on them will be keptconfidential. This means that: names and addresses will not be sent to immigrationenforcement officials; and we will not match information with other agencies ifindividuals do not have social security numbers. What visitors need to know about applyingIndividuals who are not Massachusetts residents are noteligible for MassHealth or other health care benefits thatare funded by the Commonwealth of Massachusetts.Note: For more information about the immigration laws and public benefits,see the list of advocacy organizations at the end of this booklet.They can give confidential answers to your questions about theimmigration laws. Your call and what you say will not be shared withanyone.7

8Section 2MassHealth StandardThis coverage type offers a full range of health carebenefits.Details about MassHealthcoverage types and programsThis section of the booklet will help you learn aboutthe coverage types and programs and if you mightbe eligible for any. For each of the coverage types andprograms, this section tells you: Who can get benefits What the income standards are What health services are covered When coverage beginsIf you apply, you will get a notice from us. The noticewill tell you if you can get benefits and when they willbegin. We will give you the most complete coverage thatyou qualify for. Who can get benefitsYou may be able to get MassHealth Standard if you are aresident of Massachusetts and are: pregnant, or under age 19, or a young adult aged 19 or 20, or a parent living with your children under age 19*, or an adult caretaker relative living with children underage 19 to whom you are related and for whom youare the primary caretaker when neither parent isliving in the home*, or under age 65 with breast or cervical cancer, or under age 65 and are HIV positive, or disabled according to the standards set by federaland state law. This means you have a mental orphysical condition that limits or keeps you fromworking for at least 12 months. MassHealth decides ifyou meet the disability standards, or eligible based on special rules, which let you keepthese benefits for up to 12 months after you havegone back to work or gotten a raise, no matter howmuch your new earnings are*, or a certain individual up to age 26 who was formerlyin foster care (There is no income limit for thesepersons.), or a certain individual who is otherwise eligible forMassHealth CarePlus, has been determined to havespecial health care needs, and has chosen to beenrolled in MassHealth Standard, or under age 65 and getting services, or are on a waitinglist to get services from the Department of MentalHealth.* These benefits are al

MassHealth Enrollment Center at 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). MassHealth provides health care benefits to certain low- and medium-income people living in Massachusetts. MassHealth offers these benefits to you directly or by paying part o