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MASSACHUSETTS APPLICATIONFOR HEALTH AND DENTALCOVERAGE AND HELP PAYINGCOSTSCommonwealth of Massachusetts EOHHSTHINGS TO KNOWHow to ApplyYou can submit your application in any of thefollowing ways. Sign on to your account at MAhealthconnector.org. You can create an online account if you donot already have one. Applying online may be afaster way for you to get coverage than mailinga paper application.ACA-3-LP (10/14)
Mail your filled-out, signed application toHealth Insurance Processing CenterP.O. Box 4405Taunton, MA 02780. Fax your filled-out, signed application to 617887-8770. Call the MassHealth Customer Services Centerat 1-800-841-2900 (TTY: 1-800-497-4648 forpeople who are deaf, hard of hearing, or speechdisabled) or 1-877-MA ENROLL (877-623-6765). Visit a MassHealth Enrollment Center (MEC) toapply in person. See the Member Booklet for alist of MEC addresses.Use this application to see whatcoverage choices you may qualify for. Low- or no-cost coverage from MassHealth,including the Children’s Medical Security Plan(CMSP), the Health Connector, or the HealthSafety Net (HSN). You may qualify for a low- orno-cost program, even if you earn as much as 95,000 a year (for a household of four). Affordable private health insurance plans thatoffer comprehensive coverage to help you staywell.2
A new tax credit that can help pay yourpremiums for health coverage right away.Who can use this application?This application is for people who need health ordental coverage and help paying for it, and who live in Massachusetts; are not living in or not about to go into a nursinghome; and are under age 65.This application may also be used by people ofany age who are parents of children under age 19; adult relatives living with and taking care ofchildren under age 19 when neither parent isliving in the home; or disabled and either work 40 or more hours a month or arecurrently working and have worked at least240 hours in the six months immediatelybefore the month of the application; or not working (only if under age 65).3
Who can use this application? (cont.)If this application is not for you, call theMassHealth Customer Services Center at 1-800841-2900 (TTY: 1-800-497-4648 for people whoare deaf, hard of hearing, or speech disabled).This application is available in Spanish. Please callthe number above to request one.Apply even if you or your child already has healthcoverage. You could qualify for lower-cost orno-cost coverage. Apply even if you or yourchild already has coverage through the HealthConnector or MassHealth. We need to knowabout all members of your household to make adecision on your eligibility.If someone is helping you fill out this application,you may need to fill out a separate form that givesthat person permission to act on your behalf.See Supplement C: Authorized RepresentativeDesignation Form on page 19.What you may need to apply Social security numbers4
Document numbers for any legal immigrantswho need coverage Employer and income information for everyonein your household (for example, from paystubs,W-2 forms, or wage and tax statements) Policy numbers for any current health coverage Information about any job-related healthinsurance available to your householdWhy do we ask for this information?We ask about income and other information to letyou know what coverage you qualify for and if youcan get any help paying for it. We will keep all theinformation you provide private and secure, asrequired by law. To view the Health Connector’sPrivacy Policy, go to MAhealthconnector.org.To view the MassHealth Privacy Policy see theMember Booklet or go to actices.html.What happens next?You will get instructions on the next steps tocomplete your application. If you do not hear5
from us, visit MAhealthconnector.org or call theMassHealth Customer Services Center at 1-800841-2900 (TTY: 1-800-497-4648 for people whoare deaf, hard of hearing, or speech disabled).Filling out this application does not mean youhave to buy health coverage.Get help with this applicationPhone: please call the MassHealth CustomerServices Center for help with this application or ifyou need interpreter services.The MassHealth Customer Services Center1-800-841-2900 (TTY: 1-800-497-4648 for peoplewho are deaf, hard of hearing, or speech disabled)6
MASSACHUSETTS APPLICATIONFOR HEALTH AND DENTALCOVERAGE AND HELP PAYINGCOSTSCommonwealth of Massachusetts EOHHSSTEP 1 TELL US ABOUTYOURSELF.We need one adult in the household to be thecontact person for your application.1. First name, middle name, last name, and suffix2. Home addressCheck here if you are homeless. 3. Apartment or suite number7
4. City5. State6. ZIP code7. County8. Mailing address (if different from homeaddress)9. Apartment or suite number10. City11. State12. ZIP code13. County14. Phone number15. Other telephone number16. What is your preferred spoken or writtenlanguage (if not English)?17. What is your e-mail address?8
STEP 2 TELL US ABOUT YOURHOUSEHOLD.Who do you need to include on this application?Tell us about all the household members who livewith you. If you file taxes, we need to know abouteveryone on your tax return. You do not need tofile taxes to get MassHealth.DO Include yourself;your spouse;your children under 19;your unmarried partner who needs healthcoverage;your unmarried partner if you have childrentogether who are under the age of 19;anyone your unmarried partner included on hisor her tax return (even if they do not live withyou), if you also include your unmarried partner;anyone you include on your tax return, even ifthey are over the age of 19 or do not live withyou; andanyone else under 19 who you take care of andlives with you.9
You DO NOT have to include your unmarried partner who does not needhealth coverage, unless you have childrentogether; your unmarried partner’s children unless theylive with you; your parents who live with you, but file their owntax return (if you are over 19); or other adult relatives who file their own taxreturn.The amount of help or type of program you mayqualify for depends on the number of peoplein your household and their incomes. Thisinformation helps us make sure everyone gets thecoverage they may be eligible for.Complete Step 2 for each person in yourhousehold. Start with yourself, then add otheradults and children. If you have more than threepeople in your household, including yourself, youwill need to make copies of the pages for Person3 before you fill them out, and attach them to theapplication. Be sure to tell us how each personis related to each other person. We need thisinformation to determine eligibility.10
STEP 2 PERSON 1 (START WITHYOURSELF.)Complete Step 2 for yourself and all additionalhousehold members who live with you, or anyoneon your same federal income tax return if youfile one. See page 1 for more information aboutwho to include. If you do not file a tax return,remember to still add household members wholive with you.1. First name, middle name, last name, and suffix2. Relationship to you SELF3. Date of birth (mm/dd/yyyy)4. Sex Male Female5. We need a social security number (SSN) forevery person applying for health coveragewho has one. An SSN is optional for personsnot applying for health coverage, but givingus an SSN can speed up the applicationprocess. We use SSNs to check income andother information to see who is eligible for11
help with health coverage costs. If someoneneeds help getting an SSN, call the SocialSecurity Administration at 1-800-772-1213(TTY: 1-800-325-0778 for people who are deaf,hard of hearing, or speech disabled), or goto socialsecurity.gov. Please see the MemberBooklet for more information.Do you have a social security number (SSN)? Yes NoIf yes, give us the number (optional if notapplying) - -If no, check one of the reasons below. Just applied Noncitizen exception Religious exception6. Are you applying for health or dental coveragefor YOURSELF? (Even if you have coverage,there might be a program with better coverageor lower costs.) Yes. If yes, answer all the questions below. No. If no, go to Current Job and IncomeInformation on page 19.12
7. Are you a Massachusetts resident? Yes Noa.Do you intend to reside inMassachusetts, even if you do not have afixed address? Yes Nob. Are you temporarily living outsideMassachusetts? Yes No8. Do you plan to file a federal income tax returnNEXT YEAR? You can still apply for healthcoverage even if you did not file a federalincome tax return. However, you must file a taxreturn to get help paying for coverage througha tax credit or ConnectorCare plan. Yes. If yes, please answer questions a–c No. If no, skip to question c.a.Will you file jointly with a spouse? Yes No You must file a joint federal taxreturn next year to get a tax creditor ConnectorCare plan. If you are avictim of domestic violence or are anabandoned spouse, you should indicatethat you file taxes as “single” in order tobe considered for a tax credit. You willonly need to include yourself and anydependents on this application.13
If yes, list name of spouse.b. Will you claim any dependents on yourtax return? Yes No You must claima personal exemption deduction on your2015 federal income tax return for anyindividual listed on this application as adependent who is enrolled in coveragethrough the Health Connector and whosepremium for coverage is paid in whole orin part by advance payments.If yes, list name(s) of dependents.c.Will you be claimed as a dependent onsomeone’s tax return? Yes No Ifyou are claimed by someone else as adependent on their 2015 federal incometax return, this may affect your ability toreceive a premium tax credit.If yes, please list the name of the tax filer.How are you related to the tax filer?9. Are you a U.S. citizen or U.S. national? Yes NoIf yes, are you a naturalized citizen?14
Yes No Naturalization or citizenshipnumber10. If you are a noncitizen do you have aneligible immigration status? (See the MemberBooklet or MAhealthconnector.org for moreinformation.) Yes No No responseIf no or no response, you may get only one ormore of the following: MassHealth Standard (ifpregnant), MassHealth Limited, the Children’sMedical Security Plan (CMSP), or the HealthSafety Net (HSN).a.If yes, do you have an immigrationdocument? Yes NoWe will try to prove your immigrationstatus. Please list all the immigrationstatuses and/or conditions that haveapplied to you since you entered theU.S. See the Member Booklet for moreinformation about immigration statusesand documents.Immigration statusStatus award date*(mm/dd/yyyy)15
Immigration document typeDocument ID numberAlien numberPassport or document expiration date(mm/dd/yyyy)* For battered persons, the statusaward date is the date the petition wasapproved as properly filed.b. Have you lived in the U.S. since August22, 1996? Yes Noc.Did you use the same name on thisapplication that you did to get yourimmigration status? Yes NoIf no, what name did you use?First name, middle name, last name, andsuffixd. Are you or your spouse or parent anhonorably discharged veteran or anactive-duty member of the U.S. military? Yes No11. Do you live with at least one child under theage of 19, and are you the main person takingcare of this child(ren)? Yes No16
Name(s) of child(ren)12. Do you have an injury, illness, or disability(including a disabling mental health condition)that has lasted or is expected to last for atleast 12 months? If legally blind, answer yes. Yes No13. Do you have breast or cervical cancer?(Optional) Yes NoMassHealth has special coverage rules forpeople who need treatment for breast orcervical cancer.14. Are you HIV positive? (Optional) Yes NoMassHealth has special coverage rules forpeople who are HIV positive.15. Are you pregnant? Yes NoIf yes, how many babies are expectedduring this pregnancy?b. What is your expected due date?16. Were you ever in foster care? Yes Noa.17
17. Race (optional—check all that apply.) Hispanic, Latino, or Spanish origin Cuban Mexican, Mexican-American, orChicano Puerto Rican Other Hispanic/Latino/Spanish American Indian or Alaska Native Asian Indian Black or African American Chinese Filipino Guamanian or Chamorro Japanese Korean Native Hawaiian Other Asian Other Pacific Islander Samoan Vietnamese White or Caucasian Other18
Current Job and Income Information Employed (Go to question 18.) Self-employed (Go to question 28.) Not employed (Go to question 29.)Current Job 118. Employer name and address19. Wages/tips (before taxes) Weekly Every 2 weeks Twice a month Monthly Yearly 20. Average number of hours worked each WEEK21. Is this job a sheltered workshop? Yes No22. Are you seasonally employed? Yes NoCurrent Job 2If you have more jobs and need more space,attach another sheet of paper.23. Employer name and address19
24. Wages/tips (before taxes) Weekly Every 2 weeks Twice a month Monthly Yearly 25. Average number of hours worked each WEEK26. Is this job a sheltered workshop? Yes No27. Are you seasonally employed? Yes No28. If self-employed, answer the followingquestions.a.b.Type of workHow much net income (profits oncebusiness expenses are paid) will you getfrom this self-employment this month? Other Income29. Check all that apply, and give the amountand how often you get it. NOTE: You do notneed to tell us about child support, veteran’spayment, or Supplemental Security Income(SSI). None20
Social security benefits How often? Unemployment How often? Retirement How often? Capital gains How often? Investment income How often? Net rental or royalty income How often? Net farming or fishing income How often? Alimony received How often? Other income How often?Type21
Deductions30. Check all that apply, and give the amount andhow often you get it.If you pay for certain things that can bededucted on a federal income tax return,telling us about them could make the costof health coverage a little lower. NOTE: Youshould not include a cost that you alreadyconsidered in your answers to net selfemployment income, net rental or royaltyincome, or net farming or fishing income. Alimony paid How often? Student loan interest How often? Other tax deductions (such as businessexpenses, IRA contributions, contributionsto taxable retirement income, deductible partof self-employment tax, educator expenses,health savings account contributions(deduction), moving expenses, penalty onearly withdrawal of savings, self-employmenthealth insurance, self-employment retirement22
plan, and tuition and other school-relatedcosts)Type How often?Yearly Income31. Your total income this year32. Your total income next year (if you think it willbe different)THANKS! This is all we need to know aboutyou. Go to Step 2 Person 2 to add anotherhousehold member, if needed. Otherwise, go toStep 3 American Indian or Alaska Native (AI/AN)Household Member(s).23
STEP 2 PERSON 2Complete Step 2 for each additional person inyour household who lives with you and for anyoneon your same federal income tax return if you fileone. See page 1 for more information about who toinclude. If you do not file a tax return, remember tostill add household members who live with you.1. First name, middle name, last name, and suffix2. Relationship to Person 1Does this person live with Person 1? Yes NoIf no, list address.3. Date of birth (mm/dd/yyyy)4. Sex Male Female5. We need a social security number for everyperson applying for health coverage who hasone. Please see the Member Booklet for moreinformation.24
Does this person have a social securitynumber (SSN)? Yes NoIf yes, give us the number (optional if notapplying)If no, check one of the reasons below. Just applied Noncitizen exception Religious exception6. Is this person applying for health or dentalcoverage? Even if this person has coverage,there might be a program with better coverageor lower costs. Yes. If yes, answer all the questions below. No. If no, go to Current Job and IncomeInformation on page 32.7. Is this person a Massachusetts resident? Yes Noa.Does this person intend to reside inMassachusetts, even if he or she doesnot have a fixed address? Yes Nob. Is this person temporarily living outsideMassachusetts? Yes No8. Does this person plan to file a federal incometax return NEXT YEAR? This person can still25
apply for health coverage even if he or shedoes not file a federal income tax return.However, this person must file a tax return toget help paying for coverage through a taxcredit or ConnectorCare plan. Yes. If yes, please answer questions a–c. No. If no, skip to question c.a.b.Will this person file jointly with a spouse? Yes No This person must file ajoint federal tax return next year to get atax credit or ConnectorCare plan. If thisperson is a victim of domestic violenceor is an abandoned spouse, this personshould indicate that he or she files taxesas “single” in order to be considered fora tax credit. This person will only needto include himself or herself and anydependents on this application.If yes, list name of spouse.Will this person claim any dependents onhis or her tax return? Yes No Thisperson must claim a personal exemptiondeduction on his or her 2015 federalincome tax return for any individual26
listed on this application as a dependentwho is enrolled in coverage through theHealth Connector and whose premiumfor coverage is paid in whole or in part byadvance payments.If yes, list name(s) of dependents.c.Will this person be claimed as adependent on someone’s tax return? Yes No If this person is claimedby someone else as a dependent ontheir 2015 federal income tax return, thismay affect his or her ability to receive apremium tax credit.If yes, please list the name of the tax filer.How is this person related to the tax filer?9. Is this person a U.S. citizen or U.S. national? Yes NoIf yes, is this person a naturalized citizen? Yes NoNaturalization or citizenship number10. If this person is a noncitizen does this person27
have an eligible immigration status? (See theMember Booklet or MAhealthconnector.org formore information.) Yes No No responseIf no or no response, this person may getonly one or more of the following: MassHealthStandard (if pregnant), MassHealth Limited,the Children’s Medical Security Plan (CMSP),or the Health Safety Net (HSN).a.If yes, does this person have animmigration document? Yes NoWe will try to prove immigration statusfor this person. Please list all theimmigration statuses and/or conditionsthat have applied to this person since heor she entered the U.S. See the MemberBooklet for more information aboutimmigration statuses and documents.Immigration statusStatus award date*(mm/dd/yyyy)Immigration document type28
Document ID numberAlien numberPassport or document expiration date(mm/dd/yyyy)* For battered persons, the statusaward date is the date the petition wasapproved as properly filed.b. Has thisperson lived in the U.S. since August 22,1996? Yes Noc.Did this person use the same name onthis application that this person did to gethis or her immigration status? Yes NoIf no, what name did this person use?First name, middle name, last name, andsuffixd. Is this person or his or her spouse orparent an honorably discharged veteranor an active-duty member of the U.S.military? Yes No11. Does this person live with at least one childunder the age of 19, and is this person themain person taking care of this child(ren)? Yes No29
Name(s) of child(
MassHealth Customer Services Center at 1-800-841-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled). This application is available in Spanish. Please call the number above to request one. Apply even if you or your child already has health covera
