For MassHealth and Health Connector Applicants

On behalf of myself and all persons listed on this application, I understand, represent, and agree as follows.

  1. MassHealth may require eligible persons to enroll in available employer-sponsored health insurance if that insurance meets the criteria for MassHealth payment of premium assistance.
  2. Employers of eligible persons may be notified and billed in accordance with MassHealth regulations for any services that hospitals or community health centers provide to such persons that are paid for by the Health Safety Net.
  3. I may have to pay a premium for health coverage for myself and others listed on this application. Failure to pay any premium due may result in the state deducting the amount owed from the tax refunds of responsible If I am a certain American Indian or Alaska Native, I may not have to pay premiums for MassHealth.
  4. MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided to eligible persons enrolled in MassHealth programs. Such third parties may include other health insurers, spouses, parents obligated to pay for medical support, or individuals obligated to pay under accident settlements. Eligible persons must cooperate with MassHealth in establishing third-party support and obtaining third-party payments for themselves and anyone whose rights they can legally assign. Eligible persons may be exempted from this obligation if they believe and tell MassHealth that cooperation could result in harm to them or anyone whose rights they can legally assign.
  5. A parent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from an absent parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or
  6. Eligible persons who are injured in an accident, or in some other way, and get money from a third party because of that accident or injury must use that money to repay MassHealth or the Health Safety Net for certain services provided.
  7. Eligible persons must tell MassHealth or the Health Safety Net, in writing, within 10 calendar days, or as soon as possible, about any insurance claims or lawsuits filed because of an accident or injury.
  8. The status of this application may be shared with a hospital, community health center, other medical provider, or federal or state agencies when necessary for treatment, payment, operations, or the administration of the programs listed
  9. To the extent permitted by law, after notice and an opportunity to appeal, MassHealth may place a lien against any real estate owned by an eligible MassHealth member or in which the eligible member has a legal interest, if the member is receiving long-term care in a nursing facility or other medical institution and MassHealth determines that the member is not reasonably expected to return home. If MassHealth puts a lien against such property and the property is later sold, money from the sale of that property may be used to repay MassHealth for medical services
  10. To the extent permitted by law, and unless exceptions apply, for any eligible person 55 or older receiving long-term services and supports (LTSS), or any eligible person regardless of age for whom MassHealth helps pay for long-term care in a nursing home or other medical institution, MassHealth will seek money from the eligible person’s estate after death for the total cost of care as permitted by law. For more information on estate recovery, visit gov/EstateRecovery.
  11. To the extent permitted by law, MassHealth will seek money from a Special Needs Trust belonging to an eligible individual after death for the total cost of care. The total cost of care includes the cost MassHealth paid directly for care (Fee for Service) and the total amount it paid to a health plan (like an Accountable Care Organization or a One Care plan) for care, regardless of what services the member may have received.
  12. Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the change. Eligible persons can make changes by calling (800) 841-2900, TDD/ TTY: A change in information could affect eligibility for such persons or for persons in their household.

    You can also report changes in any of the following ways.

  • Sign in to your account at MAhealthconnector.org. You can create an online account if you do not already have one.
  • Send the change information to Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780
  • Fax the change information to (857) 323-8300.
  1. MassHealth, the Massachusetts Health Connector, and the Health Safety Net will obtain from eligible persons’ current and former employers and health insurers all information about health insurance coverage for such persons. MassHealth may share information about me and members of my household with my employer(s) and/ or health insurers to obtain this This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been available to such persons or members of their household.
  2. MassHealth, the Massachusetts Health Connector, and the Health Safety Net may get records or data about persons listed on this application from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, as well as private data sources, including financial institutions, 1) to prove any information given on this application and any supplements, or other information given once a person becomes a member, 2) to document medical services claimed or provided to such persons, and 3) to support continued
  3. In connection with the eligibility and enrollment process, MassHealth, the Massachusetts Health Connector, and the Health Safety Net may send notices that contain personal information about persons listed on this application to other persons on this application, or otherwise communicate such information to such persons.
  4. Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by going to gov/ocr/ complaints/index.html.
  5. I agree to allow the Massachusetts Health Connector to use income data, including information from tax returns, to determine my eligibility in future years. Review the Health Connector Privacy Policy for more information about how the Health Connector uses your tax information. The Massachusetts Health Connector will send me a notice and let me make changes to my eligibility application. I understand that if I am eligible for an Advance Premium Tax Credit (APTC) or ConnectorCare, these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC or ConnectorCare may impact my annual tax I will be given the option to apply all, some, or none of any APTC amount I may be eligible for to my monthly premium.
  6. I agree that MassHealth or anyone acting on its behalf may contact me including by mail, email, call, or text for any communications about my relationship with MassHealth or my health care needs, benefits, eligibility, or coverage using the contact information I provide, now or in the future, or information obtained from a reliable data These calls and texts may be made using automated technology, such as an automatic dialing system or artificial or prerecorded voice messages. Standard message and data rates may apply. I also agree that MassHealth may get, use, or share my information for the purpose of coordinating other health related benefits that I may be eligible to receive.
  7. I have read or have had read to me the information on this application, including any supplements and instructions. I understand that the Member Booklet contains important information about this application.
  8. I have permission from all persons listed on this application (or their parent or other legally authorized representative) to submit this application. I also have permission to act on their behalf to complete this application and any related eligibility process, including the following.
  • Providing personal information about them, including health, health coverage, and income information, seeing such information as may be provided by the Massachusetts Health Connector, MassHealth, and the Health Safety Net, and providing consent on their behalf to the use and disclosure of their information as described in this application
  • Making choices about coverage options and how to communicate with the Massachusetts Health Connector, MassHealth, or the Health Safety Net
  • Making changes to the application or related eligibility documents and providing information about any change in their circumstances
  • Providing consent on their behalf to use government and private sources to verify the information as described in this application
  1. I understand my rights and responsibilities and the rights and responsibilities of all persons listed on this application as explained in this Step 8.
  2. I have told or will tell anyone listed on this application (or their parent or legally authorized representative, if applicable) about these rights and responsibilities so they understand them.
  3. I understand and agree that MassHealth, the Health Safety Net, and the Massachusetts Health Connector will treat any electronic or faxed signature, or copy of a signature, with the same effect as an original signature.
  4. I understand that MassHealth
  • is allowed to ask for SSNs under federal and state law;
  • uses SSNs to check income and other information to see who is eligible for help with health coverage costs;
  • uses SSNs to detect fraud, to see if anyone is getting duplicate benefits, or to see if others should be paying for services; and
  • matches the SSN of anyone in the household who is applying and anyone who has or who can get health insurance for anyone in the household with the files of agencies and financial institutions.
  1. I understand that if MassHealth pays part of anyone’s health insurance premiums, MassHealth will add the SSN or the SSN of that policyholder to the State Comptroller’s vendor file.
  2. I understand that the policyholder in my household must have a valid SSN before getting a payment from
  3. The information I have supplied is correct and complete to the best of my knowledge about myself and other persons listed on this application.
  4. I may be subject to penalties under federal law if I intentionally provide false or untrue information.

If someone does not have an SSN or needs help getting one, call the Social Security Administration at (800) 772-1213, TTY: (800) 325-0778, or go to socialsecurity.gov. For a full explanation on how we use your Social Security number, please refer to the Member Booklet for Health and Dental Coverage and Help Paying Costs.