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.
  2. Employers of eligible persons may be notified and billed in accordance with MassHealth regulations for any services that hospitals or community 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 on this application. Failure to pay any premium due may result in the State deducting the amount owed from the tax refunds of responsible persons. If I am a certain American Indian or Alaskan 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 or 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 guardian.
  6. Eligible persons who are injured in an accident, or 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 lawsuit 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 above.
  9. To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which eligible persons have a legal interest. If MassHealth puts a lien against such property and it is sold, money from the sale of that property may be used to repay MassHealth for medical services provided.
  10. To the extent permitted by law, for any eligible person age 55 or older, or any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth may seek money from the eligible person’s estate after death.
  11. Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their family’s income or employment, family 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 Eligible persons who enroll through the HIX can make changes in “My Account” or by calling 1-877-623- 6765 (TTY: 711). A change in information could affect eligibility for such persons or for persons in their household.
  12. 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. This includes, but is not limited to, information about policies, premiums, co-insurance, deductibles, and covered benefits that are, may be, or should have been available to such persons or members of their household.
  13. MassHealth and the Massachusetts Health Connector may get any records or data 1) to prove any information given on this application and any supplements, or other information I give once I am a member, 2) to document medical services claimed or provided, and 3) to support continued eligibility.