Aca 3 Form – Fill Out and Use This PDF

Massachusetts Application for Health

and Dental Coverage and Help Paying Costs

•Employer and income information for everyone in your household (for example, from paystubs or wage statements)

•Information about any job-related or other health insurance that you are currently enrolled in or have access to

To find resources and information related to the coronavirus for MassHealth applicant and members, go to

www.mass.gov/coronavirus-disease-covid-19-and-masshealth.

Massachusetts Application for Health

and Dental Coverage and Help Paying Costs

Supplemental Nutrition Assistance Program (SNAP)

The Supplemental Nutrition Assistance Program (SNAP) is a federal program that helps you buy healthy food each month.

Check this box if you want this application to be sent to the Department of Transitional Assistance to serve as an application for SNAP benefits. You must read the rights and responsibilities on pages 20-25 and sign on page 26 to proceed with the application.

STEP 1 Person 1. Tell us about yourself. Please print clearly.

We need one adult in the household to be the contact person for your application. Please note that this should be someone who appears on the application, not a third party who wishes to serve as a contact for the applicant(s). Please see the Authorized Representative Designation (ARD) Form at the end of this application to establish a third-party contact.

3. What is your email address?

No home address. Note: if you check this box, you must provide a mailing address.

20.Is anyone on this application in prison or jail?  Yes  No Please select No if this person will be released in the next 60 days. If Yes, who? Enter the name here:

If Yes, is this person awaiting trial?  Yes  No

FOR ENROLLMENT ASSISTERS ONLY

Complete this section if you are an enrollment assister and are filling out this application for someone else. Navigators must fill out a Navigator Designation Form if they have not done so already. Certified Application Counselors must fill out a Certified Application Counselor Designation Form if they have not done so already.

STEP 2 Tell us about your household.

Who do you need to include on this application?

Tell us about all the household members who live with you. If you file taxes, we need to know about everyone on your tax return. You do not need to file taxes to get MassHealth, the Health Safety Net, or the Children’s Medical Security Plan, if you qualify.

The amount of help or type of program you may qualify for depends on the number of people in your household and their incomes. This information helps us make sure everyone gets the coverage they may be eligible for.

COMPLETE STEP 2 FOR YOURSELF and ALL ADDITIONAL HOUSEHOLD MEMBERS who live with you, or anyone on your same federal income tax return if you file one. If you do not file a tax return, remember to still add household members who live with you.

STEP 2 Person 1. This section is to gather more information about the contact person named on page 1.

1. First name, middle name, last name, and suffix

MassHealth is committed to providing equitable care for all members regardless of race, ethnicity, or language spoken. Please complete this question to help us meet your language and cultural needs. Know that your response is voluntary, confidential, and will not impact your eligibility or be used for any discriminatory purpose.

6.Do you have a social security number (SSN)?  Yes  No. (optional if not applying)

We need a social security number (SSN) for every person applying for health coverage who has one. An SSN is optional for persons not applying for health coverage, but giving us an SSN can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. A social security number is required if a person is applying for MassHealth Premium Assistance. If someone needs help getting an SSN, call the Social Security Administration at (800) 772-1213 (TTY: (800) 325-0778), or go to socialsecurity.gov.

Is your name on this application the same as your name on your social security card?  Yes  No If No, what name is on your social security card?

First name, middle name, last name, and suffix

STEP 2 | PERSON 1 (CONTINUED)

7.If you get an Advance Premium Tax Credit (APTC) do you agree to file a federal tax return for the tax year that the credits are received?   Yes No

Individuals may not have needed or chosen to file a tax return in the past, but they will have to file a federal income tax return for any year that they get an APTC. They must check "Yes" to question 7 to be eligible for ConnectorCare or APTCs to help pay for your health insurance. You do NOT need to file a tax return to apply for or to get MassHealth, CMSP, or HSN, if you qualify

If Yes, please answer questions a–d. If No, skip to question d.

Individuals must file a joint federal tax return with their spouse for the year for which they are applying to get certain programs (ConnectorCare or APTCs) unless they are a victim of domestic abuse or abandonment or they will file taxes as Head of Household. If an individual will file taxes as Head of Household, they should answer No to question 7a (“Are you legally married?”). One way an individual may qualify as Head of Household is to live apart from their spouse and claim another person as a dependent. See IRS Publication 501 or consult a tax professional for tax filing information. They will only need to include themselves and any dependents on this application.

a.Are you legally married?  Yes  No If No, skip to question 7c.

If Yes, list name of spouse and date of birth.

b.Do you plan to file a joint federal tax return with your spouse for the tax year for which you are applying?  Yes  No

c.Will you claim any dependents on your federal income tax return for the year for which you are applying?  Yes  No You will claim a personal exemption deduction on your federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments. List the name(s) and date(s) of birth of dependents.

d.Will you be claimed as a dependent on someone else's federal income tax return for the year for which you are applying?

Yes  No

If you are claimed by someone else as a dependent on their federal income tax return, this may affect your ability to receive a premium tax credit. Do not answer Yes to this question if you are a child under the age of 21 being claimed by a noncustodial parent. If Yes, please list the name of the tax filer.

Is the tax filer married, filing a joint return?  Yes  No

If Yes, list name of spouse and date of birth.

Who else does the tax filer claim as dependents?

e. Are you filing taxes separately because you are a victim of domestic abuse or abandonment?  Yes  No Optional To complete this section, read the following statement. Then check Yes below the statement if:

1.You have received an APTC or ConnectorCare in the past, and

2.The statement is true for all people listed in the household.

Statement I filed a federal income tax return with the Internal Revenue Service (IRS) for every year that I received an Advance Premium Tax Credit (APTC). When I filed, I included IRS Form 8962, which had information about the tax credit I received, so the IRS could reconcile my APTC.  Yes  No

8.Are you applying for health or dental coverage for YOURSELF?  Yes  No

If Yes, answer all the questions below. If No, answer Questions 14 and 15, then go to Income Information on page 4.

9.Are you a U.S. citizen or U.S. national?  Yes  No

If Yes, are you a naturalized citizen (not born in the U.S.)?  Yes  No

10. If you are a noncitizen, do you have an eligible immigration status?  Yes  No. If No, go to Question 11.

See page 27, “Immigration Statuses and Document Types” for help. If no or no response, applicants may get only one or more of the following: MassHealth Standard (if pregnant), MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health Safety Net (HSN).

a. If Yes, do you have an immigration document?  Yes  No

It may help us to process this application faster if you include a copy of immigration documents for all the individuals who are applying. We will try to verify immigration status through an electronic data match. Please list all the immigration

STEP 2 | PERSON 1 (CONTINUED)

statuses or conditions that have applied to all the individuals on this application since they entered the U.S. If you need more space, attach another sheet of paper.

b.Did you use the same name on this application that you did to get your immigration status?  Yes  No If No, what name did you use? First, middle, last, and suffix

c.Did you arrive in the U.S. after August 22, 1996?  Yes  No

d.Are you an honorably discharged veteran or active-duty member of the U.S. military, or the spouse or child of an honorably discharged veteran or an active-duty member of the U.S. military?  Yes  No

11.Do you live with at least one child younger than age 19, and are you the main person taking care of this child(ren)? Yes  No

Name(s) and date(s) of birth of child(ren)

12.Are you living in Massachusetts, and do you either intend to reside here, even if you do not have a fixed address, or have you entered Massachusetts with a job commitment or seeking employment?  Yes  No

If you are visiting in Massachusetts for personal pleasure or for the purposes of receiving medical care in a setting other than a nursing facility, you must answer No to this question.

13.Do you have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? If legally blind, answer Yes.  Yes  No

14.Do you need reasonable accommodation because of a disability or an injury?  Yes  No If Yes, complete the rest of this application, including Supplement C: Accommodation.

15.Are you pregnant?  Yes  No

16.Optional Do you have breast or cervical cancer?  Yes  No (Special coverage rules may apply.)

17.Optional Are you HIV positive?  Yes  No (MassHealth has special coverage rules for people with HIV.)

18.Were you ever in foster care?  Yes  No

a.If Yes, in what state were you in foster care?

b.Were you getting health care through a state Medicaid program?  Yes  No

INCOME INFORMATION (You may send proof of all household income with this application.)

19.Do you have any income?  Yes  No

If you don’t have any income, skip to question 33.

EMPLOYMENT | If you need more space, attach another sheet of paper.

STEP 2 | PERSON 1 (CONTINUED)

26.Average number of hours worked each WEEK

27.Are you seasonally employed?  Yes  No. If Yes, which months do you work in a calendar year?

28.SELF-EMPLOYMENT: Are you self-employed?  Yes  No

a.If Yes, what type of work do you do?

b.On average, how much net income (profits or losses after business expenses are paid) will you get from this self- employment each month? $__________/month profit or $___________/month loss?

c.How many hours do you work per week? _______

OTHER INCOME

29.Check all that apply, and give the amount and how often you get it. NOTE: You do not need to tell us about child support, nontaxable veteran’s payments, Supplemental Security Income (SSI), or most workers’ compensation income.

If you are receiving alimony payments from a divorce, separation agreement, or court order that was finalized before January 1, 2019, enter the amount of those payments here. $

Net rental income: On average, how much net income (profits after rental expenses are paid) will you get from this rental each

Net farming or fishing income: On average, how much net income (profits after business expenses are paid) or loss will you

ONE-TIME ONLY INCOME

30.Have you or will you receive income during this calendar year as a one-time only payment?  Yes  No Examples might be a lump-sum pension payment or a one-time capital gain.

If Yes: Type ____________________ Amount $ _________ Month Received __________________ Year received _______

31.Will you receive income during the next calendar year as a one-time only payment?  Yes  No

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

STEP 2 | PERSON 1 (CONTINUED)

DEDUCTIONS

32. What deductions do you report on your income tax return?

If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower. Check all that apply. Your deductions should be what you report on your federal income tax return in the section “Adjusted Gross Income.” For each deduction you select, give the yearly amount. You can enter up to the maximum deduction amount allowed by the IRS.

Educator expense: Yearly amount $______

Certain business expenses of reservists, performing artists, or fee-based government officials: Yearly amount $______

Health Savings Account deduction: Yearly amount $______

Moving expenses for members of the Armed Forces: Yearly amount $______

Deductible part of self-employment tax: Yearly amount $______

Contribution to self-employed SEP, SIMPLE, and qualified plans: Yearly amount $______

Self-employed health insurance deduction: Yearly amount $______

Penalty on early withdrawal of savings: Yearly amount $______

Alimony paid for a divorce, separation agreement, or court order that was finalized before January 1, 2019: Yearly amount $______

Individual Retirement Account (IRA) deduction: Yearly amount $______

Student loan deduction (interest only, not total payment): Yearly amount $______

None

YEARLY INCOME

33.Did you receive any unemployment income in 2021?  Yes  No

34.What is your total expected income for the current calendar year?

35.What is your total expected income for next calendar year, if different?

THANKS! This is all we need to know about you. Go to Step 2 Person 2 to add another household member, if needed. Otherwise, go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).

STEP 2 Person 2

6.Does this person have a social security number (SSN)?  Yes  No (optional if not applying) We need a social security number (SSN) for every person applying for health coverage who has one.

For important SSN information and how to apply for SSN, please see instructions for Question 6 under Person 1.

Is the name on this application the same as the name on this person’s social security card?  Yes  No If No, what name is on this person's social security card?

First name, middle name, last name, and suffix

7.If this person gets an Advance Premium Tax Credit (APTC), does this person agree to file a federal tax return for the tax year that the credits are received?   Yes  No

See instructions for Question 7 under Person 1.

STEP 2 | PERSON 2 (CONTINUED)

If Yes, please answer questions a–d. If No, skip to question d.

b.Does this person plan to file a joint federal tax return with a spouse for the tax year for which this person is applying? Yes  No

c.Will this person claim any dependents on this person's federal income tax return for the year for which this person is applying?  Yes  No

This person will claim a personal exemption deduction on his or her federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments. List the name(s) and date(s) of birth of dependents.

d.Will this person be claimed as a dependent on someone else's federal income tax return for the year for which this person is applying?  Yes  No

If this person is claimed by someone else as a dependent on their federal income tax return, this may affect this person's ability to receive a premium tax credit. Do not answer Yes to this question if this person is a child under the age of 21 being claimed by a noncustodial parent. If Yes, please list the name of the tax filer.

Is the tax filer married, filing a joint return?  Yes  No

If Yes, list name of spouse and date of birth.

Who else does the tax filer claim as dependents?

e. Is this person filing taxes separately because they are a victim of domestic abuse or abandonment?  Yes  No

8.Is this person applying for health or dental coverage?  Yes  No

If Yes, answer all the questions below. If No, answer Questions 14 and 15, then go to Income Information on page 8.

9.Is this person a U.S. citizen or U.S. national?  Yes  No

If Yes, is this person a naturalized citizen (not born in the U.S.)?  Yes  No

10.If this person is a noncitizen, does he or she have an eligible immigration status?  Yes  No See instructions for Question 10 under Person 1.

a.If Yes, does this person have an immigration document?  Yes  No

b.Did this person use the same name on this application that he or she did to get this person's immigration status? Yes  No

If No, what name did this person use? First, middle, last, and suffix

c.Did this person arrive in the U.S. after August 22, 1996?  Yes  No

d.Is this person an honorably discharged veteran or active-duty member of the U.S. military, or the spouse or child of an honorably discharged veteran or an active-duty member of the U.S. military?  Yes  No

e.Optional Is this person a: victim of severe trafficking, a spouse, child, sibling, or parent of a trafficking victim

a battered spouse, a child or the parent of battered spouse?

11.Does this person live with at least one child younger than age 19, and is this person the main person taking care of this child(ren)?  Yes  No

Name(s) and date(s) of birth of child(ren)

STEP 2 | PERSON 2 (CONTINUED)

12.Is this person living in Massachusetts, and does this person either intend to reside here, even if he or she does not have a fixed address, or has this person entered Massachusetts with a job commitment or seeking employment?  Yes  No

If this person is visiting in Massachusetts for personal pleasure or for the purposes of receiving medical care in a setting other than a nursing facility, you must answer No to this question.

13.Does this person have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? If legally blind, answer Yes.  Yes  No

14.Does this person need reasonable accommodation because of a disability or an injury?  Yes  No If Yes, complete the rest of this application, including Supplement C: Accommodation.

16.Optional Does this person have breast or cervical cancer?  Yes  No (Special coverage rules may apply.)

17.Optional Is this person HIV positive?  Yes  No (MassHealth has special coverage rules for people with HIV.)

18.Was this person ever in foster care?  Yes  No

a.If Yes, in what state was this person in foster care?

b.Was this person getting health care through a state Medicaid program?  Yes  No

INCOME INFORMATION (You may send proof of all household income with this application.)

19.Does this person have any income?  Yes  No

If this person doesn’t have any income, skip to question 33.

EMPLOYMENT | If this person needs more space, attach another sheet of paper.

Yearly (Subtract any pre-tax deductions, such as nontaxable health insurance premiums.) b. Income effective date

22.Average number of hours worked each WEEK

23.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

26.Average number of hours worked each WEEK

27.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

28.SELF-EMPLOYMENT: Is this person self-employed?  Yes  No

a.If Yes, what type of work does this person do?

b.On average, how much net income (profits or losses after business expenses are paid) will this person get from this self- employment each month? $__________/month profit or $___________/month loss?

c.How many hours does this person work per week? _______

STEP 2 | PERSON 2 (CONTINUED)

OTHER INCOME

29.Check all that apply, and give the amount and how often this person gets it. NOTE: You do not need to tell us about child support, nontaxable veteran’s payments, Supplemental Security Income (SSI), or most workers’ compensation income.

If this person is receiving alimony payments from a divorce, separation agreement, or court order that was finalized before January 1, 2019, enter the amount of those payments here. $

Other taxable income $How often received?Type

Net rental income: On average, how much net income (profits after rental expenses are paid) will you get from this rental each

Net farming or fishing income: On average, how much net income (profits after business expenses are paid) or loss will this

ONE-TIME ONLY INCOME

30.Has or will this person receive income during this calendar year as a one-time only payment?  Yes  No Examples might be a lump-sum pension payment or a one-time capital gain.

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

31.Will this person receive income during the next calendar year as a one-time only payment?  Yes  No

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

DEDUCTIONS

32.What deductions does he or she report on their income tax return? See instructions for Question 33 under Person 1.

Educator expense: Yearly amount $______

Certain business expenses of reservists, performing artists, or fee-based government officials: Yearly amount $______

Health Savings Account deduction: Yearly amount $______

Moving expenses for members of the Armed Forces: Yearly amount $______

Deductible part of self-employment tax: Yearly amount $______

Contribution to self-employed SEP, SIMPLE, and qualified plans: Yearly amount $______

Self-employed health insurance deduction: Yearly amount $______

Penalty on early withdrawal of savings: Yearly amount $______

Alimony paid for a divorce, separation agreement, or court order that was finalized before January 1, 2019: Yearly amount $______

Individual Retirement Account (IRA) deduction: Yearly amount $______

Student loan deduction (interest only, not total payment): Yearly amount $______

None

STEP 2 | PERSON 2 (CONTINUED)

YEARLY INCOME

33.Did this person receive any unemployment income in 2021?  Yes  No

34.What is your total expected income for the current calendar year?

35.What is your total expected income for next calendar year, if different?

THANKS! This is all we need to know about this person. Go to Step 2 Person 3 to add another household member, if needed. Otherwise, go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).

STEP 2 Person 3

6.Does this person have a social security number (SSN)?  Yes  No (optional if not applying) We need a social security number (SSN) for every person applying for health coverage who has one.

For important SSN information and how to apply for SSN, please see instructions for Question 6 under Person 1.

Is the name on this application the same as the name on this person’s social security card?  Yes  No If No, what name is on this person's social security card?

First name, middle name, last name, and suffix

7.If this person gets an Advance Premium Tax Credit (APTC), does this person agree to file a federal tax return for the tax year that the credits are received?   Yes  No

See instructions for Question 7 under Person 1.

If Yes, please answer questions a–d. If No, skip to question d.

b.Does this person plan to file a joint federal tax return with a spouse for the tax year for which this person is applying? Yes  No

c.Will this person claim any dependents on this person's federal income tax return for the year for which this person is applying?  Yes  No

This person will claim a personal exemption deduction on his or her federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments. List the name(s) and date(s) of birth of dependents.

d.Will this person be claimed as a dependent on someone else's federal income tax return for the year for which this person is applying?  Yes  No

If this person is claimed by someone else as a dependent on their federal income tax return, this may affect this person's ability to receive a premium tax credit. Do not answer Yes to this question if this person is a child under the age of 21 being claimed by a noncustodial parent. If Yes, please list the name of the tax filer.

Is the tax filer married, filing a joint return?  Yes  No

If Yes, list name of spouse and date of birth.

Who else does the tax filer claim as dependents?

STEP 2 | PERSON 3 (CONTINUED)

e. Is this person filing taxes separately because they are a victim of domestic abuse or abandonment?  Yes  No

8.Is this person applying for health or dental coverage?  Yes  No

If Yes, answer all the questions below. If No, answer Questions 14 and 15, then go to Income Information on page 12.

9.Is this person a U.S. citizen or U.S. national?  Yes  No

If Yes, is this person a naturalized citizen (not born in the U.S.)?  Yes  No

10.If this person is a noncitizen, does he or she have an eligible immigration status?  Yes  No See instructions for Question 10 under Person 1.

a.If Yes, does this person have an immigration document?  Yes  No

b.Did this person use the same name on this application that he or she did to get this person's immigration status? Yes  No

If No, what name did this person use? First, middle, last, and suffix

c.Did this person arrive in the U.S. after August 22, 1996?  Yes  No

d.Is this person an honorably discharged veteran or active-duty member of the U.S. military, or the spouse or child of an honorably discharged veteran or an active-duty member of the U.S. military?  Yes  No

e.Optional Is this person a: victim of severe trafficking, a spouse, child, sibling, or parent of a trafficking victim

a battered spouse, a child or the parent of battered spouse?

11.Does this person live with at least one child younger than age 19, and is this person the main person taking care of this child(ren)?  Yes  No

Name(s) and date(s) of birth of child(ren)

12.Is this person living in Massachusetts, and does this person either intend to reside here, even if he or she does not have a fixed address, or has this person entered Massachusetts with a job commitment or seeking employment?  Yes  No

If this person is visiting in Massachusetts for personal pleasure or for the purposes of receiving medical care in a setting other than a nursing facility, you must answer No to this question.

13.Does this person have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? If legally blind, answer Yes.  Yes  No

14.Does this person need reasonable accommodation because of a disability or an injury?  Yes  No If Yes, complete the rest of this application, including Supplement C: Accommodation.

16.Optional Does this person have breast or cervical cancer?  Yes  No (Special coverage rules may apply.)

17.Optional Is this person HIV positive?  Yes  No (MassHealth has special coverage rules for people with HIV.)

18.Was this person ever in foster care?  Yes  No

a.If Yes, in what state was this person in foster care?

b.Was this person getting health care through a state Medicaid program?  Yes  No

STEP 2 | PERSON 3 (CONTINUED)

INCOME INFORMATION (You may send proof of all household income with this application.)

19.Does this person have any income?  Yes  No

If this person doesn’t have any income, skip to question 34.

EMPLOYMENT | If this person needs more space, attach another sheet of paper.

Yearly (Subtract any pre-tax deductions, such as nontaxable health insurance premiums.) b. Income effective date

22.Average number of hours worked each WEEK

23.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

26.Average number of hours worked each WEEK

27.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

28.SELF-EMPLOYMENT: Is this person self-employed?  Yes  No

a.If Yes, what type of work does this person do?

b.On average, how much net income (profits or losses after business expenses are paid) will this person get from this self- employment each month? $__________/month profit or $___________/month loss?

c.How many hours does this person work per week? _______

OTHER INCOME

29.Check all that apply, and give the amount and how often this person gets it. NOTE: You do not need to tell us about child support, nontaxable veteran’s payments, Supplemental Security Income (SSI), or most workers’ compensation income.

If this person is receiving alimony payments from a divorce, separation agreement, or court order that was finalized before January 1, 2019, enter the amount of those payments here. $

Other taxable income $How often received?Type

Net rental income: On average, how much net income (profits after rental expenses are paid) will you get from this rental each

STEP 2 | PERSON 3 (CONTINUED)

ONE-TIME ONLY INCOME

30.Has or will this person receive income during this calendar year as a one-time only payment?  Yes  No Examples might be a lump-sum pension payment or a one-time capital gain.

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

31.Will this person receive income during the next calendar year as a one-time only payment?  Yes  No

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

DEDUCTIONS

32.What deductions does he or she report on their income tax return? See instructions for Question 33 under Person 1.

Educator expense: Yearly amount $______

Certain business expenses of reservists, performing artists, or fee-based government officials: Yearly amount $______

Health Savings Account deduction: Yearly amount $______

Moving expenses for members of the Armed Forces: Yearly amount $______

Deductible part of self-employment tax: Yearly amount $______

Contribution to self-employed SEP, SIMPLE, and qualified plans: Yearly amount $______

Self-employed health insurance deduction: Yearly amount $______

Penalty on early withdrawal of savings: Yearly amount $______

Alimony paid for a divorce, separation agreement, or court order that was finalized before January 1, 2019: Yearly amount $______

Individual Retirement Account (IRA) deduction: Yearly amount $______

Student loan deduction (interest only, not total payment): Yearly amount $______

None

YEARLY INCOME

33.Did this person receive any unemployment income in 2021?  Yes  No

34.What is your total expected income for the current calendar year?

35.What is your total expected income for next calendar year, if different?

THANKS! This is all we need to know about this person. Go to Step 2 Person 4 to add another household member, if needed. Otherwise, go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).

STEP 2 | PERSON 4

If you have to include more than four people on this application, make a copy of blank information pages for Step 2 Person 4 BEFORE you fill them out. When filling out the additional pages please be sure to tell us how each person is related to each other person on the application.

6.Does this person have a social security number (SSN)?  Yes  No (optional if not applying) We need a social security number (SSN) for every person applying for health coverage who has one.

For important SSN information and how to apply for SSN, please see instructions for Question 6 under Person 1.

Is the name on this application the same as the name on this person’s social security card?  Yes  No If No, what name is on this person's social security card?

First name, middle name, last name, and suffix

7.If this person gets an Advance Premium Tax Credit (APTC), does this person agree to file a federal tax return for the tax year that the credits are received?   Yes  No

See instructions for Question 7 under Person 1.

If Yes, please answer questions a–d. If No, skip to question d.

b.Does this person plan to file a joint federal tax return with a spouse for the tax year for which this person is applying? Yes  No

c.Will this person claim any dependents on this person's federal income tax return for the year for which this person is applying?  Yes  No

This person will claim a personal exemption deduction on his or her federal income tax return for any individual listed on this application as a dependent who is enrolled in coverage through the Massachusetts Health Connector and whose premium for coverage is paid in whole or in part by advance payments. List the name(s) and date(s) of birth of dependents.

d.Will this person be claimed as a dependent on someone else's federal income tax return for the year for which this person is applying?  Yes  No

If this person is claimed by someone else as a dependent on their federal income tax return, this may affect this person's ability to receive a premium tax credit. Do not answer Yes to this question if this person is a child under the age of 21 being claimed by a noncustodial parent. If Yes, please list the name of the tax filer.

Is the tax filer married, filing a joint return?  Yes  No

If Yes, list name of spouse and date of birth.

Who else does the tax filer claim as dependents?

e. Is this person filing taxes separately because they are a victim of domestic abuse or abandonment?  Yes  No

STEP 2 | PERSON 4 (CONTINUED)

8.Is this person applying for health or dental coverage?  Yes  No

If Yes, answer all the questions below. If No, answer Questions 14 and 15, then go to Income Information on page 15.

9.Is this person a U.S. citizen or U.S. national?  Yes  No

If Yes, is this person a naturalized citizen (not born in the U.S.)?  Yes  No

10.If this person is a noncitizen, does he or she have an eligible immigration status?  Yes  No See instructions for Question 10 under Person 1.

a.If Yes, does this person have an immigration document?  Yes  No

b.Did this person use the same name on this application that he or she did to get this person's immigration status? Yes  No

If No, what name did this person use? First, middle, last, and suffix

c.Did this person arrive in the U.S. after August 22, 1996?  Yes  No

d.Is this person an honorably discharged veteran or active-duty member of the U.S. military, or the spouse or child of an honorably discharged veteran or an active-duty member of the U.S. military?  Yes  No

e.Optional Is this person a: victim of severe trafficking, a spouse, child, sibling, or parent of a trafficking victim

a battered spouse, a child or the parent of battered spouse?

11.Does this person live with at least one child younger than age 19, and is this person the main person taking care of this child(ren)?  Yes  No

Name(s) and date(s) of birth of child(ren)

12.Is this person living in Massachusetts, and does this person either intend to reside here, even if he or she does not have a fixed address, or has this person entered Massachusetts with a job commitment or seeking employment?  Yes  No

If this person is visiting in Massachusetts for personal pleasure or for the purposes of receiving medical care in a setting other than a nursing facility, you must answer No to this question.

13.Does this person have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months? If legally blind, answer Yes.  Yes  No

14.Does this person need reasonable accommodation because of a disability or an injury?  Yes  No If Yes, complete the rest of this application, including Supplement C: Accommodation.

16.Optional Does this person have breast or cervical cancer?  Yes  No (Special coverage rules may apply.)

17.Optional Is this person HIV positive?  Yes  No (MassHealth has special coverage rules for people with HIV.)

18.Was this person ever in foster care?  Yes  No

a.If Yes, in what state was this person in foster care?

b.Was this person getting health care through a state Medicaid program?  Yes  No

STEP 2 | PERSON 4 (CONTINUED)

INCOME INFORMATION (You may send proof of all household income with this application.)

19.Does this person have any income?  Yes  No

If this person doesn’t have any income, skip to question 34.

EMPLOYMENT | If this person needs more space, attach another sheet of paper.

Yearly (Subtract any pre-tax deductions, such as nontaxable health insurance premiums.) b. Income effective date

22.Average number of hours worked each WEEK

23.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

26.Average number of hours worked each WEEK

27.Is this person seasonally employed?  Yes  No. If Yes, which months does this person work in a calendar year?

28.SELF-EMPLOYMENT: Is this person self-employed?  Yes  No a. If Yes, what type of work does this person do?

b. On average, how much net income (profits or losses after business expenses are paid) will this person get from this self- employment each month? $__________/month profit or $___________/month loss?

c. How many hours does this person work per week? _______

OTHER INCOME

29.Check all that apply, and give the amount and how often this person gets it. NOTE: You do not need to tell us about child support, nontaxable veteran’s payments, Supplemental Security Income (SSI), or most workers’ compensation income.

If this person is receiving alimony payments from a divorce, separation agreement, or court order that was finalized before January 1, 2019, enter the amount of those payments here. $

Other taxable income $How often received?Type

Net rental income: On average, how much net income (profits after rental expenses are paid) will you get from this rental each

STEP 2 | PERSON 4 (CONTINUED)

ONE-TIME ONLY INCOME

30.Has or will this person receive income during this calendar year as a one-time only payment?  Yes  No Examples might be a lump-sum pension payment or a one-time capital gain.

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

31.Will this person receive income during the next calendar year as a one-time only payment?  Yes  No

If Yes: Type: ____________ Amount $ _________ Month Received __________________ Year received _______

DEDUCTIONS

32.What deductions does he or she report on their income tax return? See instructions for Question 33 under Person 1.

Educator expense: Yearly amount $______

Certain business expenses of reservists, performing artists, or fee-based government officials: Yearly amount $______

Health Savings Account deduction: Yearly amount $______

Moving expenses for members of the Armed Forces: Yearly amount $______

Deductible part of self-employment tax: Yearly amount $______

Contribution to self-employed SEP, SIMPLE, and qualified plans: Yearly amount $______

Self-employed health insurance deduction: Yearly amount $______

Penalty on early withdrawal of savings: Yearly amount $______

Alimony paid for a divorce, separation agreement, or court order that was finalized before January 1, 2019: Yearly amount $______

Individual Retirement Account (IRA) deduction: Yearly amount $______

Student loan deduction (interest only, not total payment): Yearly amount $______

None

YEARLY INCOME

33.Did this person receive any unemployment income in 2021?  Yes  No

34.What is your total expected income for the current calendar year?

35.What is your total expected income for next calendar year, if different?

THANKS! This is all we need to know about this person. Please go to Step 3 American Indian or Alaska Native (AI/AN) Household Member(s).

STEP 3 American Indian or Alaska Native (AI/AN) Household Member(s)

1.Are you or is anyone in your household an American Indian or Alaska Native?  Yes  No

If No, skip to Step 4.

If Yes, complete the rest of this application, including Supplement B: American Indian or Alaska Native Household Member.

Names(s) of person(s)

American Indians and Alaska Natives who enroll in health coverage can also get services from the Indian Health Service, tribal health programs, or Urban Indian Health Programs. If you or any household members are American Indians or Alaska Natives, you may not have to pay premiums or copayments, and may get special monthly enrollment periods.

STEP 4 Your Household's Health Coverage

MassHealth regulations require members to obtain and maintain available health insurance, including health insurance available through an employer. In order to determine continued MassHealth eligibility for you and members of your household, we may request additional information from you and your employer about your access to employer-sponsored health insurance coverage. You must cooperate in providing information necessary to maintain eligibility, including evidence of obtaining or maintaining available health insurance, or your MassHealth benefits may be terminated. See the Member Booklet for more information.

1.Is anyone listed on this application offered health coverage from a job but NOT ENROLLED in it?  Yes  No

Answer Yes, even if this insurance is from another person’s job, like a spouse, even if the person does not live in the household. If Yes, you will need to complete and include Supplement A: Health Coverage from Jobs, and the rest of this application.

Name(s) of person(s) covered

Is this a state employee benefit plan?  Yes  No

2.Does anyone qualify for or is anyone enrolled in any of the following types of health coverage?  Yes  No If Yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

Answer Yes, even if this insurance is from another person, like a spouse, even if the person does not live in the household.

Enrolled in Medicare or qualifies for a Medicare Part A plan with no premium.

Name(s) of person(s) covered

Enrolled in employer coverage. If anyone on this application is enrolled in employer coverage, you must complete and include Supplement A: Health Coverage from Jobs.

STEP 5 Health Reimbursement Arrangements

Is anyone in the household offered Health Reimbursement Arrangements (HRAs) from their employer?  Yes  No

If you have a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) do you intend to use QSEHRA family coverage benefits from your employer?  Yes  No

If you have QSEHRA, enter the maximum yearly family coverage benefit amount through the QSEHRA:

Does anyone in the household intend to accept an Individual Coverage Health Reimbursement Arrangement (ICHRA) benefit from their employer?  Yes  No

If you have a Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) do you intend to use QSEHRA family coverage benefits from your employer?  Yes  No

If you have QSEHRA, enter the maximum yearly family coverage benefit amount through the QSEHRA:

Does anyone in the household intend to accept an Individual Coverage Health Reimbursement Arrangement (ICHRA) benefit from their employer?  Yes  No

STEP 6 Parental Information

Please answer these questions for any child younger than the age of 18, who is listed on this application but who does not have two custodial parents also listed on this application.

1.Was any child adopted by a single parent? Yes No If Yes, name(s) of child(ren)

2.Does any child have a parent who has died? Yes No If Yes, name(s) of child(ren)

3.Does any child have a parent whose identity is unknown? Yes No If Yes, name(s) of child(ren)

4.Does any child have a parent who does not live with the child and who is not included in the previous questions? Yes No If Yes, name(s) of child(ren)

STEP 7 Read and sign this application.

FOR MASSHEALTH AND HEALTH CONNECTOR APPLICANTS

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

I AGREE TO THE FOLLOWING STATEMENTS. FOR MASSHEALTH AND HEALTH CONNECTOR APPLICANTS.

FOR SUPPLEMENTAL NUTRITIONAL ASSISTANCE PROGRAM (SNAP) APPLICANTS

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP) BENEFITS

If you checked the box on page 1, MassHealth will send this application to the Department of Transitional Assistance (DTA). This will serve as your application for SNAP! If you are eligible, your SNAP will start from the date DTA receives this MassHealth application. By signing below, you agree that you have read and agree to your SNAP Rights, Responsibilities, and Penalties under the program.

SIGN THIS APPLICATION — REQUIRED.

By signing this application below, I hereby certify under the pains and penalties of perjury that the submissions and statements I have made in this application are true and complete to the best of my knowledge, and I agree to accept and comply with the above rights and responsibilities of the MassHealth and Health Connector programs.

If I have indicated that I am applying for the Supplemental Nutritional Assistance Program (SNAP) on page 1 of this application, I certify that I understand and agree to the rights, rules, and penalties of the SNAP program, as outlined above. I ask that MassHealth send my information, including Protected Health Information subject to the Health Insurance Portability and Accountability Act (HIPAA), to the Department of Transitional Assistance (DTA) for the purpose of applying for SNAP benefits.

Important: For MassHealth and Health Connector applications only. If you are submitting this application as an authorized representative, you must submit an Authorized Representative Designation Form (ARD) to us or have a form on record for us to process this application. The ARD is at the end of this application.

Date

If you are under 18 years of age, are you an emancipated minor?  Yes  No

If No, we need a responsible party who is at least 18 years old to sign this application on your behalf. Please provide that person’s information below.

STEP 8 Send us your completed application.

Mail your signed application to: Health Insurance Processing Center; or Fax to: (857) 323-8300

PO Box 4405

Taunton, MA 02780

VOTER REGISTRATION INFORMATION

The form to register to vote is included with this application or can be found at www.sec.state.ma.us. More information on how to register to vote can also be found at www.sec.state.ma.us. If you have any questions about the voter registration process, or if you need help filling out the form, please visit a local MassHealth Enrollment Center or call the MassHealth Customer Service Center at (800) 841-2900, TTY: (800) 497-4648.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration application form, we will help you. The decision to seek or accept help is yours. You may fill out the application form in private.

If you believe that someone has interfered with your right to register or to decline to register to vote, with your right to privacy in deciding to register or in applying to register to vote, or with your right to choose your own political party or other political preference, you may file a complaint with:

If you or anyone else in your application are not registered to vote where you live now, would you like to apply to register to vote today?  Yes  No

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

IMMIGRATION STATUSES AND DOCUMENT TYPES

Question 10a on the application asks noncitizens about their immigration status and about the type or types of immigration documents they have to support their immigration status. Please refer to the following lists to fill out Question 10a.

If you need further help, details can be found online at www.mahealthconnector.org/immigration-document-types.

RACE OR ETHNICITY (OPTIONAL) Choose the options that best describe you. Write in all that apply. Please specify in Question 11 on pages 4, 8, 12, and 16.

For any race or ethnicity not listed here, please specify in Question 11.

SUPPLEMENT A Health Coverage from Jobs

Answer these questions if someone in the household is eligible for health coverage from a job whether or not they are enrolled in the coverage. Attach a copy of this page for each job that offers coverage.

EMPLOYEE INFORMATION

3.a. Is at least one person on this application currently eligible for or enrolled in coverage offered by this employer, or will at least one person on this application become eligible within the next 3 months?  Yes  No

If the answer to 3a is Yes, continue. If the answer to 3a is No, stop here and skip the rest of Supplement A. b. If any person is in a waiting or probationary period, when can this person enroll in coverage? (mm/dd/yyyy)

EMPLOYER INFORMATION

11. Who can we contact about employee health coverage at this job?

TELL US ABOUT THE HEALTH PLAN OFFERED BY THIS EMPLOYER.

14.Does the employer offer a health plan that meets the minimum value standard*?  Yes  No

15.a. What is the name of the lowest cost self-only health plan offered to the employee?*

b.Does the health plan offered by the employer meet the minimum value standard for coverage?  Yes  No

c.How much did this employee pay in premiums to enroll in this plan, or how much does this employee pay for this plan?

$

d.How often would or does this employee pay this amount?

16.What change will the employer make for the new plan year (if known)?

a.Employer will not offer health coverage Coverage end date (mm/dd/yyyy):

b.The person plans to drop the employer’s health coverage Coverage end date (mm/dd/yyyy):

c.Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs.)

How much does the employee have to pay in premiums for the lowest cost-plan that meets the minimum value standard? Only tell us about the cost of the individual (self only) health plans, not the cost of a family health plan. $

How often? Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy)

*An employer-sponsored health plan meets the "minimum value standard" if the plan's share of the total allowed benefit costs covered by the plan is at least 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986.

Complete this supplement if you or a household member are an American Indian or Alaska Native.

TELL US ABOUT YOUR AMERICAN INDIAN OR ALASKA NATIVE HOUSEHOLD MEMBER(S).

American Indians and Alaska Natives can get services from the Indian Health Service, tribal health programs, or urban Indian health programs. They also may not have to pay premiums or copayments and may get special monthly enrollment periods. Answer the following questions to make sure your household gets the most help possible.

NOTE: If you have more people to include, make a copy of this page and attach it.

SUPPLEMENT C

If you answered Yes to Question 14 in Step 2 about yourself or any household member needing reasonable accommodation because of a disability or injury, check all that apply below, and list name(s).

1.Condition

Blind—Name(s):

Deaf—Name(s):

Developmentally disabled—Name(s):

Hard of hearing—Name(s):

Intellectually disabled—Name(s):

Low vision—Name(s):

Physically disabled—Name(s):

Other (Please explain.)—Name(s):

2.Accommodation

American Sign Language (ASL) interpreter—Name(s):

Assistive listening device—Name(s):

Communication Access Real-time Translations (CART)—Name(s):

Large print publications—Name(s):

Publications in braille—Name(s):

Publications in electronic format—Name(s):

Text telephone (TTY)—Name(s):

Video Relay Service (VRS)—Name(s):

Other (Please explain.)—Name(s):

Authorized Representative

Designation Form

You can submit this form if you would like to designate an authorized representative to act on your behalf. If an authorized representative signed your application for you, or if you are an authorized representative applying on behalf of someone else, you MUST submit this form for the application to be processed.

You do not need to fill out this form if you live in an institution and want copies of eligibility notices sent to you and to your spouse who still lives at home. We will do that automatically.

Note: An authorized representative has the authority to act on an applicant's or member's behalf in all matters with MassHealth and the Health Connector, and will receive personal information about the applicant or member until we receive a cancellation notice terminating their authority, or upon the death of the applicant or member. Their authority will not automatically terminate once we process your application.

You can choose someone to help you.

You may choose an authorized representative to help you get health care coverage through programs offered by MassHealth and the Health Connector. You can do this by filling out this form (the Authorized Representative Designation Form). You or a representative can sign for yourself and for any of your dependent children under the age of 18 for whom you are the custodial parent. You are not required to have a representative in order to apply for or receive benefits.

Who can help me?

1.An authorized representative can be a friend, family member, relative, or other person or organization of your choosing who agrees to help you. It is up to you to choose an authorized representative if you want one. Neither MassHealth nor the Health Connector will choose an authorized representative for you. You must designate in writing (fill out Section I, Part A) the person or organization who you want to be your authorized representative. Your authorized representative must also fill out Section I, Part B. We sometimes refer to this person or organization as a “Section I authorized representative.”

2.If you cannot designate an authorized representative in writing and you do not have an existing authorized representative or other person who is authorized by law to act on your behalf, a person (not an organization) who certifies that he or she will act responsibly on your behalf can be your authorized representative if that person fills out Section II of this form. We sometimes refer to this person as a “Section II authorized representative.”

3.An authorized representative can also be someone who has been appointed by law to act on your behalf, or on behalf of the estate of an applicant or member who has died. This person must fill out Section III and either you or this person must submit to us, together with this form, a copy of the applicable legal document stating that this person has authority to represent you, or the estate of a deceased applicant or member. We sometimes refer to this person as a “Section III authorized representative.”

4.A Section III authorized representative may be a legal guardian, conservator, holder of power of attorney, or health care proxy, or, if the applicant or member has died, the personal representative of the estate.

What can an authorized representative do?

ASection I or II authorized representative may

•fill out your application or renewal forms;

•fill out other MassHealth or Health Connector eligibility or enrollment forms;

•give proof of information reported on these forms;

•report changes in income, address, or other circumstances;

•get copies of all of your MassHealth and Health Connector eligibility and enrollment notices; and

•act on your behalf in all other matters with MassHealth and the Health Connector.

What a Section III authorized representative is authorized to do for you (or for the estate of a deceased applicant or member) will

depend on the wording of the legal appointment.

Please note: Eligibility notices may include information about other members of an applicant’s or member’s household. If there are multiple people in your household we may not be able to send copies of some of your notices to your authorized representative unless each household member has also designated the same authorized representative by completing a separate Authorized Representative Designation Form.

SECTION 1 Authorized Representative Designation (if applicant or member is able to sign)

Part A—to be filled out by applicant or member. Please print, except for signature.

Please note: Your social security number (SSN) is required if one has been issued.

I certify that I have chosen the following person or organization to be the authorized representative for myself and any dependent children under the age of 18 for whom I am the custodial parent and that I understand the duties and responsibilities this person or organization will have (as explained earlier in this form).

Authorized representative’s address (mailing address, city, state, zip)

Part B—to be filled out by authorized representative. Please print, except for signature.

B1. COMPLETE IF AUTHORIZED REPRESENTATIVE IS A PERSON.

I certify that I will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to me by MassHealth or the Health Connector.

If I am also a provider, staff member, or volunteer affiliated with an organization, and am acting in my capacity as a provider, staff member, or volunteer in connection with my designation as an authorized representative, I certify that I will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information and conflicts of interest including those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10, and 45 C.F.R. § 155.260(f).

B2. COMPLETE IF AUTHORIZED REPRESENTATIVE IS AN ORGANIZATION.

I certify, on behalf of the organization set forth below, that such organization will at all times maintain the confidentiality of any information regarding the applicant or member set forth above and, if applicable, the dependent children of such applicant or member, that is provided to the organization by MassHealth or the Health Connector.

I, the provider, staff member, or volunteer of the organization set forth below, completing this form, certify on behalf of myself and on behalf of the organization I represent, that any providers, staff members, or volunteers acting on behalf of the organization in connection with this authorized representative designation will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information, and conflicts of interest, including those set forth at 42 C.F.R. part 431, subpart F, 42 C.F.R. § 447.10, and 45 C.F.R. § 155.260(f).

Printed name of provider, staff member, or volunteer completing form

To be filled out by authorized representative. Please print, except for signature. Please provide a separate form for each applicant

or member.

AN ORGANIZATION IS NOT ELIGIBLE TO BE AN AUTHORIZED REPRESENTATIVE UNDER THIS SECTION.

I certify that the applicant or member set forth below cannot provide written designation and to the best of my knowledge does not otherwise have an individual who can act on his or her behalf such as an existing authorized representative, guardian, conservator, personal representative of the estate, holder of power of attorney, or an invoked health-care proxy. In addition, I certify that I am sufficiently aware of this applicant’s or member’s circumstances to assume responsibility for the accuracy of the statements made on his or her behalf during the eligibility process and in other communications with MassHealth or the Health Connector, that I understand my rights and responsibilities as this person’s authorized representative (as explained earlier in this form). If this person can understand, I have told the person that MassHealth and the Health Connector will send me a copy of all MassHealth and Health Connector eligibility and enrollment notices and this person agrees to this, and I have told this person that he or she may remove or replace me as his or her authorized representative at any time by the methods described earlier in this

form.

I further certify that I will at all times maintain the confidentiality of any information regarding the applicant or member set forth below that is provided to me by MassHealth or the Health Connector.

If I am also a provider, staff member, or volunteer affiliated with an organization, and I am acting in my capacity as a provider, staff member, or volunteer in connection with my designation as an authorized representative, I further certify that I will at all times adhere to all applicable state and federal laws and regulations regarding confidentiality of information and conflicts of interest including those set forth at 42 CFR part 431 subpart F., 42 CFR §477.10, and 45 CFR §155.260(f).

Please note that the applicant’s or member’s social security number (SSN) is required if one has been issued.

Applicant’s/Member’s name

If the Section II authorized representative is affiliated with an organization, and is acting in such capacity, an individual authorized to act on behalf of the organization, such as an officer, must sign below to indicate the organization’s acknowledgment of and agreement with the representations and warranties made above.

SECTION 3 Authorized Representative Designation (if appointed by law)

To be filled out by an authorized representative appointed by law (with authority to act on behalf of the applicant or member in making decisions related to health care including, but not limited to, a guardian, conservator, personal representative of the estate of an applicant or member, holder of power of attorney, or an invoked health care proxy.) Please print, except for signature. Please submit a copy of the applicable legal document with this form.

I certify that I will at all times maintain the confidentiality of any information regarding the applicant or member as set forth below, that is provided to me by MassHealth or the Health Connector.

Please note that the applicant’s or member’s social security number (SSN) is required if one has been issued.

Applicant’s/Member’s name

How does an authorized representative designation end?

If you decide that you no longer want a Section I or Section II authorized representative, you must notify us at the time you want the designation to end by mail, fax, or phone. See our contact information below. If you mail or fax this notice to us, the notice must include your name, address, and date of birth, the name of your authorized representative, a statement that the designation has ended and your signature or, if you cannot provide written notice, the signature of someone acting on your behalf (in the case of a Section II authorized representative only).

In addition, if your authorized representative notifies us that such person or organization is no longer acting on your behalf, we will no longer recognize the person or organization as your authorized representative.

The authority of a Section I or Section II authorized representative will end upon the death of the applicant or member.

ASection III authorized representative’s designation ends when his or her legal appointment ends. The authorized representative must notify us as instructed above.

In addition, an authorized representative’s designation for a minor child ends on the child’s 18th birthday.

How do I submit this form?

If you are applying for health benefits, send your filled-out Authorized Representative Designation Form to us with your application.

If you are already getting benefits, you must submit the form to us at the time you want to designate an authorized representative, or you want the declared designation to end, by

• Mailing your form to

Health Insurance Processing Center

P. O. Box 4405

Taunton, MA 02780;

•Faxing your form to (857) 323-8300; or

•Calling us at (800) 841-2900, TTY: (800) 497-4648 for people who are deaf, hard of hearing, or speech disabled.