Masshealth Eligibility Review Form – Fill Out and Use This PDF

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Renewal Application for Health Coverage for Seniors and People Needing Long-Term-Care Services

HOW TO APPLY

Please identify which program each household member is applying for on page 1 of the application.

In order to get any benefits you are entitled to as quickly as possible, you may send us any documentation you have that verifies all household income and assets.

You can use this application to apply for the Supplemental Nutrition Assistance Program (SNAP). SNAP is a federal program that helps you buy food each month. If you are interested, check the box on page 1 then read and sign the SNAP rights and responsibilities on pages 17-23. Your application will then be sent automatically to the Department of Transitional Assistance. You do not have to apply for the SNAP Program to be considered for MassHealth.

MASSHEALTH and the HEALTH SAFETY NET | Who Can Use This Application

MASSACHUSETTS HEALTH CONNECTOR | Who Can Use This Application

SACA-2-ERV-0721

WHAT YOU NEED WHEN YOU APPLY

The following MUST be sent with the application when applying for MassHealth,

the Health Safety Net, and the Massachusetts Health Connector

WHAT HAPPENS NEXT and WHERE TO GET HELP

SACA-2-ERV-0721

Renewal Application for Health Coverage for Seniors and People Needing Long-Term-Care Services

Please Print Clearly. Be sure to answer all questions. Fill out all parts of the application, along with all supplements that apply. If you need more space, attach a separate piece of paper to the application. Put Person 1’s name and social security number at the top of any attached paper. For each member in your household, please put the name(s) of the individual(s) under the program or programs he or she wants to apply for. Please see the Senior Guide to learn more about coverage under these programs.

Please list the names of everyone who is applying for health coverage on this application.

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 17-23 and sign on page 23 to proceed with the application.

STEP 1 Person 1 (YOU)—Tell us about YOURSELF.

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) at the end of this application, to establish a third-party contact.

9.Is this a hospital, nursing facility, or other institution?  Yes  No If Yes, facility name

21.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 Person 1

4.Are you applying for health or dental coverage for YOURSELF?  Yes  No If Yes, answer all the questions below in Step 2 for Person 1 (yourself).

If No, answer Question 16 (accommodations), then go to the Income Information section on page 4.

5.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. 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

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

You may not have needed or chosen to file a tax return in the past, but you will have to file a federal income tax return for any year that you get an APTC. You 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 or HSN, if you qualify.

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

You must file a joint federal tax return with your spouse for the year for which you are applying to get certain programs (ConnectorCare or APTCs) unless you are a victim of domestic abuse or abandonment or you will file taxes as Head of Household. If you will file taxes as Head of Household, you should answer No to question 7a (“Are you legally married?”). One way you may qualify as Head of Household is to live apart from your spouse and claim another person as a dependent. See IRS Publication 501 or consult a tax professional for tax filing information. You will only need to include yourself 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 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 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 a U.S. citizen or U.S. national?  Yes  No

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

9.If you are a noncitizen, do you have an eligible immigration status?  Yes  No

See page 28, “Immigration Statuses and Document Types” for help. If No or no response, you 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). Go to Question 10.

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 your immigration document with the application. We will try to verify your immigration status through an electronic data match. Please list all the immigrations statuses and/or conditions that have applied to you since you 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

e.Optional Are you 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?

10.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.

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

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

12.Are you pregnant?  Yes  No

If Yes, how many babies are you expecting? _____ What is the expected due date?

13.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

14.Do you rent or own your property?  Rent  Own

15.DISABILITY Answer this question if you are under age 65 or age 65 or older and working.

Do you have a 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 Name:

16.Do you need reasonable accommodation(s) because of a disability or injury?  Yes  No If No, go to the next question. If Yes, answer questions a and b.

a.Condition

17.Are you applying because of an accident or injury that someone else might be responsible for?  Yes  No

a.Did someone else cause your injury, illness, or disability, or could someone else's insurance or your own insurance, other than health insurance (like homeowner's or auto insurance) cover it?  Yes  No

b.Have you filed a lawsuit, a workers' compensation claim, or an insurance claim for this accident or injury?  Yes  No

18.Did you ever get Supplemental Security Income (SSI)?  Yes  No If No, go to Income Information. If Yes, answer questions a and b.

a.When did you last get SSI? (mm/yyyy)

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 income, skip to question 30.

CURRENT JOB | If you have more jobs and need more space, attach another sheet of paper.

b. Income effective date

22.Average number of hours worked each WEEK

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

Jan. Feb. March April May June July August Sept. Oct. Nov. Dec.

SELF-EMPLOYMENT | If self-employed, answer the following questions. If you need more space, attach another sheet of paper.

24.Are you self-employed?  Yes  No

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

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

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

OTHER INCOME

25.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 or Supplemental Security Income (SSI).

Trusts $ How often received?

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. $

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

RENTAL INCOME

26.Do you get rental income? (You must answer this question.)  Yes  No

If Yes, send proof of current rental income, such as a written statement from each tenant, a copy of the lease, or a current federal tax return. Also send proof of all of the following expenses, if applicable, for the last 12 months: mortgage, taxes, utilities (gas/ electric), heat, water/sewer, insurance, condo or co-op fee, repairs and maintenance.

a.What type of real estate do you own? one-family two-family three-family other (describe):

b.How much monthly rental income or loss do you get from each rental unit from the real estate indicated above? (List each rental unit and address separately.)

ONE-TIME-ONLY INCOME

27.Have you or will you receive income during this calendar year as a one-time only payment?  Yes  No Examples of one-time only income include a lump pension payment or a one-time capital gain.

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

28.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 _______

DEDUCTIONS

29.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: alimony payments for a divorce, separation agreement, or court order that was finalized before January 1, 2019, enter the amount of those payments here. Yearly amount $______

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

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

None

YEARLY INCOME

30.Did you receive unemployment income in 2021?  Yes  No

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

32.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—Spouse or other people in this household

Fill out this part for your spouse who lives with you or anyone included on your federal income tax return, if you file one.

If you have to include more than two people on this application, make a copy of blank information pages for Step 2 Person 2 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. We need this information to determine eligibility. You can also download pages for additional persons at mass.gov/masshealth. Under MassHealth Publications, click on MassHealth Member Library. Click on MassHealth Member Applications, then Massachusetts Application for Health and Dental Coverage and Help Paying Costs – Additional Persons.

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

6.Is this a hospital, nursing facility, or other institution?  Yes  No If Yes, facility name

14.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.

15.Is this person applying for health or dental coverage?  Yes  No If Yes, answer all the questions below in Step 2 for Person 2

If No, answer Question 26 (accommodations), then go to the Income Information section on page 9.

16.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. 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 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

17.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

He or she may not have needed or chosen to file a tax return in the past, but this person will have to file a federal income tax return for any year that he or she gets an APTC. You must check "Yes" to question 17 to be eligible for ConnectorCare or APTCs to help pay for this person’s health insurance. This person does NOT need to file a tax return to apply for or to get MassHealth or

HSN, if he or she qualifies.

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

This person must file a joint federal tax return with a spouse for the year for which this person is applying to get certain programs (ConnectorCare or APTCs) unless this person is a victim of domestic abuse or abandonment or they will file taxes as Head of Household. If this person will file taxes as Head of Household, he or she should answer No to question 17a (“Are you legally married?”). One way this person may qualify as Head of Household is to live apart from his or her spouse and claim another person as a dependent. See IRS Publication 501 or consult a tax professional for tax filing information. This person will only need to include him- or herself and any dependents on this application.

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 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

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

If Yes, is he or she a naturalized citizen (not born in the U.S.)?  Yes  No

19.If this person is a noncitizen, does he or she have an eligible immigration status?   Yes  No

See page 28, “Immigration Statuses and Document Types” for help. If No or no response, you 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). Go to Question 20.

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

It may help us to process this application faster if you include a copy of his or her immigration document with the application. We will try to verify this person’s immigration status through an electronic data match. Please list all the immigrations statuses and/or conditions that have applied to this person since he or she entered the U.S. If you need more space, attach another sheet of paper.

b.Did this person use the same name on this application to get his or her 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?

20.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.

21.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

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

22.Is this person pregnant?  Yes  No

If Yes, how many babies is she expecting? _____ What is the expected due date?

23.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