Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 28
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34Special Enrollment
SUPPlEMENt
D
Period form
You must complete and submit an application for health insurance along with this form. Do not submit this form by itself.
•
Complete this form if anyone on this application needs to get health insurance after the open enrollment period has ended.
•
Certain life events allow you to get coverage during a special enrollment period with the Health Connector, even though the
open enrollment has ended.
•
You can enroll any time of year without one of the life events below if
-
you qualify for MassHealth;
-
you now qualify for a ConnectorCare plan through the Health Connector after not qualifying in the past,
or after applying for the first time; or
-
you are a member of a federally recognized tribe or you are an Alaska Native shareholder.
•
If you have not had any of the life events below, you do not have to fill out this form.
lifE EVENtS: tEll US ABoUt ANy of tHE followiNg CHANgES iN yoUR HoUSEHolD.
1. Someone lost health coverage within the last 60 days, or expects to lose it within the next 60 days
Name(s)
Date coverage ended or will end (mm/dd/yyyy): _____ / _____ / _________
Did coverage end because of not paying premiums?
Yes
No
Did coverage end because you chose to cancel coverage?
Yes
No
2. Someone added a household member because of a marriage within the last 60 days.
Name(s)
Date of marriage (mm/dd/yyyy): _____ / _____ / _________
3. Someone was born, adopted, or placed in foster or court order care within the last 60 days.
Name(s)
Date of birth, adoption, foster care, or court order care (mm/dd/yyyy): _____ / _____ / _________
4. Someone gained an eligible immigration status within the last 60 days.
Name(s)
Date that status was awarded (mm/dd/yyyy): _____ / _____ / _________
5. Someone in the household had a divorce, annulment, or legal separation within the last 60 days.
Name(s)
Date of divorce, annulment, separation (mm/dd/yyyy): _____ / _____ / _________
6. There was a death in the household within the last 60 days
Name(s)
Date of death (mm/dd/yyyy): _____ / _____ / _________
7. Someone moved to Massachusetts within the last 60 days, or expects to move to Massachusetts within the next 60 days.
Name(s)
Date of move (mm/dd/yyyy): _____ / _____ / _________
ViSit oR CAll 1-877 MA ENRoll (1-877-623-6765) oR
tty: 1-877-623-7773, MoNDAy tHRoUgH fRiDAy, 8:00 A.M. to 6:00 P.M.
Page 26
ACA-3 (Rev. 10/16)
SUPPlEMENt D Special Enrollment Period Form
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