Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form
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32Massachusetts Application for Health
and Dental Coverage and Help Paying Costs
HOW TO APPLY
You can submit your application in any of the following ways.
• Sign on to your account at .
You can create an online account if you do not already have one.
Applying online may be a faster way for you to get coverage than mailing
a paper application.
• Mail
your filled-out, signed application to
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780.
• Fax
your filled-out, signed application to 1-857-323-8300.
• Call
us at 1-800-841-2900
(TTY: 1-800-497-4648 for people who are deaf, hard of hearing, or speech disabled)
or 1-877-MA ENROLL (877-623-6765).
• Visit
a MassHealth Enrollment Center (MEC) to apply in person. See the Member
Booklet for Help with Health and Dental Coverage and Help Paying Costs for a list
of MEC addresses.
USE THIS
•
Affordable coverage from MassHealth, the Children’s Medical Security Plan (CMSP),
the Health Connector, or the Health Safety Net (HSN). You may qualify for a one of
APPLICATION
these programs, even if you earn as much as $98,400 a year (for a household of four).
TO SEE WHAT
•
Affordable private health insurance plans that offer comprehensive
COVERAGE CHOICES
coverage to help you stay well.
YOU MAY QUALIFY
•
A tax credit that can help pay your premiums for health coverage right away.
FOR.
•
Certain life events allow you to get coverage during a special enrollment period
with the Health Connector, even if Open Enrollment has ended. See Supplement
D: Special Enrollment Period Form, for a list of these life events. Please fill out
Supplement D if one of these events applies to you or someone on your application.
If you are not sure, you should fill out the supplement. MassHealth members are not
limited to a special enrollment period.
WHO CAN USE
This application is for people who need health or dental coverage and help paying for it,
whose income is within the income limits for a coverage type, and who
THIS APPLICATION?
•
live in Massachusetts;
•
are not living in or not about to go into a nursing home; and
•
are younger than age 65.
This application may also be used by people of any age who are
•
parents of children younger than age 19;
•
adult relatives living with and taking care of children younger than age 19 when
neither parent is living in the home; or
•
disabled and are either
-
working 40 or more hours a month or are currently working and have worked at
least 240 hours in the six months immediately before the month of the application;
or
-
not working (only if younger than age 65).
ACA-3 (Rev. 07/17)
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