Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 2
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32WHO CAN USE
If this application is not for you, call us at 1-800-841-2900 (TTY: 1-800-497-4648).
THIS APPLICATION?
This application is available in Spanish. Please call the number above to request one.
(CONT.)
Apply even if you or your child already has health coverage including coverage
from Health Connector and MassHealth. You could qualify for lower-cost or no-cost
coverage. We need to know about all members of your household to make a decision
on your eligibility.
If someone is helping you fill out this application, you may need to fill out a separate
form that gives that person permission to act on your behalf. See the Authorized
Representative Designation Form at the end of this application.
WHAT YOU MAY
•
Social security numbers
NEED TO APPLY
•
Document numbers for any legal immigrants who need coverage
•
Employer and income information for everyone in your household (for example,
from paystubs, W-2 forms, or wage and tax statements)
•
Policy numbers for any current health coverage
•
Information about any job-related health insurance available to your household
WHY DO WE
We ask about income and other information to let you know what coverage you qualify
for and if you can get any help paying for it. We will keep all the information you
ASK FOR THIS
provide private and secure, as required by law. To view the Health Connector's Privacy
INFORMATION?
Policy, go to . To view the MassHealth Privacy Policy see the
Member Booklet or go to
masshealth/member-information/notice-of-privacy-practices.html.
WHAT HAPPENS
You will get instructions on the next steps to complete your eligibility process. If you're
eligible for a MassHealth plan, you can choose a plan by going to
NEXT?
masshealth and clicking on the "MassHealth Members and Applicants" button, and
then "Enroll in a Health Plan." If you do not hear from us, visit
or call us at 1-800-841-2900 (TTY: 1-800-497-4648). Filling out this application does not
mean you have to buy health coverage.
GET HELP WITH
Phone: please call us for help with this application or if you need interpreter services.
1-800-841-2900 (TTY: 1-800-497-4648)
THIS APPLICATION
GENERAL
•
Please print clearly and answer all questions completely. There are a few sections
where you may be instructed to skip some questions. Other than those exceptions,
INSTRUCTIONS
blank or incomplete answers will slow down the processing of your application.
•
You can download pages for additional persons at masshealth.
Be sure to tell us how each person is related to each other person. We need this
information to determine eligibility.
•
It is not necessary to send blank pages for Step 2 if you do not have that many
people in your household. Please make sure that you indicate in Section 1 the
number of people applying, and send all other sections even if they are blank or
partially blank.
ACA-3 (Rev. 07/17)
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