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STEP

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

If yes, name(s) of child(ren)

2. Does any child have a parent who has died?

Yes

If yes, name(s) of child(ren)

3. Does any child have a parent whose identity is unknown?

Yes

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

If yes, name(s) of child(ren)

STEP

Read and sign this application.

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

1. MassHealth may require eligible persons to enroll in available employer-sponsored health insurance if that insurance meets the

criteria for MassHealth payment of premium assistance.

2. Employers of eligible persons may be notified and billed in accordance with MassHealth regulations for any services that

hospitals or community health centers provide to such persons that are paid for by the Health Safety Net.

3. Eligible persons may have to pay a premium for health coverage for themselves and others listed on this application. Failure to

pay any premium due may result in the state deducting the amount owed from the tax refunds of responsible persons. If an

eligible person is a certain American Indian or Alaska Native, such person may not have to pay premiums for MassHealth.

4. MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided

to eligible persons enrolled in MassHealth programs. Such third parties may include other health insurers, spouses, or parents

obligated to pay for medical support, or individuals obligated to pay under accident settlements. Eligible persons must

cooperate with MassHealth in establishing third-party support and obtaining third-party payments for themselves and anyone

whose rights they can legally assign. Eligible persons may be exempted from this obligation if they believe and tell MassHealth

that cooperation could result in harm to them or anyone whose rights they can legally assign.

5. A parent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from an

absent parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or guardian.

6. Eligible persons who are injured in an accident, or in some other way, and get money from a third party because of that

accident or injury must use that money to repay MassHealth or the Health Safety Net for certain services provided.

7. Eligible persons must tell MassHealth or the Health Safety Net, in writing, within 10 calendar days, or as soon as possible, about

any insurance claims or lawsuits filed because of an accident or injury.

8. The status of this application may be shared with a hospital, community health center, other medical provider, or federal or

state agencies when necessary for treatment, payment, operations, or the administration of the programs listed above.

9. To the extent permitted by law, MassHealth may place a lien against any real estate owned by eligible persons or in which

eligible persons have a legal interest. If MassHealth puts a lien against such property and it is sold, money from the sale of that

property may be used to repay MassHealth for medical services provided.

10. To the extent permitted by law, and unless exceptions apply, for any eligible person 55 years of age or older, or any eligible person for

whom MassHealth helps pay for care in a nursing home, MassHealth will seek money from the eligible person’s estate after death.

11. MassHealth, the Health Connector, and the Health Safety Net will obtain from eligible persons’ current and former employers

and health insurers all information about health insurance coverage for such persons. This includes, but is not limited to,

information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been

available to such persons or members of their household.

12. MassHealth, the Health Connector, and the Health Safety Net may get records or data about persons listed on this application

from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service,

the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, as well as private data

sources, including financial institutions, 1) to prove any information given on this application and any supplements, or other

information given once a person becomes a member, 2) to document medical services claimed or provided to such persons,

and 3) to support continued eligibility.

Page 19

ACA-3 (Rev. 07/17)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 21

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