Looking for a Masshealth Forms And Templates? Download it for free!

STEP 6 (continued)

13. To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the

Massachusetts Health Connector to use income data, including information from tax returns for the next three coverage

years. The Massachusetts Health Connector will send me a notice and let me make changes. I understand that if I am eligible

for an Advance Premium Tax Credit (APTC) or ConnectorCare, these payments will be made directly to my selected insurance

carrier(s). Acceptance of APTC or ConnectorCare may impact my tax liability for this year. I will be given the option to apply all,

some, or none of any APTC amount I may be eligible for to my monthly premium.

14. In connection with the eligibility and enrollment process, MassHealth, the Health Connector, and the Health Safety Net may

send notices that contain personal information about persons listed on this application to other persons on this application, or

otherwise communicate such information to such persons.

15. Under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, sexual orientation,

gender identity, or disability. I can file a complaint of discrimination by going to

16. Eligible persons must tell the health care program(s) in which they enroll about any changes in their or their household’s

income or employment, household size, health insurance coverage, health insurance premiums, and immigration status, or

about changes in any other information on this application and any supplements to it within 10 calendar days of learning of the

change. Eligible persons can make changes by calling 1-800-497-2900 (TTY: 1-800-497-4648 for people who are deaf, hard of

hearing, or speech disabled). A change in information could affect eligibility for such persons or for persons in their household.

You can also report changes 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.

•

Send the change information to

Health Insurance Processing Center

P.O. Box 4405

Taunton, MA 02780.

•

Fax the change information to 1-857-323-8300.

17. No one applying for health coverage on this application is in prison or in jail except as set forth below. If someone applying for

health coverage is in prison or jail, write their name below and answer the following three questions.

is in prison or jail.

Is this person awaiting trial?

Yes

Is this person being released within 30 days of submitting this application?

Yes

Is this person an inmate who will be admitted to a hospital for at least 24 hours and then returned to prison or jail?

Yes

I AGREE TO THE FOLLOWING STATEMENTS.

•

I have read or have had read to me the information on this application, including any supplements and instruction pages, and I

understand that the Member Booklet contains important information.

•

I have permission from all persons listed on this application (or their parent or other legally authorized representative) to submit

this application and to act on their behalf to complete this application and any ongoing or subsequent eligibility process and

activity, including, for example:

providing personal information about them, including health, health coverage, and income information, seeing such

information as may be provided by the Health Connector, MassHealth, and the Health Safety Net, and providing consent on

their behalf to the use and disclosure of their information as described in this application;

making choices about coverage options and methods of communication with the Health Connector, MassHealth, and the

Health Safety Net;

making changes to the application or related eligibility documents and providing information about any change in their

circumstances; and

providing consent on their behalf to use government and private sources to verify information as described in this application.

•

I understand my rights and responsibilities and the rights and responsibilities of all persons listed on this application as explained

in this Step 6.

•

I have told or will tell all such persons (or their parent or legally authorized representative, if applicable) about these rights and

responsibilities so they understand them.

•

I understand and agree that MassHealth, the Health Safety Net, and the Health Connector will treat electronic, faxed, or copies of

signatures with the same force and effect as an original signature(s).

•

The information I have supplied is correct and complete to the best of my knowledge about myself and other persons listed on

this application.

•

I may be subject to penalties under federal law if I intentionally provide false or untrue information.

Page 20

ACA-3 (Rev. 07/17)

Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 22

Related Articles

Related forms

Related Categories