Form Aca-3 - Massachusetts Application For Health And Dental Coverage And Help Paying Costs - Masshealth Form Page 4
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STEP
Tell us about your household.
Who do you need to include on this application?
Tell us about all the household members who live with you. If you file taxes, we need to know about everyone on your tax return.
You do not need to file taxes to get MassHealth.
DO Include
You DO NOT have to include
•
Yourself and your spouse (if married)
•
Your unmarried partner, unless you have children together
•
Your natural, adoptive, or step children younger than age 19
•
Your unmarried partner’s children, unless they live with you
or your unmarried partner included them on his or her tax
•
Your unmarried partner who lives with you if you have
return
children together who are younger than age 19
•
Your parents whom you live with and who file their own taxes
•
Your unmarried partner’s children who live with you and who
if they do not claim you as tax dependent (if you are age 19
are younger than age 19, if you also include this partner
or older)
•
Anyone you include on your tax return (even if they do not
•
Other adult relatives whom you do not claim as tax
live with you)
dependents
•
Anyone your unmarried partner included on his or her tax
return (even if they do not live with you), if you also include
your unmarried partner
•
Anyone else younger than age 19 who you live with and take
care of
The amount of help or type of program you may qualify for depends on the number of people in your household and their incomes.
This information helps us make sure everyone gets the coverage they may be eligible for.
COMPLETE STEP 2 FOR EACH PERSON IN YOUR HOUSEHOLD. Start with yourself, then add other adults and children.
This section is to gather more information about the contact person named
2
STEP
Person 1.
on page 1. Please complete this section for that person.
Complete Step 2 for yourself and all additional household members who live with you, or anyone on your same federal income tax
return if you file one. If you do not file a tax return, remember to still add household members who live with you.
1. First name, middle name, last name, and suffix
2. Relationship to you
SELF
3. Date of birth (mm/dd/yyyy)
4. Gender
Male
Female
5. We need a social security number (SSN) for every person applying for health coverage who has one, including those applying
for MassHealth Premium Assistance. An SSN is optional for persons not applying for health coverage, but giving us an SSN
can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with
health coverage costs. If someone needs help getting an SSN, call the Social Security Administration at 1-800-772-1213 (TTY:
1-800-325-0778), or go to socialsecurity.gov. Please see the Member Booklet for more information.
Do you have a social security number (SSN)?
Yes
No
If yes, give us the number (optional if not applying)
-
-
If no, check one of the following reasons.
Just applied
Noncitizen exception
Religious exception
Is your name on this application the same as your name on your Social Security card?
Yes
No
If no, what name is on your Social Security card?
First name, middle name, last name, and suffix
6. If you get an Advance Premium Tax Credit (APTC) for 2017, do you agree to file a federal tax return for tax year 2017?
Yes
No
Page 2
ACA-3 (Rev. 07/17)
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