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Office of the Inspector General
Commonwealth of Massachusetts
Glenn A. Cunha
Inspector General
Ongoing Review of MassHealth
and Noncustodial Parents’
Health Insurance
February 28, 2014
One Ashburton Place, Room 1311 | Boston, MA 02108 | (617) 727-9140 | www.mass.gov/ig
2
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i
Table of Contents
Executive Summary ...................................................................................................................... 1
Background ................................................................................................................................... 5
I. Office of the Inspector General ............................................................................................5
II. The Medicaid Program ........................................................................................................5
A. Federal Regulations ................................................................................................ 5
B. MassHealth Categories and Coverage .................................................................... 7
C. MassHealth Application.......................................................................................... 8
D. MassHealth Eligibility Determination Process ..................................................... 12
Findings ........................................................................................................................................ 13
I. Review of MassHealth and Health Insurance Orders ........................................................13
A. Methodology ......................................................................................................... 13
B. MassHealth Paid Over $1.5 Million in Claims for Dependent Children and
Custodial Parents Who Had Health Insurance Orders Mandating that the
Noncustodial Parent Provide Health Insurance. ................................................... 14
II. Evaluation of MassHealth’s Resources to Identify Employer-sponsored Health
Insurance ............................................................................................................................16
III. Update on the Office’s 2013 Recommendations ...............................................................17
A. The Office Recommended that MassHealth Simplify the Language on, and
Add New Questions to, the Medicaid Application. .............................................. 17
B. The Office Recommended that MassHealth Require Applicants to Answer
All of the Questions on Supplement B and Any Other Questions Related
to the Noncustodial Parents’ Health Insurance. .................................................... 18
C. The Office Recommended that MassHealth Expand Its Efforts to Use
Noncustodial Parent Information to Evaluate Opportunities to Get
Medicaid Recipients Coverage Through Noncustodial Parents’ Health
Insurance. .............................................................................................................. 20
Recommendations ....................................................................................................................... 23
I. MassHealth Should Continue to Identify Noncustodial Parents’ Health Insurance. .........23
A. MassHealth Should Ask for the Name, Date of Birth and Social Security
Number of the Custodial and Noncustodial Parents for Each Dependent
Child Listed as a Household Member in Part 2: Tell Us About Other
People in This Household of the Medicaid Application. ...................................... 23
ii
B. MassHealth Should Use its Current Data Verification and Matching
Processes to Independently Verify Applicants’ Answers to NCP-1
Questions............................................................................................................... 24
C. MassHealth Should Utilize its Vendor to Identify Noncustodial Parents
With, or With Access to, Employer-sponsored Insurance that Does Not
Currently Cover the Dependent Child or Custodial Parent. ................................. 24
D. MassHealth Should Refer More Cases to DOR/CSE and Should Explore
Additional Methods of Obtaining Health Insurance Coverage from
Noncustodial Parents. ........................................................................................... 24
II. MassHealth Should Consider Simplifying and Clarifying its Forms. ...............................25
III. The Legislature Should Consider Funding to Allow the Courts to Develop a Data-
Match System that Would Allow MassHealth and DOR/CSE to Identify When a
Court Issues a Health Insurance Order. .............................................................................25
Appendix A: Application for Health Coverage and Help Paying Costs Instructions
Appendix B: Absent Parent/Non-Custodial Parent Form
1
Executive Summary
For the past three years, the Legislature has directed the Office of the Inspector General
(“Office”) to study the administration of the Massachusetts Medicaid program (“Medicaid”) by
MassHealth, the state entity that runs the program. This year, pursuant to Section 160 of Chapter
38 of the Acts of 2013, the Office continued its examination of Medicaid and MassHealth’s
obligation to ensure that Medicaid is the payer of last resort.
In situations where one parent has custody of a dependent child, the courts will often enter a
health insurance order requiring the noncustodial parent to provide health insurance for the child
and/or the custodial parent. Even absent a court order, parents have an obligation to provide
health insurance for their children. Furthermore, under federal regulations, MassHealth has an
obligation to identify alternate sources of health insurance for Medicaid recipients, such as a
noncustodial parent’s commercial health insurance.
On March 1, 2013, the Office issued its Report Pursuant to Section 182 of Chapter 139 of the
Acts of 2012: Assessing MassHealth’s Identification and Recovery of Noncustodial Parents’
Health Insurance. That report examined two issues important to the financial well being of
Medicaid:
1. How MassHealth gathers and verifies information from custodial parents regarding
the availability of commercial health insurance from noncustodial parents; and
2. To what extent MassHealth uses that information to obtain commercial health
insurance coverage for a Medicaid recipient.
The Office found that MassHealth did not collect enough information about noncustodial
parents’ health insurance and did not utilize the information it did collect.
Since last year’s review, MassHealth has made progress in addressing the Office’s concerns.
MassHealth adopted the Office’s recommendations to simplify and add new language to the
Medicaid application, and to require custodial parents to answer all of the questions on the
Absent Parent/Non-Custodial Parent Form, used to obtain noncustodial parent information. In
addition, MassHealth and the Department of Revenue’s Child Support Enforcement Division
(“DOR/CSE”) began a pilot project to determine whether it is cost effective for MassHealth to
refer cases to DOR/CSE to determine noncustodial parents’ responsibility to obtain and provide
health insurance.
This year, following up on its 2013 report, the Office reviewed a sample of 500 households for
which a custodial parent indicated on the Medicaid application that a court had issued an order
requiring a noncustodial parent to provide health insurance for the custodial parent and/or
dependent children. The Office reviewed the available court orders for the sampled households
and determined which orders required noncustodial parents to provide Medicaid recipients with
2
health insurance.
1
The Office also gathered Medicaid payment information for the 500
households from the Office of the State Auditor (“Auditor”),
2
and used the actual payment
information to estimate the potential financial impact on the entire Massachusetts Medicaid
program.
The Office also evaluated whether MassHealth could utilize existing resources to identify
noncustodial parents who have commercial health insurance that could cover their dependent
children and/or the custodial parent. Finally, the Office reviewed MassHealth’s response to the
Office’s 2013 recommendations; this included monitoring MassHealth’s pilot project with
DOR/CSE, described above.
The Office found:
1. MassHealth paid $1.5 million in claims and other health care costs on behalf of the
500 households sampled that a noncustodial parent’s health insurance policy should
have covered during hospital fiscal year 2011;
3
2. Extrapolating from those actual claims to all cases in which a recipient reported that a
health insurance order exists, MassHealth could potentially be spending as much as
$17.5 million annually for health care that a noncustodial parent’s health insurance
plan should have covered. This figure could be even greater if MassHealth pursues
health insurance orders for appropriate cases where no order is currently in place; and
3. MassHealth has access to commercial health insurance information that it could use
to identify noncustodial parents who have, or who have access to, employer-
sponsored health insurance.
Based on these findings, the Office makes the following recommendations:
1. MassHealth should amend its Medicaid application to require identifying information,
including Social Security numbers, for custodial and noncustodial parents for all the
children included in the application;
2. MassHealth should use its current data verification and matching processes to
independently verify applicants’ answers to questions about noncustodial parents;
3. MassHealth should use the vendor it currently uses for Medicaid eligibility
determinations to identify noncustodial parents with (or with access to) employer-
sponsored insurance;
1
The Office appreciates the assistance of the County Registrars of Probate and their staffs, as well as the staff of the
Administrative Office of the Probate and Family Court, in identifying cases and locating court records.
2
The Office appreciates the Auditor’s assistance in assembling and providing this information, which was essential
to the Office’s claims analysis.
3
Hospital fiscal year 2011 ran from October 1, 2010 to September 30, 2011.
3
4. MassHealth and DOR/CSE should formalize the process for MassHealth referrals to
DOR/CSE, which can then initiate proceedings against noncustodial parents to obtain
health insurance coverage for the dependent child and/or custodial parent;
5. MassHealth should continue the process of simplifying and clarifying the Medicaid
application form; and
6. The Legislature should consider funding a data-match system that would allow
MassHealth and DOR/CSE to easily identify when a court orders a noncustodial
parent to provide health insurance to a custodial parent and/or dependent children.
The Office does not suggest that any current recipients are ineligible for Medicaid. Even when a
recipient is added to a noncustodial parent’s health insurance, it is likely that the recipient would
maintain Medicaid as a secondary insurance. The recommendations above, however, could
make a positive financial impact on MassHealth and would help ensure that Medicaid is the
payor of last resort.
4
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5
Background
I. Office of the Inspector General
Created in 1981, the Office was the first state inspector general’s office in the country. The
Office’s mission is to prevent and detect fraud, waste and abuse in the expenditure of public
funds. The Office investigates allegations of fraud, waste and abuse at all levels of government;
conducts programmatic reviews to identify systemic vulnerabilities and opportunities for
improvement; and provides assistance to the public and private sectors to help prevent fraud,
waste and abuse in government spending. The Office also offers comprehensive training and
certification programs designed to promote excellence in public procurement and to enhance
public purchasing officials’ ability to operate effectively.
II. The Medicaid Program
The Medicaid program was created in 1965 for the purpose of providing medical assistance to
low-income Americans, particularly children, through a shared state-federal commitment.
Today, Medicaid is an entitlement program that finances medical care, as well as long-term care,
for tens of millions of Americans. Each state administers its own version of Medicaid under
federal and state laws and regulations.
A. Federal Regulations
MassHealth must administer Medicaid pursuant to a number of basic federal guidelines that
beneficiaries must meet and mandates with which the state must comply. The federal law
governing the administration of the Medicaid program underwent significant changes as a result
of the Patient Protection and Affordable Care Act of 2010 (“ACA”). In January 2013, new
federal regulations regarding Medicaid were proposed to comply with the ACA.
4
1. Payor of last resort and identification of third-party liability
The federal government has determined that Medicaid must be the payor of last resort. This
means that Medicaid must ensure that it is paying only for individuals who have no other source
of payment for their health care, or that Medicaid pays last when other insurance does not cover
the full cost of medical services.
5
To carry out this mandate, federal regulations require that
MassHealth take “reasonable measures” to determine if any other entity is legally liable to pay
for health care services.
6
Although there are a number of different sources of third-party legal
liability, for this report the Office focused on noncustodial parents’ commercial health insurance.
4
Medicaid, Children's Health Insurance Programs, and Exchanges, 78 Fed. Reg. 4594-01, 4628 (proposed January
22, 2013) (to be codified at 42 C.F.R. pt. 433).
5
42 CFR § 433.138(b).
6
Id. § 433.138(a).
6
To meet the “reasonable measures” standard under federal regulations, MassHealth must:
[D]uring the initial application and each redetermination process, obtain from the
applicant or recipient such health insurance information as would be useful in
identifying legally liable third-party resources so that the agency may process
claims under the third-party liability payment procedures . . . . Health insurance
information may include, but is not limited to, the name of the policyholder, his or
her relationship to the applicant or recipient, the social security number (SSN) of
the policyholder, and the name and address of insurance company and policy
number.
7
The federal regulations further require MassHealth to use the Social Security number and
information regarding the custodial and noncustodial parents’ employer(s) to determine the
availability of employer-sponsored health insurance.
8
In situations with a custodial parent and a noncustodial parent, courts will often enter a health
insurance order requiring one parent to provide health insurance for the child and/or the other
parent. To ensure that it is using reasonable measures to determine if there is any other entity
that is legally liable to pay for health care services, MassHealth has an obligation to gather
information that will identify whether commercial health insurance is available to cover a
recipient, as well as whether a health insurance order exists.
2. Assignment of rights and cooperation
The Center for Medicare and Medicaid Services (“CMS”), the federal agency that oversees the
state’s administration of Medicaid, now requires a streamlined application process as a part of
the implementation of the ACA. States must now set up the Medicaid application process so that
a single member of a household may apply for Medicaid for all members of his immediate
household. CMS refers to the applicant as the single signer; the single signer does not have to be
a parent, relative or legal guardian of the child on the Medicaid application, and need not be
related to the other adults on that application.
The applicant must assign to the Medicaid agency (in this case, MassHealth) his rights to any
third-party payments for medical health care, such as payments he receives under a legal
settlement or a court order. He must also assign the rights of each individual in the household
for whom he can legally make such an assignment. The applicant must also agree to cooperate
with MassHealth to: (1) establish paternity for any child born out of wedlock listed on the
application; and (2) obtain health insurance for himself and any other person for whom the
individual can legally assign rights.
9
7
Id. § 433.138(b)(1).
8
Id. § 433.138(d)(1)(i-ii). Federal regulations also require MassHealth to enter into agreements with other entities
to identify additional potential sources of third party liability, such as workers’ compensation and motor vehicle
accident coverage. Id. § 433.138(d)(4)(i-ii).
9
Medicaid, Children's Health Insurance Programs, and Exchanges, 78 Fed. Reg. at 4628.
7
In this context, “cooperation” means that MassHealth may require the individual to come to a
MassHealth office to provide information or evidence; appear as a witness at a court or other
proceeding; provide information, or attest to lack of information, under penalty of perjury; pay
MassHealth any support or medical care funds he has received; and take any other reasonable
steps to assist in securing medical support and payments, and in identifying and providing
information to assist MassHealth in pursuing any liable third party (such as health insurance
from a noncustodial parent).
10
3. Good cause for refusal to cooperate
MassHealth may waive the cooperation requirements if it determines that there is good cause for
an individual’s refusal to cooperate. To do so, MassHealth must find that cooperation is not in
the best interest of a child. Similarly, for an individual who is applying only for himself,
MassHealth may waive cooperation if it determines that cooperation would result in reprisal
against, and cause physical or emotional harm to, the individual.
11
When MassHealth waives
cooperation, it must do so in a manner that is consistent with the federal child support
enforcement program.
12
B. MassHealth Categories and Coverage
13
Although the federal government partially funds Medicaid, the Commonwealth is responsible for
administering the program. As the administrator, MassHealth must ensure that the program
meets both federal and state mandates. With permission from the federal government, the
Commonwealth may create programs that broaden health care services to include individuals
who do not meet all the federal Medicaid standards.
MassHealth currently administers seven different types of Medicaid programs and three
additional non-Medicaid benefits programs. The MassHealth Medicaid programs are:
1. Standard: for pregnant women, children, parents and caretaker relatives, young
adults, disabled individuals, certain persons who are HIV positive, individuals with
breast or cervical cancer, independent foster care adolescents, Department of Mental
Health clients, and medically frail individuals;
2. CommonHealth: for disabled adults, young adults, and disabled children who are not
eligible for MassHealth Standard;
3. CarePlus: for adults 21 through 64 years of age who are not eligible for MassHealth
Standard;
10
42 CFR § 433.147(b).
11
Id. § 433.147(c)(2).
12
Id. § 433.147(c & d).
13
All Code of Massachusetts Regulations (CMR) citations in this report reference the CMR in effect as of January
1, 2014.
8
4. Family Assistance: for children, young adults, certain noncitizens and persons who
are HIV positive who are not eligible for MassHealth Standard, CommonHealth, or
CarePlus;
14
5. Small Business Employee Premium Assistance: for adults or young adults who:
a. work for small employers;
b. are not eligible for MassHealth Standard, CommonHealth, Family Assistance, or
CarePlus;
c. do not have anyone in their premium billing family group who is otherwise
receiving a premium assistance benefit; and
d. have been determined ineligible for a Qualified Health Plan with a Premium Tax
Credit due to access to affordable employer-sponsored insurance coverage;
6. Limited: for certain lawfully present immigrants, nonqualified permanent residents
under color of law and certain other noncitizens; and
7. Senior Buy-In: for certain Medicare beneficiaries.
15
The three non-Medicaid benefits programs are:
1. the Children’s Medical Security Plan, which provides certain uninsured children and
adolescents with primary and preventive medical and dental coverage;
2. the Healthy Start Program, which provides health insurance to low-income,
uninsured pregnant women to improve access to early, comprehensive and continuous
prenatal care to improve the health of newborns and their mothers; and
3. the Health Safety Net, which provides care for uninsured and underinsured
individuals who are otherwise not eligible for MassHealth programs.
MassHealth also assists in the administration of the eligibility process for Commonwealth Care,
a state program that offers affordable health insurance to uninsured Massachusetts adults who
meet certain income and other requirements but who do not qualify for Medicaid.
C. MassHealth Application
In October 2013, MassHealth rolled out a new form for people to use to apply for health care
benefits. Specifically, the new Application for Health Coverage and Help Paying Costs
Instructions form (“ACA-2”) replaced MassHealth’s previous application, the Medical Benefit
Request form (“MBR”). The ACA-2 now serves as the entry point for all individuals, families
and small business employees in the Commonwealth to access the state’s health care programs,
14
Some limited aspects of this program do not fall within Medicaid.
15
130 CMR § 505.001(A).
9
including Medicaid, the Health Connector health plans
16
and the Health Safety Net. See
Appendix A for the ACA-2. Applicants must answer all the questions in the ACA-2 and provide
any other required information, including proof of citizenship for any member of the household
who is applying for Medicaid.
As of the writing of this report, an individual can complete the ACA-2 in one of three ways: (1)
by downloading the paper application form from the MassHealth website and then mailing or
faxing the form to MassHealth; (2) by telephone; or (3) in person at one of the four MassHealth
Enrollment Centers. Although there is an online application for Medicaid on the Health
Connector’s website, according to MassHealth the online system is not reliably making
eligibility determinations at this time. MassHealth has stated that this is due to a backlog in
change requests for the vendor hired to implement the new ACA-compliant Health Connector
website. As of the release of this report, MassHealth did not have a timeline for when the online
system will be making eligibility determinations, but stated it is working with its vendors to
address the issues as quickly as possible.
If MassHealth does receive an application submitted through the Health Connector’s website,
there is a manual process to ensure that the application complies with the ACA. For this report,
the Office focused on the process that is currently in place for paper, telephone and in-person
applications.
1. ACA-2 questions regarding other insurance and noncustodial parents
The ACA-2 asks for information regarding other health insurance. Specifically, the application
asks if any household member has Medicare, health insurance from the U.S. military, or any
other type of health insurance, including insurance from a “parent who is not living in the
household” (that is, a noncustodial parent). If the applicant responds affirmatively to any of
these questions, the ACA-2 instructs him to provide detailed information aimed at identifying the
other insurance. This includes asking for the policyholder’s name, Social Security number and
contribution to premium costs, as well as the insurance company’s name, policy type, policy start
date, policy number, covered services, and the names of covered family members. If the
applicant responds negatively to all of the questions regarding other health insurance, the ACA-2
directs the applicant to answer four questions regarding the noncustodial parents of the children
listed on the application:
17
1. Was any child in the household adopted by a single parent?
2. Does any child in the household have a parent who has died?
3. Does any child in the household have a parent who is unknown?
16
According to its website, the Health Connector is meant to be “Massachusetts’ health insurance marketplace,
where individuals, families and small businesses can shop among the state’s leading health insurance carriers and
choose the right plan to meet their needs and budget.” See www.mahealthconnector.info/portal/site/connector.
17
By contrast, if the applicant answers affirmatively to any questions about other insurance, the applicant is not
directed to answer any questions about noncustodial parents.
10
4. Does any child in the household have a parent who does not live with the child and
who is not included in the previous questions?
If the applicant answers “yes” to questions three or four, MassHealth will send a separate form to
the custodial parent to fill out and return. This stand-alone form is called the Absent
Parent/Noncustodial Parent Form (“NCP-1”).
18
See Appendix B for the NCP-1.
2. The ACA-2’s rights, responsibilities and signature pages
The final section of the ACA-2 states: “On behalf of myself and all persons listed on this
application, I understand, represent and agree” to 17 enumerated rights and responsibilities. The
rights and responsibilities include authorizing MassHealth to pursue a third party, such as a
noncustodial parent, when a Medicaid recipient has a health insurance order that requires the
noncustodial parent to provide health insurance. The applicant, and anyone listed on the
application whose rights they can legally assign, must also cooperate with MassHealth in
“establishing third-party support and obtaining third-party payments.” In addition, the parent or
legal guardian, who may or may not be the person applying for Medicaid, must agree to
cooperate with efforts to “collect medical support from the noncustodial parent,” unless he
believes that cooperation would result in harm to the child or himself.
By signing the Medicaid application, the applicant attests, under the pains and penalties of
perjury, that he has permission to submit the application on behalf of all adults and minor
children listed. The applicant also attests that he will inform all of the individuals listed that he
has submitted an application for Medicaid on their behalf. Finally, the applicant must assert,
under the pains and penalties of perjury, that the information about himself and all household
members is “correct and complete” to the best of the applicant’s knowledge.
3. NCP-1 and questions regarding noncustodial parents
As indicated above, MassHealth sends the NCP-1 to the custodial parent of the child listed on the
ACA-2 if the applicant states that the child’s parent (1) is unknown; or (2) does not live with the
child. The custodial parent must fill out and sign the form for all of the children who have a
noncustodial parent.
The custodial parent must also agree to cooperate with MassHealth and the Department of
Revenue’s Child Support Enforcement Division (“DOR/CSE”) “in collecting medical support
from noncustodial parents,” unless there is good cause for not cooperating. The NCP-1
therefore asks the custodial parent to indicate whether any of the following situations apply:
1. Adoption of the child is in process.
2. The child was a result of sexual abuse or assault.
18
MassHealth uses the terms “noncustodial parent” and “absent parent” interchangeably. The NCP-1 form took the
place of the Supplement B in the prior version of the application (the MBR).
11
3. Cooperation is not in the best interest of the child (for example, cooperation could
result in serious physical or emotional harm to the custodial parent and/or the child).
4. The custodial parent adopted the child as a single parent.
5. The child’s noncustodial parent is deceased.
6. The custodial parent does not know the identity of the child’s noncustodial parent.
7. The custodial parent is pregnant and not married to the child’s father.
If the custodial parent indicates that one of these seven situations applies, MassHealth considers
there to be “good cause” for not cooperating and the custodial parent does not need to provide
any information about the noncustodial parent. If none of the situations is applicable, the
custodial parent must complete the remaining sections of the NCP-1 for each dependent child
who is receiving Medicaid.
In particular, the applicant must provide the noncustodial parent’s name, address, telephone
number, Social Security number (if it exists and the applicant can obtain it), date of birth,
driver’s license number, gender, and employer’s name and address. The NCP-1 also asks about
the noncustodial parent’s health insurance. First, the form asks if the noncustodial parent has
insurance that currently covers dependents and/or the custodial parent. If the answer is “yes,”
the NCP-1 prompts the custodial parent to provide the policyholder’s name, the insurance
company’s name, the policy number, and the group number. Next, the NCP-1 asks if a court has
issued an order for the noncustodial parent to provide health insurance for the child or the
custodial parent. If the custodial parent answers “yes,” the form asks “where and when” the
court issued that order. The NCP-1 requires the custodial parent to provide this information for
each of the children on whose behalf the custodial parent is completing the NCP-1.
Once the custodial parent receives the NCP-1, he then has 90 days to complete and return the
form to MassHealth.
19
During these 90 days, the custodial parent receives provisional Medicaid
coverage if he meets all of the other eligibility requirements. If the custodial parent does not
return the NCP-1 within that timeframe, MassHealth closes the custodial parent’s coverage.
However, if the custodial parent returns the NCP-1 within 90 days, but it is incomplete,
MassHealth sends the custodial parent a second verification form (“VC-1”) to obtain the missing
information. The custodial parent then receives an additional 90 days to complete and return the
VC-1 to MassHealth. Thus, the custodial parent could potentially receive provisional Medicaid
coverage for up to 180 days without providing the required noncustodial parent information.
20
19
130 CMR §§ 502.001(B), 502.003.
20
MassHealth only terminates the custodial parent’s Medicaid. Children and other adults in the household remain
on Medicaid, regardless of whether the custodial parent has provided the required information about the dependent
children’s noncustodial parent. Also, pregnant women cannot lose eligibility for failing to provide the required
information.
12
D. MassHealth Eligibility Determination Process
As part of the eligibility determination process, MassHealth’s regulations permit it to take data
from the ACA-2 and match it with information held by other agencies and information sources.
These agencies and information sources may include, but are not limited to: Division of
Unemployment Assistance, Department of Public Health’s Bureau of Vital Statistics,
Department of Industrial Accidents, Department of Veterans’ Services, Department of Revenue,
Bureau of Special Investigations, Social Security Administration, Federal Data Services Hub,
Systematic Alien Verification for Entitlements, Department of Transitional Assistance, and
commercial health insurance carriers.
21
In addition to its responsibility for obtaining complete information and matching that information
with other sources, MassHealth is responsible for reviewing the accuracy of the information that
it collects. In particular, MassHealth regulations refer to its Quality Control Division, which
“periodically conducts an independent review of eligibility factors in a sampling of case files.”
22
21
130 CMR § 502.004.
22
130 CMR § 501.010(C).
13
Findings
I. Review of MassHealth and Health Insurance Orders
The Office evaluated whether pursuing noncustodial parents’ health insurance could have a
meaningful financial impact on Massachusetts’ Medicaid program. The Office concluded that it
could. Specifically, the Office examined a sample of cases in which a court had ordered a
noncustodial parent to provide health insurance for a Medicaid recipient (either the custodial
parent and/or dependent child). The Office found that in hospital fiscal year 2011,
23
MassHealth
paid up to $1.5 million in claims that a noncustodial parents’ health insurance policy should have
covered.
A. Methodology
To perform its review, the Office began with a “snapshot” of MassHealth’s Medicaid database
(referred to as “MA21”) from May 2011. MassHealth uses MA21 to determine eligibility and to
maintain information for every individual in the Medicaid programs that it administers.
24
The
data showed that as of May 2011, MassHealth had information (such as name and address) about
noncustodial parents for 232,563 Medicaid recipients (including both dependent children and
custodial parents). The data also contained information that 15,503 recipients (again, both
dependent children and custodial parents) had reported the existence of a court order requiring
the noncustodial parent to provide health insurance to the recipient.
25
From those 15,503
recipients, the Office selected a statistically valid, random sample of 500 households,
representing 1,352 individual Medicaid recipients.
The Office then reviewed files at Probate and Family Courts throughout Massachusetts to
determine if the 500 households in the sample in fact had valid court orders requiring the
noncustodial parent to provide health insurance to a dependent child or custodial parent. The
Office identified court records associated with 338 of the 500 households in the sample. The
Office could not locate court files or orders for the remaining 162 households.
26
Of the 338
households with court records, the Office could not review files for 56 households because the
court had impounded the records. The Office examined the case files for the remaining 282
23
In Massachusetts, hospitals operate on a fiscal year that runs from October 1 to September 30.
24
To comply with the Affordable Care Act, MassHealth planned to transition by January 1, 2014 to a new system
for determining Medicaid eligibility. That system, called the Health Insurance Exchange/Integrated Eligibility
System (“HIX/IES’), will eventually fully integrate eligibility determinations for a variety of state health and human
services programs. As of the writing of this report, HIX/IES had not been fully implemented due to technical issues
with the vendor. The issues and recommendations set forth in this report are equally relevant to the current MA21
system and the new HIX/IES system.
25
This does not mean that the remaining recipients did not have a health insurance order from a court. In the May
2011 snapshot, the vast majority of applicants did not answer questions on the application about health insurance
orders.
26
There are several reasons that the Office could not locate a court order. For example, the order could have been
issued in another state, or there could have been an error on the application that misidentified the parties to the court
order.
14
households to look for documentation pertaining to the provision of health care coverage for the
custodial parents and the dependent children who were Medicaid recipients at the time of the
sample.
The Office categorized the documentation that it found in the case files of the 282 households
into five groups:
1. An “Unconditional Order” compels the noncustodial parent to obtain or continue to
provide health care insurance for a dependent child or custodial parent.
2. A “Conditional Order” compels the noncustodial parent to provide health care
insurance if and when it is available at a reasonable cost.
3. A “Head of Household Order” (“HOH Order”) compels the head of the household
(i.e., the custodial parent) to provide health care insurance to dependent children.
4. An “Other” designation describes a unique circumstance regarding health care
coverage, such as a judicial order that a family remain on Medicaid.
5. A “No Order” designation describes cases with no order on file pertaining to health
care.
The Office then worked closely with the Office of the State Auditor (“Auditor”) to obtain
Medicaid claims data for the 500 households in the sample for hospital fiscal year 2011. The
Auditor was instrumental in enabling the Office to review the possible fiscal impact on
MassHealth for the sample households that had health insurance orders. The claims data
included the amount that MassHealth paid for each of the 1,352 individual Medicaid recipients in
the 500 households included in the sample.
27
The Office received additional data from
MassHealth to identify whether any noncustodial parents’ health insurance policies already
covered any recipients in the sample. The Office then performed a fiscal impact analysis
utilizing the claims, court orders and MassHealth data.
B. MassHealth Paid Over $1.5 Million in Claims for Dependent Children and
Custodial Parents Who Had Health Insurance Orders Mandating that the
Noncustodial Parent Provide Health Insurance.
As detailed above, the Office found and reviewed court case files for 778 recipients, representing
282 households, from the sample population. The Office eliminated 46 recipients because they
indicated good cause for not cooperating with MassHealth to obtain health insurance from the
27
In this report, the term “claims” includes capitation payments. A capitation payment is a payment MassHealth
makes periodically to a managed care organization (“MCO”) on behalf of a recipient who is enrolled in the MCO.
MassHealth makes the payment regardless of whether the recipient receives services during the period covered by
the payment. 42 C.F.R. § 438.2.
15
noncustodial parent.
28
The remaining 732 recipients were the focus of the Office’s fiscal
analysis.
Of the remaining 732 recipients, 182 fell into one of three categories: HOH Order (78
recipients), No Order (71 recipients), and Other (33 recipients). The Office eliminated these
cases from the review of claims paid because there was no order in place for a noncustodial
parent to provide health insurance coverage for the dependent child and/or custodial parent. The
Office further refined its analysis using the data obtained for MassHealth, which indicated that
73 recipients were already enrolled in a noncustodial parent’s employer-sponsored health
insurance. Because the noncustodial parent was providing health insurance as required, the
Office removed these recipients from its sample.
The Office focused the rest of its analysis on the remaining 477 recipients, from 208 households,
with health insurance orders. Of these recipients, 237 had an Unconditional Order and 240 had a
Conditional Order. After performing a financial analysis for these individual recipients, the
Office found that MassHealth paid claims totaling $1,518,703.72 for this population during
hospital fiscal year 2011.
Type of Health
Insurance Order
# of Households
# of Recipients
Total Payments
Conditional
107
240
$760,862.83
Unconditional
101
237
$757,840.89
Total
208
477
$1,518,703.72
As detailed above, the Office drew its sample from the 15,503 recipients who had reported the
existence of a court order obligating a noncustodial parent to provide health insurance.
Extrapolating from the statistically valid sample to claims for the 15,503 recipients who reported
court orders, the expected average cost of claims that may be subject to an Unconditional Order
is in the range of about $8.7 million per year. Extrapolating from the statistically valid sample to
claims for this same group, the expected average cost of claims that may be subject to a
Conditional Order is in the range of about $8.8 million per year, for a total of $17.5 million
annually.
The extrapolated totals are estimates and may not represent dollars that MassHealth might
recover because in many cases the noncustodial parent cannot obtain insurance, or in other cases
Medicaid would have paid for some portion of the claims as the secondary insurer. However, the
total potential impact could also be much higher, because the analysis accounts only for the
15,503 recipients who disclosed the existence of a health insurance order. As of May 2011,
MassHealth had information concerning noncustodial parents for approximately 232,563
Medicaid recipients (both dependent children and custodial parents). The majority of recipients
28
There are instances where a health insurance order may be in place before a Medicaid member claims good cause.
In those cases, MassHealth will not enforce the health insurance order because the good cause exemption takes
precedence. The Office therefore removed these 46 recipients from the sample.
16
had left blank all questions on the application asking about health insurance orders. Thus,
because other recipients may have – or could obtain – health insurance orders, the financial
impact on MassHealth could exceed the figures discussed above.
II. Evaluation of MassHealth’s Resources to Identify Employer-sponsored Health
Insurance
MassHealth contracts with a vendor to perform many of its eligibility determinations for the
Medicaid program. The vendor performs data matches using several public and private
databases, including a database containing information about members of more than 1,000
commercial health insurance companies. Currently, however, MassHealth does not have the
vendor perform data matches to identify noncustodial parents who have, or who have access to,
employer-sponsored health insurance.
29
The Office therefore sought to determine whether such a match would be beneficial. The Office
requested data from the vendor to identify custodial parents enrolled in Medicaid in 2013 who
met the following criteria:
1. has Medicaid primary coverage;
2. has indicated that a child in the family has a parent who does not live with the child;
3. has not indicated that there is “good cause” to decline to help MassHealth get medical
support from a noncustodial parent of a child;
4. has provided the Social Security number for the noncustodial parent; and
5. has indicated that there is a health insurance order against a noncustodial parent.
The Office further requested that the vendor provide data identifying whether any of the
noncustodial parents (1) have employer-sponsored health insurance, and if so, whether any of
their children were covered by that policy; or (2) have access to, but are not enrolled in,
employer-sponsored health insurance.
MassHealth’s vendor provided the Office with a randomly selected sample of 500 households
that met the criteria.
30
The sample data showed that only 19 of the noncustodial parents had
enrolled their dependent child in employer-sponsored health insurance. Of the remaining 480,
there were 133 noncustodial parents (or 26.6% of the sample) who had, or had access to,
employer-sponsored health insurance but had not enrolled their children. The vendor could not
locate employer-sponsored health insurance for the remaining 347 noncustodial parents.
29
The vendor does use information about Medicaid recipients to identify those who also have some other form of
health insurance (for instance, a custodial parent’s health insurance). This match will not, however, identify
situations in which a noncustodial parent has health insurance but has not included the dependent children or
custodial parent on that insurance.
30
The sample included one record that contained blank fields regarding the noncustodial parent.
17
The fact that the data match found 26.6% of the sample with, or with access to, employer-
sponsored health insurance highlights the benefit of matching all noncustodial parents against the
vendor’s commercial health insurance database. If applied to the total population of
noncustodial parents, including cases where the custodial parent did not indicate that a health
insurance order was in place, the results could be substantial. In short, these results demonstrate
that (1) MassHealth can perform data matches to identify noncustodial parents who have (or
have access to) employer-sponsored health insurance; and (2) it is worthwhile to perform these
data matches.
III. Update on the Office’s 2013 Recommendations
The Office reviewed MassHealth’s efforts to address the recommendations in the Office’s 2013
report. In general, MassHealth has made progress in the past year but it could do more to ensure
that, in the appropriate circumstances, recipients are added to the noncustodial parents’ health
insurance.
A. The Office Recommended that MassHealth Simplify the Language on, and
Add New Questions to, the Medicaid Application.
In its 2013 report, the Office recommended that MassHealth make the Medicaid application, now
called the ACA-2, more accessible to applicants by simplifying language and adding new
questions. In response to this recommendation, MassHealth added the check box “I don’t know”
to allow the applicant to complete all the answers on the application. MassHealth also simplified
the language that asks the applicant if there is a health insurance order for the noncustodial
parent to provide health insurance. However, there are two recommendations that MassHealth
did not implement: (1) adding a question asking if the noncustodial parent is currently married;
and (2) requiring that the custodial parent give MassHealth a copy of any health insurance orders
issued by a court.
31
The Office still believes MassHealth should implement these changes.
In the past year, MassHealth necessarily focused on the ACA, including ensuring that its new
application forms are ACA-compliant. In the coming year, MassHealth could strengthen its
ability to obtain information about noncustodial parents by clarifying and simplifying its forms.
As an example, the ACA-2 asks applicants four preliminary questions about the noncustodial
parents of the dependent children included in the application. MassHealth sends out a follow-up
form (the NCP-1) to gather information about the noncustodial parents based on the applicants’
answers to those four questions.
However, MassHealth does not direct every applicant to answer the four preliminary questions.
Instead, the form instructs applicants to answer those questions only if they answered “no” to a
series of insurance questions unrelated to noncustodial parents.
32
For instance, one question asks
if any member of the household has Medicare. The fact that one member of the household may
be eligible for Medicare has no bearing on the need to identify the noncustodial parents for the
31
If the noncustodial parent is married, it could provide insight into that parent’s access to health insurance.
32
In certain limited exceptions, the insurance information could pertain to a noncustodial parent.
18
dependent children included in the application. MassHealth should make it clear that all
applicants need to answer the four preliminary questions.
Similarly, the ACA-2 states that if the applicant answers “no” to the first two preliminary
questions about noncustodial parents, then he should go to the next section of the
application. However, there is no direction on what he should do if he answers “yes” to either
question. This sort of ambiguity can be confusing when filling out complex forms.
As a final example, the NCP-1 asks whether the noncustodial parent has an insurance policy that
covers dependents. The form should go a step further and ask if the noncustodial parent has
access to insurance that would cover dependents. This is an important piece of information that
could lead to coverage for some Medicaid recipients.
B. The Office Recommended that MassHealth Require Applicants to Answer All
of the Questions on Supplement B and Any Other Questions Related to the
Noncustodial Parents’ Health Insurance.
The Office also recommended that MassHealth require applicants to answer all of the questions
on Supplement B (now known as NCP-1) to the Medicaid application. Supplement B asked the
custodial parent to provide extensive information about the noncustodial parent, including
information aimed at identifying the availability of commercial health insurance. Before the
Office’s 2013 report, however, MassHealth considered Supplement B to be complete if the
custodial parent signed it and answered three questions about the noncustodial parent: name, the
names of the noncustodial parent’s children, and the noncustodial parent’s relationship to the
children (i.e., mother or father).
33
Consequently, the Office found that applicants frequently did
not provide important information about noncustodial parents. Table 2 shows the number of
applications that had blanks for various fields on Supplement B.
33
Appropriately, MassHealth also considered the form to be complete if there was good cause for not providing the
information and in other limited circumstances not pertinent here.
19
TABLE 2: MassHealth Data Collection for May 2011*
Required Field on Supplement B
Count of Fields
Left Blank
% of Total
Date of Birth
61,629
42%
Address
100,714
68%
Last Name
26,160
18%
Social Security number
108,298
73%
Employer Name
127,129
86%
Health Insurance Court Order
97,226
66%
Gender
7,078
5%
Last Name of Child of
Noncustodial Parent
0
0%
First Name of Child of
Noncustodial Parent
0
0%
Total Blank Fields
147,394
Total MassHealth Caseload
1,301,764
*Excludes recipients with good cause
not to provide the information.
Since the Office’s 2013 report, MassHealth has demonstrated a commitment to collect
information relevant to the identification of the noncustodial parent. As noted earlier,
MassHealth now requires that the information requested on the NCP-1 be provided within 180
days of receiving the NCP-1. This timeframe includes the initial 90 days after MassHealth sends
the NCP-1 to the custodial parent and the additional 90 days after MassHealth sends the second
request (the VC-1). Moreover, if the custodial parent does not provide the noncustodial parent
information within that timeframe, MassHealth is supposed to terminate the custodial parent’s
Medicaid coverage.
34
The Office still has concerns regarding the collection of data. For example, although the
custodial parent is supposed to complete the information on the NCP-1 within 90 days, the NCP-
1 does not list any timeframe for returning the form to MassHealth. See Appendix B.
Also, the Social Security number is a vital piece of data to identify the noncustodial parent and
his access to health insurance. However, many applicants do not know the noncustodial parent’s
Social Security number. MassHealth has other data elements available to it that would allow it
to identify the noncustodial parent’s Social Security number. MassHealth has stated, however,
that federal regulations do not authorize state Medicaid agencies to use information on the
Medicaid application, such as the noncustodial parent’s name and date of birth, to obtain a
noncustodial parent’s Social Security number from a third-party data source (such as from the
34
MassHealth only removes the custodial parent from Medicaid. Children and other adults in the household remain
on Medicaid, regardless of whether the custodial parent has provided the required information about the dependent
children’s noncustodial parent. Also, pregnant women cannot lose eligibility for failing to provide the required
information.
20
Social Security Administration).
35
The Office believes the regulations allow for the
identification of the noncustodial parent’s Social Security number.
It is important that MassHealth collect, verify and act on information about noncustodial parents
and their health insurance. Collection of accurate and timely information is crucial to ensuring
that Medicaid is used appropriately. Further, identification of the noncustodial parent’s Social
Security number will assist in appropriately shifting some of the responsibility of providing
health care to noncustodial parents.
C. The Office Recommended that MassHealth Expand Its Efforts to Use
Noncustodial Parent Information to Evaluate Opportunities to Get Medicaid
Recipients Coverage Through Noncustodial Parents’ Health Insurance.
The third recommendation that the Office made was for MassHealth to make better use of the
information that it receives regarding noncustodial parents. In response to this recommendation,
MassHealth has taken some steps to better use the information on the ACA-2 and NCP-1 to
pursue noncustodial parents’ health insurance for Medicaid recipients.
Historically, MassHealth has not referred cases to the Department of Revenue’s Child Support
Enforcement Division (“DOR/CSE”) to initiate proceedings against noncustodial parents to
obtain health insurance orders for dependent children and custodial parents. Since 2009,
MassHealth and DOR/CSE have periodically considered such referrals, but have not yet adopted
any rules or procedures for determining when referrals are appropriate. After the Office
identified its concern last year about the lack of referrals, MassHealth and DOR/CSE revived
their collaboration and created a pilot project designed to identify those instances in which it
would be cost-effective for MassHealth to pursue noncustodial parents’ health insurance by
referring cases for DOR/CSE to initiate proceedings to obtain health insurance orders.
The pilot focused on households that listed a noncustodial parent on a Medicaid application filed
after mid-2011. As an initial matter, the pilot excluded all households that met any of the
following criteria:
1. The custodial parent did not make an assignment of rights to MassHealth;
2. The custodial parent claimed good cause for not assisting MassHealth in
pursuing a health insurance order;
35
MassHealth referred the Office to a federal regulation, 42 CFR § 433.138, as its reason for not using data to
identify the noncustodial parent’s Social Security number. That regulation provides that state Medicaid agencies
must “incorporate into the eligibility case file the names and Social Security numbers of absent or custodial parents
of Medicaid beneficiaries to the extent such information is available.” Id. § 433.138(c). The same regulation also
states that if a state Medicaid agency determines that an individual is eligible for Medicaid, the agency “must . . .
obtain from the applicant or beneficiary such health insurance information as would be useful in identifying legally
liable third-party resources.” Id. § 433.138(b)(1). The regulation also indicates that health insurance information
“may include, but is not limited to” the individual’s name, relationship to the child, and the Social Security number
of the health insurance policyholder. Id.
21
3. The custodial parent did not provide enough information about the
noncustodial parent to make it cost-effective for MassHealth and DOR/CSE to
pursue a health insurance order; or
4. The noncustodial parent was receiving assistance from a public program (e.g.,
Medicaid, Medicare, Commonwealth Care, or Transitional Aid to Families
with Dependent Children).
About 13,700 Medicaid households met none of these criteria. Selecting from this group of
households, MassHealth sent DOR/CSE a random sample of 355 households, which were
associated with 373 noncustodial parents. DOR/CSE matched the 355 households against its
case file and excluded any active cases it was already pursuing.
36
This reduced the sample to
206 households associated with 224 noncustodial parents. DOR/CSE obtained the Social
Security numbers for 148 of these 224 noncustodial parents because the custodial parent had, on
the Medicaid application, either provided the Social Security number or provided enough other
identifying information (e.g., the noncustodial parent’s birth date, address, and/or employer
name) so that DOR/CSE could obtain the Social Security number.
Once DOR/CSE obtained the 148 noncustodial parents’ Social Security numbers, it matched
them against its first quarter 2013 state wage file
37
and found that 56 noncustodial parents had
reported earnings for that quarter. After further investigation, DOR/CSE eliminated 20 of these
cases because circumstances had changed, causing the cases to fall short of legal criteria for a
health insurance order. This left 36 cases out of the original sample of 373 noncustodial parents
potentially eligible for a health insurance order. As of the writing of this report, DOR/CSE was
able to provide the Office with the status of the 36 cases that matched the criteria and the wage
file: five cases are in litigation; three custodial parents did not cooperate with DOR/CSE’s efforts
and were reported to MassHealth for noncooperation; 22 cases are still under review awaiting
additional information, confirmation or verification of information provided; and six cases met
federal case-closing criteria.
38
The results in a short period of time demonstrate that MassHealth has the potential to hold
noncustodial parents accountable for providing health insurance for their children. Based on the
results to date of the pilot program, MassHealth and DOR/CSE have indicated they are
committed to ongoing collaboration and using the lessons learned from the pilot program to
create a more effective and efficient referral process. With continued cooperation between
MassHealth and DOR/CSE, more cases may be identified and greater enforcement will lead to
lower costs to MassHealth.
36
DOR/CSE receives referral cases from other state agencies, such as those provided by the Department of
Transitional Assistance, that administer public benefits programs. Thus, DOR/CSE already had cases involving
households in the sample because it received a referral for those households from a different state agency.
37
The state wage file is the database maintained by the Massachusetts Department of Revenue that collects quarterly
wage reports from employers throughout the state.
38
Federal case-closing criteria are reasons for which the state child support agency, in this case DOR/CSE, may
close a child support case. There are 13 reasons delineated in the regulation for which a case may be closed. 45
CFR § 303.11.
22
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23
Recommendations
Based on the findings above, the Office makes the following recommendations for MassHealth
to strengthen its efforts to identify noncustodial parents, verify the existence of health insurance
coverage and take steps to add recipients to the noncustodial parent’s health insurance policy
whenever appropriate. The Office does not suggest that any such recipients are ineligible for
Medicaid. Even when a recipient is added to a noncustodial parent’s health insurance, it is likely
that the recipient would maintain Medicaid as a secondary insurance. The recommendations
below, however, could make a positive financial impact on MassHealth and would help ensure
that Medicaid is the payor of last resort.
I. MassHealth Should Continue to Identify Noncustodial Parents’ Health Insurance.
Federal regulations require MassHealth to take “reasonable measures” to determine if there is
any other source, including health insurance from a noncustodial parent, to pay for a Medicaid
recipient’s health care. MassHealth should continue its current efforts, and should also take
additional steps to identify noncustodial parents who have, or have access to, commercial health
insurance that could cover their dependent children and/or the custodial parent.
A. MassHealth Should Ask for the Name, Date of Birth and Social Security
Number of the Custodial and Noncustodial Parents for Each Dependent
Child Listed as a Household Member in Part 2: Tell Us About Other People in
This Household of the Medicaid Application.
The Office recommends that MassHealth ask the applicant for the name, date of birth and Social
Security number of both the custodial and noncustodial parents for each child in Part 2: Tell us
about other people in this household of the ACA-2 (the initial application). The application
should ask whether the applicant is seeking benefits for any children under the age of 19, and if
she is, the application should ask for information about the children’s parent(s). The Office
recommends that MassHealth ask for this information so that it may begin the process of
identifying other health insurance which may cover recipients. Obtaining this information at the
beginning of the eligibility process is important because under the current model, MassHealth
may not get this basic and fundamental information until six months after the family has been
found eligible for benefits.
Also, it is important to ask about both parents because under the ACA, any adult in the
household may apply for Medicaid on behalf of the entire household; thus, the person filling out
the application may not be a parent of the children listed on the application. Further, as
demonstrated by the vendor match the Office requested and DOR/CSE’s pilot project, Social
Security numbers are central to determining whether a parent is enrolled in, or has access to,
employer-sponsored health insurance.
The Office recognizes MassHealth’s concerns that it cannot require immediate cooperation from
custodial parents to obtain a health insurance order. The Office believes there are ways to
request the necessary information without conflicting with federal regulations. MassHealth
24
could consider, for example, requesting the information on the application and granting
provisional benefits if the information is not provided.
B. MassHealth Should Use its Current Data Verification and Matching
Processes to Independently Verify Applicants’ Answers to NCP-1 Questions.
The proposed federal regulations for the streamlined single signer application for Medicaid
require that state agencies determine eligibility before the applicant cooperates in establishing
paternity and obtaining a health insurance order.
39
In light of this mandate and the related
requirement that Medicaid agencies provide provisional Medicaid coverage before an applicant
cooperates, early data verification and matching is even more crucial. MassHealth already uses
data matches with other state and federal agencies to verify applicant information. It should use
these same databases to verify the noncustodial parent’s information. The databases could also
be used to obtain crucial identifying information, such as Social Security numbers, that are often
missing from the NCP-1. This would allow MassHealth to more efficiently determine if the
noncustodial parent has employer-sponsored health insurance.
C. MassHealth Should Utilize its Vendor to Identify Noncustodial Parents With,
or With Access to, Employer-sponsored Insurance that Does Not Currently
Cover the Dependent Child or Custodial Parent.
The Office recommends that MassHealth work more closely with its vendor and expand its
efforts to detect whether a noncustodial parent has health insurance but does not insure his
dependent child or the custodial parent. Given that MassHealth may have paid potentially $17.5
million in claims for recipients who had a health insurance order on file, MassHealth would
benefit from using all of the tools at its disposal to locate other health insurance. Moreover, the
vendor match – which found that 26.6% for the noncustodial parents in the sample had, or had
access to, employer-sponsored health insurance – demonstrates the importance of data matches.
In particular, the vendor could match noncustodial parents’ information against its database of
commercial health insurance. Finally, MassHealth should explore other data matches that its
vendor could utilize to identify other sources of health insurance.
D. MassHealth Should Refer More Cases to DOR/CSE and Should Explore
Additional Methods of Obtaining Health Insurance Coverage from
Noncustodial Parents.
MassHealth should evaluate all avenues for ensuring that, in the appropriate circumstances,
recipients are added to the noncustodial parent’s insurance. For example, MassHealth should
continue its collaboration with DOR/CSE and adopt formal policies and procedures for referring
cases to DOR/CSE. Consistent with its mandate to take reasonable measures to identify other
sources of health care coverage, MassHealth should explore other options in addition to
DOR/CSE referrals. MassHealth could, for instance, examine adopting procedures for
requesting noncustodial parents to add dependents to their health insurance.
39
Medicaid, Children’s Health Insurance Programs, and Exchanges, 78 Fed. Reg. at 4628.
25
II. MassHealth Should Consider Simplifying and Clarifying its Forms.
As set forth above, the application and verification forms that MassHealth uses could be clearer
and could request additional information. For example, the application should direct all
applicants to answer the preliminary questions about noncustodial parents. Similarly, the NCP-1
asks if the noncustodial parent has insurance that covers dependents. The form should go a step
further and ask if the noncustodial parent has access to insurance that could cover dependents.
Also, MassHealth should update the forms to allow a legal guardian of a child to provide
information regarding both parents. Currently, the NCP-1 is organized so that applicants can
only provide information about one parent per child. Since legal guardians can fill out the NCP-
1, and because each parent could have access to health insurance, the form should be adjusted.
III. The Legislature Should Consider Funding to Allow the Courts to Develop a Data-
Match System that Would Allow MassHealth and DOR/CSE to Identify When a
Court Issues a Health Insurance Order.
The Office’s review of court files across the Commonwealth illustrated the need for a formal
process for MassHealth and DOR/CSE to identify and obtain health insurance orders. The
Office obtained court files for 338 of the 500 households in its sample. Gathering these court
files required time-intensive research at courts or through direct communication with court staff.
It would not be cost-effective for MassHealth to perform this research for all recipients.
MassHealth and the Probate and Family Courts should explore developing a data match that
would allow MassHealth to identify whether a recipient is the subject of a health insurance order.
This system could provide another tool to augment MassHealth’s referrals to DOR/CSE.
Specifically, it would allow MassHealth and DOR/CSE to focus on enforcement when a court
has ordered a noncustodial parent to provide health insurance, but that parent has not done so. In
order for MassHealth to ensure it is the payor of last resort, it must collect the relevant
information. This would be another source for MassHealth to utilize.
26
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Appendix A: Application for Health Coverage and Help Paying Costs
Instructions
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 
 
Application for Health Coverage
and Help Paying Costs Instructions
Commonwealth of Massachusetts | EOHHS
Please read these instructions before you fill out the application.
Apply faster online! Go to: MAhealthconnector.org. You will get results quickly. You can create a secure online account
where you can see copies of notices and get important news fast.
Please read the attached Member Booklet carefully before you fill out the application. Keep the booklet.
It may answer questions you have later.
Use this application to apply for subsidized health coverage
This is your application for MassHealth, the Children’s
Medical Security Plan (CMSP), the Massachusetts Health
Connector (Health Connector), and the Health Safety Net
(HSN). MassHealth gives health care coverage and helps pay
for health insurance premiums for families, children, and
individuals. The kind of health coverage you get depends
on your household size, income, and other circumstances.
This information helps us make sure everyone gets the best
coverage. Fill out all information for each person in your
household.
The Massachusetts Health Connector is the state’s marketplace
for health and dental insurance. The Health Connector can
help you shop and enroll in insurance plans from leading
health insurers in the state. You can also find out through the
Health Connector if you are eligible for any programs that
help you pay for health insurance premiums and lower your
out-of-pocket health care costs. For more information about
programs that are available through the Health Connector, see
pages 3 and 18-19 in the Member Booklet.
After you fill out your application and submit it, we will review
it. If you are eligible, you will get the most complete coverage
available.
Who can use this application
This application is for people who need health insurance and
help paying for it, and who:
• live in Massachusetts,
• are not living in or about to go into a nursing home, and
• are under age 65.
This application may also be used by people of any age who are:
• parents of children under age 19,
• adult relatives living with and taking care of children
under age 19 when neither parent is living in the home, or
• disabled and either:
work 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 under age 65).
If this application is not for you, call MassHealth Customer
Service at 1-800-841-2900 (TTY: 1-800-497-4648 for people
who are deaf, hard of hearing, or speech disabled).
Tell us about your household
Tell us about all household members who live with you. If you
file taxes, we need to know about everyone on your tax return.
If you do not file taxes, list all of the household members who
are applying for coverage.
Do include
• Yourself
• Your spouse
• Your natural, adoptive, or step children under age 19
• Your unmarried partner if you have children together who
are under age 19
• Your unmarried partner’s children who live with you and
who are under age 19, if you include your unmarried partner
• Anyone you include on your tax return (even if they do not
live with you)
• Anyone your unmarried partner included on his or her tax
return (even if they do not live with you), if you include
your unmarried partner
• Anyone else under age 19 who you live with and take care of
You do not have to include
• Your unmarried partner, unless you have children together
• Your unmarried partner’s children, unless they live with you
• Your parents who you live with and who le their own taxes
(if you are aged 19 or older)
• Other adult relatives who you do not claim as a tax
dependent
ACA-2 (10/13)
over
Filling out the application
Start with yourself, and then add other adults and children. If
you have more than four people in your household including
yourself, you will need to make copies of the pages for Person
4 before you fill them out, and attach them to the application.
Generally, you do not need to give us the immigration statuses,
or the social security security numbers (SSNs) of household
members who are not applying. However, you must give us an
SSN or proof that one has been applied for for every household
member who is applying, unless one of the following
exceptions applies.
• You or any household member has a religious exemption
as described in federal law.
• You or any household member is eligible only for a
nonwork SSN.
• You or any household member is not eligible for an SSN.
We need social security numbers (SSNs) for all other persons
applying for health coverage. 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 does not have an SSN or
needs help getting one, call the Social Security Administration
at 1-800-772-1213 (TTY: 1-800-325-0778 for people who
are deaf, hard of hearing, or speech disabled), or go to
socialsecurity.gov. Please see the Member Booklet for more
information.
We keep the information provided to us private, and only use
and disclose it in accordance with applicable law, unless you
give us permission to share information, or allow another
person to represent you.
We will try to prove your information and determine eligibility
with matches through federal data sources, such as the Social
Security Administration (SSA), the Internal Revenue Service
(IRS), the Department of Homeland Security (DHS), and state
data sources, such as the Department of Revenue (DOR), the
Registry of Motor Vehicles (RMV), and other state-run public
programs. If we are not able to prove your information or
need more information, we will contact you. We may give you
provisional coverage for up to 90 days during the time period
that we are waiting for proof of information (other than a
determination of disability). See the Member Booklet for more
information about disability.
To help us see if you are eligible:
• ll out the application completely,
• be sure to tell us in Part 3 about health insurance you may
be able to get through your job,
• answer all questions in Part 5 and in Supplement C about
any health insurance that you may have now, and
• ll out the parts of Supplement A that apply, if you answer
yes to any questions about injury, illness, disability,
accommodation, or applying due to an accident or injury
caused by someone else. Do not leave any answer blank.
When we get the signed and dated application, we will
review it. If we need more information after we complete the
data matches, we will contact you. Once we get all needed
information, we will make a decision about your eligibility. We
will send you a written notice about this decision. If you need
medical care and you pay for it before you get an approval
notice from us, you may be able to get a refund from your
health care provider for what you paid.
To start filling out this application, go to page 1.
Remember, you must read, sign, and date the Rights and
Responsibilities and Signature pages (Part 7, pages 17-19)
after you have filled out the application.
You can submit your application in any of the
following ways.
• Sign on to your account at
www.MAhealthconnector.org. You can create an
online account if you do not already have one.
• Send your lled-out, signed application to:
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780.
• Fax your lled-out, signed application to:
617-887-8770.
• Call MassHealth Customer Service at
1-800-841-2900 (TTY: 1-800-497-4648 for people
who are deaf, hard of hearing, or speech disabled).
If you have any questions about this
application or the information you need to
send, please call MassHealth Customer Service
at 1-800-841-2900 (TTY: 1-800-497-4648
for people who are deaf, hard of hearing,
or speech disabled).
Application for Health Coverage
and Help Paying Costs
Commonwealth of Massachusetts | EOHHS
Please print clearly. Be sure to answer all questions. Fill out all parts of the application and all supplements that apply. If you need
more space, attach a separate piece of paper to the application. Put your name and social security number at the top of the paper.
We need one adult in your household to be the contact person for your application.
PART 1 Tell us about you (Person 1)—Fill out this part for yourself.
1. First name Middle initial Last name
Sux (ex.,
Jr.)
Relationship to you
SELF
2. Home street address
Apt. #
City
State
Zip code
3. Are you homeless?
Ye s No
4. Mailing address (if dierent from home address)
City State Zip code
5. Telephone number Other telephone number 6. Email address
7. Date of birth (mm/dd/yyyy) 8. Gender
M F
9.
Written language choice
10. Spoken language choice
We need social security numbers for every person applying for health insurance who has one. An SSN is optional for persons not applying for health insurance,
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 for people who are
deaf, hard of hearing, or speech disabled), or go to socialsecurity.gov. Please see the application instructions or the Member Booklet for more information.
11. Do you have a social security number (SSN)?
Ye s No
If yes, give us the number. — — (Optional, if not applying)
If no, check one of the reasons below.
Applied, but have not received SSN
Religious exemption Only eligible for nonwork SSN
Not eligible to get SSN Eligible for SSN, but have not applied
12. Will you file a federal income tax return next year? Ye s No
(You can still apply for health coverage even if you do not file a federal income tax return.)
If yes, answer 12.a., 12.b., and 12.c. If no, answer 12.c.
12.a. Will you file jointly with a spouse? Ye s No If yes, name of spouse:
12.b. Will you claim any dependents on your income tax return? Ye s No
If yes, list name(s) of dependents:
12.c. Will someone else claim you as a dependent on his or her tax return? Ye s No
If yes, name of tax filer: How are you related to the tax filer?
13. Are you pregnant? Ye s No
13.a. If yes, how many children are you expecting? 13.b. What is the due date? (mm/dd/yyyy)
ACA-2 (10/13)
1
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14. Are you applying for health coverage for yourself? Ye s No
If no, go to Part 2: Tell us about other people in this household on page 3. If yes, answer all questions below for Person 1 (yourself).
15. Are you living in Massachusetts and planning to stay? Ye s No
16. Do you live with at least one child under age 19? Ye s No
16.a. If yes, are you the main person taking care of this child? Ye s No
17. Are you in jail or prison? Ye s No
If no, go to the next question.
17.a. If yes, are you (Check one.):
Convicted? What is your expected release date? (mm/dd/yyyy) Not convicted? (For example: confined only)
18. Did you age out of foster care at the age of 18 or older? Ye s No
“Aging out” means the individual was in the custody of the state child welfare agency when he or she turned 18 years of age, or older if the individual decided
to stay in placement after age 18.
19. Are you a U.S. citizen, national, or naturalized U.S. citizen? Ye s No
If yes, go to Question 20.
19.a. If no, do you have an eligible immigration status? (See the Member Booklet for more information.) Ye s No No response
If no or no response, you may get only one or more of the following: MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the Health
Safety Net (HSN). Go to Question 20.
19.b. If yes, do you have an immigration document? Ye s No
We will try to prove your immigration status. Please list all the immigration statuses and/or conditions that have applied to you since you entered the U.S.
(See the Member Booklet for more information about immigration statuses and documents.)
Immigration status
Date status awarded ( mm/dd/yyyy) Immigration document type Document ID number
19.c. Did you come to live in the U.S. before August 22, 1996? Ye s No
19.d. Did you use a dierent name to get your immigration status? Ye s No If yes, what is it?
First name Middle name Last name Sux (ex., Jr.)
19.e. Are you an honorably discharged veteran or an active-duty member of the U.S. military? Ye s No
19.f. Are you a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
19.g. Are you an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
20. Do you have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12 months?
(If legally blind, answer yes.) Ye s No
If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 21.
21. Do you or any household member need reasonable accommodation(s) because of a disability or injury? Ye s No
If no, go to the next question. If yes, fill out Part B of Supplement A: Illness, Disability, or Accommodation on page 21.
22. Are you applying because of an accident or injury that someone else might be responsible for? Ye s No
If no, go to the next question. If yes, ll out Part C of Supplement A: Illness, Disability, or Accommodation on page 21.
23. Do you have breast or cervical cancer? Ye s No (Optional)
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
If no, go to the next question. If yes, we will send you a certificate to be filled out by your doctor to prove your breast or cervical cancer diagnosis.
Then MassHealth can see if your MassHealth benefits give you the most coverage possible.
2
Please go to the next page.
24. Are you HIV positive? Ye s No (Optional) If you are HIV positive, you may be eligible for additional coverage or benets.
If no, go to the next question. If yes, you will need to give us proof of your HIV-positive status. Then MassHealth can see if your MassHealth benefits give
you the most coverage possible.
25. Did you ever get Supplemental Security Income (SSI)?
Ye s No
25.a. When did you last get SSI? (mm/yyyy)
25.b. Do you (Please check one.):
live alone? live with a spouse? live in a rest home?
live and share expenses with another or others (not a spouse)? live in an assisted living facility? live in someone else’s home?
26. Check the box below that best describes you. (Optional)
American Indian/Alaska Native (Wampanoag)
American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation) Asian Black or African American Hispanic/Latino/Black
Hispanic/Latino/White Hispanic/Latino/Other Native Hawaiian or other Pacific Islander White Other
27. If you are an American Indian or Alaska Native, fill out Supplement B: American Indian (AI)/Alaska Native (AN) on page 23. American Indians and
Alaska Natives may not have to pay cost sharing and may get special monthly enrollment periods.
Go to Part 2 to add other household members, if needed, or go to Part 3: Current Job and Income Information on page 9.
PART 2 Tell us about other people in this household
Fill out this part for your spouse or partner and children who live with you and/or anyone included on your federal income tax return, if you file one. See the
application instructions for more information about who to include. If you do not file an income tax return, remember to add other persons who live with you.
Person 2
1. First name Middle initial Last name Sux (ex., Jr.) Relationship to you
2. Home street address Apt. #
City State Zip code
3. Is Person 2 homeless?
Ye s No
4. Mailing address (if dierent from home address)
City State Zip code
5. Telephone number 6. Date of birth (mm/dd/yyyy) 7. Gender
M F
8. Written language choice 9. Spoken language choice
We need social security numbers for every person applying for health insurance who has one. Please see the application instructions or the Member Booklet
for more information.
10. Does Person 2 have a social security number (SSN)?
Ye s No
If yes, give us the number. — — (Optional, if not applying)
If no, check one of the reasons below.
Applied, but have not received SSN
Religious exemption Only eligible for nonwork SSN
Not eligible to get SSN Eligible for SSN, but have not applied
11. Will Person 2 file a federal income tax return next year? Yes No
(Person 2 can still apply for health coverage even if he or she does not file a federal income tax return.)
If yes, answer 11.a., 11.b., and 11.c. If no, answer 11.c.
11.a. Will Person 2 file jointly with a spouse?
Ye s No If yes, name of spouse:
11.b. Will Person 2 claim any dependents on his or her income tax return? Ye s No
If yes, list name(s) of dependents:
11.c. Will someone else claim Person 2 as a dependent on his or her tax return? Ye s No
If yes, name of tax filer: How is Person 2 related to the tax filer?
3
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12. Is Person 2 pregnant? Yes No
12.a. If yes, how many children is she expecting? 12.b. What is the due date? (mm/dd/yyyy)
13. Is Person 2 applying for health coverage?
Ye s No
If no, go to Person 3 or Part 3: Current Job and Income Information on page 9. If yes, answer all questions below for Person 2.
14. Is Person 2 living in Massachusetts and planning to stay? Ye s No
15. Does Person 2 live with at least one child under age 19? Ye s No
15.a. If yes, is Person 2 the main person taking care of this child? Ye s No
16. Is Person 2 in jail or prison? Ye s No
If no, go to the next question.
16.a. If yes, is Person 2 (Check one.):
Convicted? What is his or her expected release date? (mm/dd/yyyy) Not convicted? (For example: confined only)
17. Did Person 2 age out of foster care at the age of 18 or older? Ye s No
“Aging out” means the individual was in the custody of the state child welfare agency when he or she turned 18 years of age, or older if the individual
decided to stay in placement after age 18.
18. Is Person 2 a U.S. citizen, national, or naturalized U.S. citizen? Yes No
If yes, go to Question 19.
18.a. If no, does Person 2 have an eligible immigration status? (See the Member Booklet for more information.) Ye s No No response
If no or no response, Person 2 may get only one or more of the following: MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the
Health Safety Net (HSN). Go to Question 19.
18.b. If yes, does Person 2 have an immigration document? Ye s No
We will try to prove Person’s 2 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 2 since he or she
entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)
Immigration status
Date status awarded ( mm/dd/yyyy) Immigration document type Document ID number
18.c. Did Person 2 come to live in the U.S. before August 22, 1996? Yes No
18.d. Did Person 2 use a dierent name to get his or her immigration status? Ye s No If yes, what is it?
First name Middle name Last name Sux (ex., Jr.)
18.e. Is Person 2 an honorably discharged veteran or an active-duty member of the U.S. military? Ye s No
18.f. Is Person 2 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
18.g. Is Person 2 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
19. Does Person 2 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12
months? (If legally blind, answer yes.) Ye s No
If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 21.
20. Is Person 2 applying because of an accident or injury that someone else might be responsible for? Ye s No
If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 21.
4
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21. Does Person 2 have breast or cervical cancer? Ye s No (Optional)
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
If no, go to the next question. If yes, we will send a certificate to be filled out by Person 2’s doctor to prove his or her breast cancer or her cervical cancer
diagnosis. Then MassHealth can see if Person 2’s MassHealth benefits give him or her the most coverage possible.
22. Is Person 2 HIV positive?
Ye s No (Optional)
If Person 2 is HIV positive, he or she may be eligible for additional coverage or benefits.
If no, go to the next question. If yes, Person 2 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 2’s MassHealth
benefits give him or her the most coverage possible.
23. Did Person 2 ever get Supplemental Security Income (SSI)?
Ye s No
23.a. When did Person 2 last get SSI? (mm/yyyy)
23.b. Does Person 2 (Please check one.):
live alone? live with a spouse? live in a rest home?
live and share expenses with another or others (not a spouse)? live in an assisted living facility? live in someone else’s home?
24. Check the box below that best describes Person 2. (Optional)
American Indian/Alaska Native (Wampanoag)
American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation)
Asian Black or African American Hispanic/Latino/Black
Hispanic/Latino/White Hispanic/Latino/Other Native Hawaiian or other Pacific Islander White Other
25. If Person 2 is an American Indian or Alaska Native, fill out Supplement B: American Indian (AI)/Alaska Native (AN) on page 23. American Indians or
Alaska Natives may not have to pay cost sharing and may get special monthly enrollment periods. Continue adding other household members, if needed,
or go to Part 3: Current Job and Income Information on page 9.
Person 3
1. First name Middle initial Last name Sux (ex., Jr.) Relationship to Person 1
2. Home street address Apt. # Relationship to Person 2
City State Zip code
3. Is Person 3 homeless?
Ye s No
4. Mailing address (if dierent from home address)
City State Zip code
5. Telephone number 6. Date of birth (mm/dd/yyyy) 7. Gender
M F
8. Written language choice 9. Spoken language choice
We need social security numbers for every person applying for health insurance who has one. Please see the application instructions or the Member Booklet
for more information.
10. Does Person 3 have a social security number (SSN)?
Ye s No
If yes, give us the number. — — (Optional, if not applying)
If no, check one of the reasons below.
Applied, but have not received SSN
Religious exemption Only eligible for nonwork SSN
Not eligible to get SSN Eligible for SSN, but have not applied
11. Will Person 3 file a federal income tax return next year? Yes No
(Person 3 can still apply for health coverage even if he or she does not file a federal income tax return.)
If yes, answer 11.a., 11.b., and 11.c. If no, answer 11.c.
11.a. Will Person 3 file jointly with a spouse?
Ye s No If yes, name of spouse:
11.b. Will Person 3 claim any dependents on his or her income tax return? Ye s No
If yes, list name(s) of dependents:
5
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11.c. Will someone else claim Person 3 as a dependent on his or her tax return? Ye s No
If yes, name of tax filer: How is Person 3 related to the tax filer?
12. Is Person 3 pregnant? Ye s No
12.a. If yes, how many children is she expecting? 12.b. What is the due date? (mm/dd/yyyy)
13. Is Person 3 applying for health coverage?
Ye s No
If no, go to Person 4 or Part 3: Current Job and Income Information on page 9. If yes, answer all questions below for Person 3.
14. Is Person 3 living in Massachusetts and planning to stay? Ye s No
15. Does Person 3 live with at least one child under age 19? Ye s No
15.a. If yes, is Person 3 the main person taking care of this child? Ye s No
16. Is Person 3 in jail or prison? Ye s No
If no, go to the next question.
16.a. If yes, is Person 3 (Check one.):
Convicted? What is his or her expected release date? (mm/dd/yyyy) Not convicted? (For example: confined only)
17. Did Person 3 age out of foster care at the age of 18 or older? Ye s No
“Aging out” means the individual was in the custody of the state child welfare agency when he or she turned 18 years of age, or older if the individual
decided to stay in placement after age 18.
18. Is Person 3 a U.S. citizen, national, or naturalized U.S. citizen? Yes No
If yes, go to Question 19.
18.a. If no, does Person 3 have an eligible immigration status? (See the Member Booklet for more information.) Ye s No No response
If no or no response, Person 3 may get only one or more of the following: MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the
Health Safety Net (HSN). Go to Question 19.
18.b. If yes, does Person 3 have an immigration document? Ye s No
We will try to prove Person’s 3 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 3 since he or she
entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)
Immigration status
Date status awarded ( mm/dd/yyyy) Immigration document type Document ID number
18.c. Did Person 3 come to live in the U.S. before August 22, 1996? Yes No
18.d. Did Person 3 use a dierent name to get his or her immigration status? Ye s No If yes, what is it?
First name Middle name Last name Sux (ex., Jr.)
18.e. Is Person 3 an honorably discharged veteran or an active-duty member of the U.S. military? Ye s No
18.f. Is Person 3 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
18.g. Is Person 3 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
19. Does Person 3 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12
months? (If legally blind, answer yes.) Ye s No
If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 21.
20. Is Person 3 applying because of an accident or injury that someone else might be responsible for? Ye s No
If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 21.
6
Please go to the next page.
21. Does Person 3 have breast or cervical cancer? Ye s No (Optional)
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
If no, go to the next question. If yes, we will send a certificate to be filled out by Person 3’s doctor to prove his or her breast cancer or her cervical cancer
diagnosis. Then MassHealth can see if Person 3’s MassHealth benefits give him or her the most coverage possible.
22. Is Person 3 HIV positive?
Ye s No (Optional)
If Person 3 is HIV positive, he or she may be eligible for additional coverage or benefits.
If no, go to the next question. If yes, Person 3 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 3’s MassHealth
benefits give him or her the most coverage possible.
23. Did Person 3 ever get Supplemental Security Income (SSI)?
Ye s No
23.a. When did Person 3 last get SSI? (mm/yyyy)
23.b. Does Person 3 (Please check one.):
live alone? live with a spouse? live in a rest home?
live and share expenses with another or others (not a spouse)? live in an assisted living facility? live in someone else’s home?
24. Check the box below that best describes Person 3. (Optional)
American Indian/Alaska Native (Wampanoag)
American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation) Asian Black or African American Hispanic/Latino/Black
Hispanic/Latino/White Hispanic/Latino/Other Native Hawaiian or other Pacific Islander White Other
25. If Person 3 is an American Indian or Alaska Native, fill out Supplement B: American Indian (AI)/Alaska Native (AN) on page 23. American Indians or
Alaska Natives may not have to pay cost sharing and may get special monthly enrollment periods. Continue adding other household members, if needed,
or go to Part 3: Current Job and Income Information on page 9.
If you have more than three people to add, make a copy of Person 4’s blank information pages (pages 7-9) before you fill them out.
Person 4
1. First name Middle initial Last name Sux (ex., Jr.) Relationship to Person 1
2. Home street address Apt. # Relationship to Person 2
City State Zip code Relationship to Person 3
3. Is Person 4 homeless?
Ye s No
4. Mailing address (if dierent from home address)
City State Zip code
5. Telephone number 6. Date of birth (mm/dd/yyyy) 7. Gender
M F
8. Written language choice 9. Spoken language choice
We need social security numbers for every person applying for health insurance who has one. Please see the application instructions or the Member Booklet
for more information.
10. Does Person 4 have a social security number (SSN)?
Ye s No
If yes, give us the number. — — (Optional, if not applying)
If no, check one of the reasons below.
Applied, but have not received SSN
Religious exemption Only eligible for nonwork SSN
Not eligible to get SSN Eligible for SSN, but have not applied
11. Will Person 4 file a federal income tax return next year? Yes No
(Person 4 can still apply for health coverage even if he or she does not file a federal income tax return.)
If yes, answer 11.a., 11.b., and 11.c. If no, answer 11.c.
11.a. Will Person 4 file jointly with a spouse?
Ye s No If yes, name of spouse:
11.b. Will Person 4 claim any dependents on his or her income tax return? Ye s No
If yes, list name(s) of dependents:
7
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11.c. Will someone else claim Person 4 as a dependent on his or her tax return? Ye s No
If yes, name of tax filer: How is Person 4 related to the tax filer?
12. Is Person 4 pregnant? Ye s No
12.a. If yes, how many children is she expecting? 12.b. What is the due date? (mm/dd/yyyy)
13. Is Person 4 applying for health coverage?
Ye s No
If no, go to Part 3: Current Job and Income Information on page 9. If yes, answer all questions below for Person 4.
14. Is Person 4 living in Massachusetts and planning to stay? Ye s No
15. Does Person 4 live with at least one child under age 19? Ye s No
15.a. If yes, is Person 4 the main person taking care of this child? Ye s No
16. Is Person 4 in jail or prison? Ye s No
If no, go to the next question.
16.a. If yes, is Person 4 (Check one.):
Convicted? What is his or her expected release date? (mm/dd/yyyy) Not convicted? (For example: confined only)
17. Did Person 4 age out of foster care at the age of 18 or older? Ye s No
“Aging out” means the individual was in the custody of the state child welfare agency when he or she turned 18 years of age, or older if the individual
decided to stay in placement after age 18.
18. Is Person 4 a U.S. citizen, national, or naturalized U.S. citizen? Yes No
If yes, go to Question 19.
18.a. If no, does Person 4 have an eligible immigration status? (See the Member Booklet for more information.) Ye s No No response
If no or no response, Person 4 may get only one or more of the following: MassHealth Limited, the Children’s Medical Security Plan (CMSP), or the
Health Safety Net (HSN). Go to Question 19.
18.b. If yes, does Person 4 have an immigration document? Ye s No
We will try to prove Person’s 4 immigration status. Please list all the immigration statuses and/or conditions that have applied to Person 4 since he or she
entered the U.S. (See the Member Booklet for more information about immigration statuses and documents.)
Immigration status
Date status awarded ( mm/dd/yyyy) Immigration document type Document ID number
18.c. Did Person 4 come to live in the U.S. before August 22, 1996? Yes No
18.d. Did Person 4 use a dierent name to get his or her immigration status? Ye s No If yes, what is it?
First name Middle name Last name Sux (ex., Jr.)
18.e. Is Person 4 an honorably discharged veteran or an active-duty member of the U.S. military? Ye s No
18.f. Is Person 4 a spouse or unremarried surviving spouse of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
18.g. Is Person 4 an unmarried dependent child of an immigrant who is an honorably discharged veteran or an active-duty member
of the U.S. military? Ye s No
19. Does Person 4 have an injury, illness, or disability (including a disabling mental health condition) that has lasted or is expected to last for at least 12
months? (If legally blind, answer yes.) Ye s No
If no, go to the next question. If yes, fill out Part A of Supplement A: Illness, Disability, or Accommodation on page 21.
20. Is Person 4 applying because of an accident or injury that someone else might be responsible for? Ye s No
If no, go to the next question. If yes, fill out Part C of Supplement A: Illness, Disability, or Accommodation on page 21.
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21. Does Person 4 have breast or cervical cancer? Ye s No (Optional)
MassHealth has special coverage rules for people who need treatment for breast or cervical cancer.
If no, go to the next question. If yes, Person 4 will send a certificate to be filled out by Person 4’s doctor to prove his or her breast cancer or her cervical
cancer diagnosis. Then MassHealth can see if Person 4’s MassHealth benefits give him or her the most coverage possible.
22. Is Person 4 HIV positive?
Ye s No (Optional)
If Person 4 is HIV positive, he or she may be eligible for additional coverage or benefits.
If no, go to the next question. If yes, Person 4 will need to give us proof of his or her HIV-positive status. Then MassHealth can see if Person 4’s MassHealth
benefits give him or her the most coverage possible.
23. Did Person 4 ever get Supplemental Security Income (SSI)?
Ye s No
23.a. When did Person 4 last get SSI? (mm/yyyy)
23.b. Does Person 4 (Please check one.):
live alone? live with a spouse? live in a rest home?
live and share expenses with another or others (not a spouse)? live in an assisted living facility? live in someone else’s home?
24. Check the box below that best describes Person 4. (Optional)
American Indian/Alaska Native (Wampanoag)
American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation) Asian Black or African American Hispanic/Latino/Black
Hispanic/Latino/White Hispanic/Latino/Other Native Hawaiian or other Pacific Islander White Other
25. If Person 4 is an American Indian or Alaska Native, fill out Supplement B: American Indian (AI)/Alaska Native (AN) on page 23. American Indians or
Alaska Natives may not have to pay cost sharing and may get special monthly enrollment periods. Continue adding other household members, if needed,
or go to Part 3: Current Job and Income Information.
PART 3 Current Job and Income Information
We use your income to see of you are eligible for health coverage. See the Member Booklet. If you are self-employed, and pay yourself wages, fill out both the
Current Job and Self-employed income sections.
About You (Person 1)
1. (Check all that apply.)
Employed (Go to Current Job 1.) Self-employed (Go to Self-employed income.) Not employed (Go to Money from other sources section.)
Current Job 1
2. Employer name
Employer address
City State Zip code
Employer telephone Employer Identification Number (EIN—if you know)
3. Does this job oer health insurance?
Ye s No
If yes, check one.
This job oers health insurance now.
This job will oer health insurance, starting (mm/dd/yyyy).
3.a. If this job oers health insurance now or will at a later date, can the health plan cover an employee’s spouse or dependent(s)?
Yes List the name(s): No
• How much will the employee pay for the lowest-cost individual health plan? $
How often? (Check one.) Weekly Monthly Twice a month Yearly
• Ifanemployeejoinsaprogramtostopsmokingorusingtobacco,howmuchmoneycouldheorshesaveonthemonthlypremium?$
• Doesthehealthinsuranceplan(s)oeredbytheemployermeetthe“minimumvalue”standard?
Ye s No
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
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3.b. What changes will this job make for the next year? (if you know)
This job will stop oering health insurance.
This job will start oering health insurance to employees or change the premium for the lowest-cost available plan.
• How much will the employee’s premiums be (for an individual plan)? $
How often? (Check one.)
Weekly Monthly Twice a month Yearly
• Date of change: (mm/dd/yyyy)
3.c. No health insurance plans oered by the employer will meet the “minimum value” standard.
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
4. Does this employer have 50 or fewer full-time employees? Yes No
If yes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage.
5. Is this job a sheltered workshop? Ye s No
6. How much do you currently earn in gross wages, less pre-tax deductions? $
6.a. How often are you paid? (Check one.) Weekly Every 2 weeks Twice a month Monthly Yearly
6.b. About how many hours do you work each WEEK?
6.c. When did you begin getting this income? (mm/dd/yyyy)
7. If this is a seasonal job, check the months you work.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Self-employed Income
8. a. (Check one.)
Partnership S-Corporation Self-employed
8.b. Business name:
8.c.What is your expected yearly income from this source,less any business expenses? (Do not include your wages and tips.) $
8.d. Date you began getting this income (mm/dd/yyyy)
Current Job 2 (If none, go to Money from other sources section.)
9. Employer name
Employer address
City State Zip code
Employer telephone Employer Identification Number (EIN—if you know)
s
10.
Does this job oer health insurance?
Ye No
If yes, check one.
This job oers health insurance now.
This job will oer health insurance, starting (mm/dd/yyyy).
10.a. If this job oers health insurance now or will at a later date, can the health plan cover an employee’s spouse or dependent(s)?
Yes List the name(s): No
• How much will the employee pay for the lowest-cost individual health plan? $
How often? (Check one.) Weekly Monthly Twice a month Yearly
• Ifanemployeejoinsaprogramtostopsmokingorusingtobacco,howmuchmoneycouldheorshesaveonthemonthlypremium?$
• Doesthehealthinsuranceplan(s)oeredbytheemployermeetthe“minimumvalue”standard?
Ye s No
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
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10.b. What changes will this job make for the next year? (if you know)
This job will stop oering health insurance.
This job will start oering health insurance to employees or change the premium for the lowest-cost available plan.
• How much will the employee’s premiums be (for an individual plan)? $
How often? (Check one.)
Weekly Monthly Twice a month Yearly
• Date of change: (mm/dd/yyyy)
10.c. No health insurance plans oered by the employer will meet the “minimum value” standard.
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
11. Does this employer have 50 or fewer full-time employees? Ye s No
If yes, we may be able to help you pay for your coverage. For more information, see the Member Booklet for description of coverage.
12. Is this job a sheltered workshop? Ye s No
13. How much do you currently earn in gross wages, less pre-tax deductions? $
13.a. How often are you paid? (Check one.) Weekly Every 2 weeks Twice a month Monthly Yearly
13.b. About how many hours do you work each WEEK?
(mm/dd/yyyy) 13.c.
When did you begin getting this income?
14. If this is a seasonal job, check the months you work.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Self-employed Income
15. a. (Check one.)
Partnership S-Corporation Self-employed
15.b. Business name:
15.c.What is your expected yearly income from this source, less any business expenses? (Do not include your wages and tips.) $
15.d. Date you began getting this income (mm/dd/yyyy)
Money from other sources
16. Do you get money from other sources? Ye s No
Check all of the sources, give the amount, and how often you get it.
(You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)
Unemployment $ How often? Trusts $ How often?
Pension or annuity $ How often? Interest $ How often?
Social Security $ How often? Net farming/shing $ How often?
Net rental income $ How often? Royalty $ How often?
Capital gains $ How often? Alimony received $ How often?
Gambling proceeds $ How often? Conservation easement $ How often?
Taxable veterans’money $ How often? Taxable retirement income $ How often?
Taxable military retirement pay$ How often? Tax-excluded foreign income $ How often?
Ordinary or qualied dividend $ How often?
Tax refund, credit, or oset of state or local income taxes $ How often?
Other income (Specify:) $ How often?
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Deductions allowed on federal tax return
All or part of certain expenses can be deducted from income so that you do not pay taxes on them. These amounts are not counted in your income, and may
lower the cost of your health coverage.
17. Do you have any of the deductible expenses below? Ye s No
If yes, please check all of the types you have, fill in the deductible amount, and how often you have this expense.
Do not include an expense that you already claimed under self-employment income above.
Alimony paid $ How often?
Student loan interest $ How often?
Business expenses $ How often?
IRA contribution $ How often?
Contributions to taxable retirement income $ How often?
Deductible part of self-employment tax $ How often?
Educator expenses $ How often?
Health savings account contributions (deduction) $ How often?
Moving expenses $ How often?
Penalty on early withdrawal of savings $ How often?
Self-employment health insurance $ How often?
Self-employment retirement plan $ How often?
Tuition and other school-related costs $ How often?
Other tax deductions (Type): $ How often?
Total income (Person 1)
18. Do you expect your total income (including earned income and money from other sources) to be the same next year? Ye s No
(If you are not sure, answer no to this question.)
If no,what do you expect your total income to be next year? $
Person 2
(If you have income to report for more than two persons, make a copy of pages 12-15 before you fill them out.)
19. Name:
Employed (Go to Current Job 1.) Self-employed (Go to Self-employed income.) Not employed (Go to Money from other sources section.)
20. (Check all that apply.)
Current Job 1
21. Employer name
Employer address
City State Zip code
Employer telephone Employer Identification Number (EIN—if you know)
22. Does this job oer health insurance?
Ye s No
If yes, check one.
This job oers health insurance now.
This job will oer health insurance, starting (mm/dd/yyyy).
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22.a. If this job oers health insurance now or will at a later date, can the health plan cover an employee’s spouse or dependent(s)?
Yes List the name(s): No
• How much will the employee pay for the lowest-cost individual health plan? $
How often? (Check one.) Weekly Monthly Twice a month Yearly
• Ifanemployeejoinsaprogramtostopsmokingorusingtobacco,howmuchmoneycouldheorshesaveonthemonthlypremium?$
• Doesthehealthinsuranceplan(s)oeredbytheemployermeetthe“minimumvalue”standard?  Ye s No
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
22.b. What changes will this job make for the next year? (if you know)
This job will stop oering health insurance.
This job will start oering health insurance to employees or change the premium for the lowest-cost available plan.
• How much will the employee’s premiums be (for an individual plan)? $
How often? (Check one.)
Weekly Monthly Twice a month Yearly
• Date of change: (mm/dd/yyyy)
22.c. No health insurance plans oered by the employer will meet the “minimum value” standard.
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
23. Does this employer have 50 or fewer full-time employees? Ye s No
If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage.
24. Is this job a sheltered workshop? Ye s No
25. How much does this person currently earn in gross wages, less pre-tax deductions? $
25.a. How often is this person paid? (Check one.) Weekly Every 2 weeks Twice a month Monthly Yearly
25.b. About how many hours does this person work each WEEK?
25.c. When did this person begin getting this income? (mm/dd/yyyy)
26. If this is a seasonal job, check the months this person works.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Self-employed Income
27. a. (Check one.)
Partnership S-Corporation Self-employed
27.b. Business name:
27.c. What is this person’s expected yearly income from this source, less any business expenses?
(Do not include his or her wages and tips.) $
27.d. Date this person began getting this income (mm/dd/yyyy)
Current Job 2 (If none, go to Money from other sources section.)
28. Employer name
Employer address
City State Zip code
Employer telephone Employer Identification Number (EIN—if you know)
29. Does this job oer health insurance? Ye s No
If yes, check one.
This job oers health insurance now.
This job will oer health insurance, starting (mm/dd/yyyy).
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29.a. If this job oers health insurance now or will at a later date, can the health plan cover an employee’s spouse or dependent(s)?
Yes No List the name(s):
• How much will the employee pay for the lowest-cost individual health plan? $
How often? (Check one.) Weekly Monthly Twice a month Yearly
• Ifanemployeejoinsaprogramtostopsmokingorusingtobacco,howmuchmoneycouldheorshesaveonthemonthlypremium?$
• Doesthehealthinsuranceplan(s)oeredbytheemployermeetthe“minimumvalue”standard?
Ye s No
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
29.b. What changes will this job make for the next year? (if you know)
This job will stop oering health insurance.
This job will start oering health insurance to employees or change the premium for the lowest-cost available plan.
• How much will the employee’s premiums be (for an individual plan)? $
How often? (Check one.)
Weekly Monthly Twice a month Yearly
• Date of change: (mm/dd/yyyy)
29.c. No health insurance plans oered by the employer will meet the “minimum value” standard.
Minimum value means that the health insurance plan pays at least 60% of the total health insurance costs of the average enrollee. (The employer or
insurance company will know this information.)
30. Does this employer have 50 or fewer full-time employees? Ye s No
If yes, we may be able to help pay for this coverage. For more information, see the Member Booklet for description of coverage.
31. Is this job a sheltered workshop? Ye s No
32. How much does this person currently earn in gross wages, less pre-tax deductions? $
32.a. How often is this person paid? (Check one.) Weekly Every 2 weeks Twice a month Monthly Yearly
32.b. About how many hours does this person work each WEEK?
32.c. When did this person begin getting this income? (mm/dd/yyyy)
33. If this is a seasonal job, check the months you work.
Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec
Self-employed Income
34. a. (Check one.)
Partnership S-Corporation Self-employed
34.b. Business name:
34.c. What is this person’s expected yearly income from this source, less any business expenses?
(Do not include his or her wages and tips.) $
34.d. Date this person began getting this income (mm/dd/yyyy)
Money from other sources
35. Does this person get money from other sources? Ye s No
Check all of the sources, give the amount, and how often this person gets it.
(You do not need to tell us about child support, nontaxable veterans’ payments, or Supplemental Security Income (SSI).)
Unemployment $ How often?
Pension or annuity $ How often?
Social Security $ How often?
Net rental income $ How often?
Capital gains $ How often?
Gambling proceeds $ How often?
Taxable veterans’money $ How often?
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Taxable military retirement pay $ How often?
Trusts $ How often?
Interest $ How often?
Net farming/shing $ How often?
Royalty $ How often?
Alimony received $ How often?
Conservation easement $ How often?
Taxable retirement income $ How often?
Tax-excluded foreign income $ How often?
Ordinary or qualied dividend $ How often?
Tax refund, credit, or oset of state or local income taxes $ How often?
Other income (Specify:) $ How often?
Deductions allowed on federal tax return
All or part of certain expenses can be deducted from income so that this person does not pay taxes on them. These amounts are not counted in this person’s
income, and may lower the cost of his or her health coverage.
36. Does this person have any of the deductible expenses below? Ye s No
If yes, please check all of the types he or she has, fill in the deductible amount, and how often this person has this expense.
Do not include an expense that he or she already claimed under self-employment income above.
Alimony paid $ How often?
Student loan interest $ How often?
Business expenses $ How often?
IRA contribution $ How often?
Contributions to taxable retirement income $ How often?
Deductible part of self-employment tax $ How often?
Educator expenses $ How often?
Health savings account contributions (deduction) $ How often?
Moving expenses $ How often?
Penalty on early withdrawal of savings $ How often?
Self-employment health insurance $ How often?
Self-employment retirement plan $ How often?
Tuition and other school-related costs $ How often?
Other tax deductions (Type): $ How often?
Total income (Person 2)
37. Do you expect Person 2’s total income (including earned income and money from other sources) to be the same next year? Ye s No
(If you are not sure, answer no to this question.)
If no,what do you expect Person 2’s total income to be next year? $
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PART 4 Additional Questions to Apply for Immediate Coverage
Do you or any household member want to apply for immediate coverage? Yes No
If yes, you must fill out this part.
NOTE: Eective 1/1/2014, the Aordable Care Act will change eligibility rules for MassHealth and Commonwealth Care. If you want coverage
before 1/1/2014, you will need to give us additional information so we can determine the best coverage that is available to you.
1. Long-term unemployment
If you indicated in Part 3 that you or any household member is not employed or is getting unemployment compensation, you must fill out this part.
Name of person:
Has this person worked in the last 12 months before the date of application? Ye s No
If yes, how much did this person earn in the last 12 months before taxes and deductions?
Note: If you answered yes to this question,you must enter a dollar amount on this line. $
Is this person getting unemployment benefits?
Ye s No
If yes, is this check from the Commonwealth of Massachusetts? Ye s No
If yes, in the 12 months before this person became unemployed, did this person work for an employer in Massachusetts? Ye s No
(Do not include federal employers, like the U.S. Postal Service.)
Enter the monthly amount of unemployment benets (before taxes and deductions). $
2. College student
Are you or any household member a college student? (You must answer this question.)
Ye s No
If yes, fill out this part and answer all questions.
If no, go to Part 5: Health Insurance You Have Now on page 17.
Name of college student
Is this person eligible for health insurance from college? Ye s No
Is this person a college student in Massachusetts with at least 75% of a full-time schedule? Yes No
(Note: If you are not sure that this person has 75% of a full-time schedule, contact the school to find out if the number of credits the student is taking would
require the student to get the health insurance the school oers to students.)
If yes, is this student planning to get health insurance coverage from the school, but is waiting for coverage to start?
Ye s No
If yes, what is the date that the health insurance coverage starts? (mm/dd/yyyy)
3. Subsidized health insurance you may be eligible for
Are you or any household member in one of the uniformed services? Ye s No
(The uniformed services are the Army, Navy, Air Force, Marine Corps, Coast Guard, Public Health Services, National Oceanic and Atmospheric Administration, and
the National Guard or Reserves.)
Name of person
Active Duty? Ye s No
Retiree? Ye s No
Reserves? Ye s No
Medal of Honor? Ye s No
Have you or any household member served in the U.S. military, or can you be considered a dependent of someone who has served in the U.S. military?
Yes, I have served. Name:
Yes, I am a dependent of someone who has served. Name:
No, I am neither a veteran nor a dependent. Name:
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PART 5 Health Insurance You Have Now
Please answer the questions below about health insurance, and follow the instructions. If someone has enrolled in one of the health insurance plans below,
but the benefits have not yet started, check yes to the question. MassHealth may be able to help pay premiums.
1. Does any household member have Medicare? Ye s No
If yes, fill out Part A of Supplement C: Health Insurance on page 21.
2. Does any household member have federal health insurance provided by the U.S. military (Veterans’ Aairs or TRICARE)
or other federal coverage?
Ye s No
If yes, fill out Part B of Supplement C: Health Insurance on page 21.
3. Does any household member currently have any other type of health insurance (This includes insurance through an employer, union, college or university,
former employer (COBRA), and coverage bought by a household member or parent who is not living in the household)?
Ye s No
If yes, fill out Part C of Supplement C: Health Insurance on page 21.
If you answered no to all three questions above, go to Part 6: Noncustodial Parent.
PART 6 Noncustodial Parent
1. Was any child in the household adopted by a single parent? Ye s No
2. Does any child in the household have a parent who has died? Ye s No
3. Does any child in the household have a parent who is unknown? Yes No
4. Does any child in the household have a parent who does not live with the child and who is not included in the previous questions? Ye s No
If the answer to questions #1 and #2 is no for all children in the household, go to Part 7: Rights and Responsibilities and Signature Page.
If the answer to question #3 or #4 is yes,
we will send a form to the child’s custodial parent to fill out and return to us.
This form asks questions about any
parents who do not live with the child. Go to Part 7: Rights and Responsibilities and Signature Page.
PART 7 Rights and Responsibilities and Signature Page
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 these persons that are paid for by the Health Safety Net.
3. Health coverage premiums must be paid for all persons listed on this application who are applying. Failure to pay any premium due
may result in the State deducting the amount owed from the tax refunds of responsible persons. If any person applying is a certain
American Indian or Alaska Native, MassHealth premiums may not have to be paid.
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. These 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 eorts to collect medical support from a noncustodial
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.
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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 that 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, for any eligible person aged 55 or older, or for any eligible person for whom MassHealth helps pay for
care in a nursing home, MassHealth may seek money from the eligible person’s estate after death.
11. 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 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf, hard of hearing, or speech disabled). A
change in information could aect eligibility for these persons or for persons in their household.*
12. MassHealth, the Massachusetts 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 these 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 these persons or members of their household.
13. MassHealth and the Massachusetts Health Connector may get any records or data: 1) to prove any information given on this
application and any supplements, or other information once an individual becomes a member, 2) to document medical services
claimed or provided, and 3) to support continued eligibility.
(For renewal of coverage in future years)
14. MassHealth and the Health Safety Net will use income data, including information from tax returns to determine eligibility. The
Massachusetts Health Connector will use these data to the extent the applicant authorizes. The Health Connector will send the
individual a notice, let him or her make any changes, and allow the individual to opt out at any time.
On behalf of all persons applying for health coverage, I: (Check one.)
permit use of the data for the next five years; or
permit use of the data for: (Check one.)
one year, two years, three years, four years
do not permit the Health Connector to use tax data to renew my eligibility for help paying for health coverage.
(MassHealth will still use this information. If you are not applying for MassHealth, choosing this option may aect you
being able to get help paying for health coverage at renewal.)
15. If you are acting on behalf of someone in filling out this application and any supplements, you must also fill out and send the
enclosed MassHealth Authorized Representative Designation Form with this application. Your signature on this application and any
supplements as an authorized representative certifies that the information on this application and any supplements, including those
submitted with this application as well as any other forms or documents that may be submitted to or required by MassHealth, is
correct and complete to the best of your knowledge.
16. If I think that the Health Connector or MassHealth has made a mistake in eligibility for me and/or other household members, I have
the right to appeal or file a grievance. If I disagree with the action taken by MassHealth or the Health Connector, I have the right to
appeal and ask for a hearing before an impartial hearing ocer. I can also ask for a hearing if I did not receive a notice telling me
about the action that was taken. To find out how to appeal, please call 1-888-665-9993 (TTY: 1-888-665-9997 for people who are deaf,
hard of hearing, or speech disabled). I understand that I may be eligible to continue getting benefits while my appeal is being decided.
I may have a lawyer or other person represent me, but I may also represent myself. The Health Connector or MassHealth will not pay
for anyone to represent me. Additional information about appeals will be provided with any notices I receive, as well as during the
appeal process.
17. 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 www.hhs.gov/ocr/oce/file.
* You can also report changes in any of the following ways.
• Sign on to your account at www.MAhealthconnector.org.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: 617-887-8770.
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I certify under the penalties of perjury that:
• I have read or have had read to me the information on this application, including any supplements and instruction pages, and
understand that the Member Booklet contains important information;
• I have permission to submit this application for all adults and all minor children listed on this application and as allowed by any
legal documents I have submitted with this application;
• I understand my rights and responsibilities and the rights and responsibilities of all persons for whom I am submitting this
application, as explained in the rights and responsibilities before this signature page;
• I have told or will tell all persons for whom I am submitting this application about these rights and responsibilities so they also
understand their rights and responsibilities;
• I understand and agree that the Health Connector and MassHealth will treat electronic,faxed, telephonic, or copies of
signatures with the same force and eect as an original signature(s);
• The information I have supplied is correct and complete to the best of my knowledge about myself and other members of my
household; and
• I may be subject to penalties under federal law if I intentionally provide false or untrue information.
X
Signature of applicant or authorized representative Print name Date
For certified application counselors, navigators, agents, and brokers only.
Fill out this section if you are a certified application counselor, navigator, agent, or broker filling out this application for someone else.
Application start date (mm/dd/yyyy) First name, middle initial, last name, sux
Organization name
Send the filled-out application to:
Health Insurance Processing Center
P.O. Box 4405
Taunton, MA 02780
19
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SUPPLEMENT A
Illness, Disability, or Accommodation
Part A
If you answered yes to Question 20 in Part 1 or Question 19 in Part 2 about having an injury, illness, or disability that has lasted or
may last for at least 12 months, answer the next three questions.
1. Does this person get money from Social Security for a disability? Ye s No
If yes, name(s):
2. Did this person ever get Supplemental Security Income (SSI)? Ye s No
If yes, name(s):
3. Is this person legally blind? Ye s No
If yes, name(s):
Part B
If you answered yes to Question 21 in Part 1 about you or any household member needing reasonable accommodation because of a disability or
injury, check all that apply below, and list name(s).
1. Condition
Low vision—Name(s):
Blind—Name(s):
Deaf—Name(s):
Hard of hearing—Name(s):
Developmentally disabled—Name(s):
Intellectually disabled—Name(s):
Physically disabled—Name(s):
Other (Please explain.)—Name(s):
2. Accommodation
Text telephone (TTY)—Name(s):
Large print publications—Name(s):
American Sign Language interpreter—Name(s):
Video Relay Service (VRS)—Name(s):
Communication Access Real-time Translations (CART)—Name(s):
Publications in Braille—Name(s):
Assistive listening device—Name(s):
Publications in electronic format—Name(s):
Other (Please explain.)—Name(s):
Part C
If you answered yes to Question 22 in Part 1 or Question 20 in Part 2 about applying because of an accident or injury that someone else may be responsible
for, answer the next two questions.
1. Did someone else cause this person’s injury, illness, or disability, or could someone else’s insurance or this person’s own insurance, other than health
insurance (like homeowner’s or auto insurance) cover it? Ye s No
If yes, name the injured person(s):
2. Has this person filed a lawsuit, a workers’ compensation claim, or an insurance claim for this accident or injury? Ye s No
If yes, name the injured person(s):
21
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SUPPLEMENT B
American Indian (AI)/Alaska Native (AN)
Fill out this supplement if you or any household member is an American Indian or Alaska Native.
American Indians and Alaska Natives who enroll in MassHealth can also get services from the Indian Health Services, tribal health programs, or urban Indian
health programs.
If you or any household members are American Indians or Alaska Natives, you may not have to pay cost sharing and may get special monthly enrollment
periods. To make sure you and your household members get the most help possible, please fill out this supplement.
AI/AN Person 1
Name: First Middle initial Last Sux
1. Is this person a member of a federally recognized tribe? Ye s No
If yes, check the box that applies.
American Indian/Alaska Native (Mashpee Wampanoag) American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation)
2. Did this person ever get a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of
these programs? Ye s No
3. If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral
from one of these programs?
Ye s No
Certain money received may not be counted for MassHealth. List the combined income from the following sources.
• Per capita payments from a tribe that come from natural resources, usage rights,leases, or royalties
• Payments from natural resources, farming, ranching, shing, leases or royalties from land designated as Indian trust land by the Department of Interior
(including reservations and former reservations)
• Money from selling things that have cultural signicance
$
How often? Weekly Biweekly Monthly Other (Explain)
AI/AN Person 2
Name: First Middle initial Last Sux
1. Is this person a member of a federally recognized tribe?
Ye s No
If yes, check the box that applies.
American Indian/Alaska Native (Mashpee Wampanoag) American Indian/Alaska Native (Wampanoag Tribe of Gay Head (Aquinnah))
American Indian/Alaska Native (Other Tribal Nation)
2. Did this person ever get a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of
these programs? Ye s No
3. If no, is this person eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health programs, or through a referral
from one of these programs?
Ye s No
Certain money received may not be counted for MassHealth. List the combined income from the following sources.
• Per capita payments from a tribe that come from natural resources, usage rights,leases, or royalties
• Payments from natural resources, farming, ranching, shing, leases or royalties from land designated as Indian trust land by the Department of Interior
(including reservations and former reservations)
• Money from selling things that have cultural signicance
$
How often? Weekly Biweekly Monthly Other (Explain)
23
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SUPPLEMENT C
Health Insurance
Part A: Medicare
Fill out this part if any household member answered yes to having Medicare in the health insurance part (Part 5).
1. Name:
Medicare claim number: When did coverage start?
(mm/dd/yyyy)
1.a. Does this person have a Medicare Part D plan?
Ye s No
If yes, when did coverage start? (mm/dd/yyyy)
1.b. Does this person have a Medigap/Medicare supplemental policy? Yes No
If yes, name of coverage plan: When did coverage start? (mm/dd/yyyy)
2. Name: Medicare claim number: When did coverage start?
(mm/dd/yyyy)
2.a. Does this person have a Medicare Part D plan?
Ye s No
If yes, when did coverage start? (mm/dd/yyyy)
2.b. Does this person have a Medigap/Medicare supplemental policy? Yes No
If yes, name of coverage plan: When did coverage start? (mm/dd/yyyy)
3. Do any of the persons above want to apply for help paying for the Medicare Part B premiums? Ye s No
If yes, name(s):
Part B: Federal health insurance benets
Fill out this part if any household member answered yes in the health insurance part (Part 5) to having federal health insurance provided by the U.S. military
(Veterans’ Aairs or TRICARE) or other federal coverage.
Name of insurance plan or policy: Policyholder name:
Names of covered household members:
Claim/policy number: When did coverage start? (mm/dd/yyyy)
Part C: Other health insurance
Fill out this part if any household member answered yes in the health insurance part (Part 5) to having any other type of health insurance.
This includes insurance through an employer, union, college or university, former employer (COBRA), and coverage bought by a household member or parent
who is not living in the household.
1. Name of insurance plan or policy: Policyholder name: Date of birth: (mm/dd/yyyy) SSN (if you know):
Names of covered household members:
Policy number: Group number (if you know): When did coverage start? (mm/dd/yyyy)
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Source: (Check one.)
Employer-sponsored (give employer name): Union-sponsored (give union name):
College/university COBRA Retiree Coverage provided by someone outside household
Other (Please explain.):
Type of coverage this plan provides: (Check all that apply.)
Doctor’s visits and hospitalizations Vision coverage Dental coverage Pharmacy coverage Catastrophic only
Premium cost:
$
Premium frequency: (Check one.)
Weekly Every two weeks Twice a month Monthly Quarterly Yearly
2. Name of insurance plan or policy: Policyholder name: Date of birth: (mm/dd/yyyy) SSN (if you know):
Names of covered household members:
Policy number: Group number (if you know): When did coverage start? (mm/dd/yyyy)
Source: (Check one.)
Employer-sponsored (give employer name): Union-sponsored (give union name):
College/university COBRA Retiree Coverage provided by someone outside household
Other (Please explain.):
Type of coverage this plan provides: (Check all that apply.)
Doctor’s visits and hospitalizations Vision coverage Dental coverage Pharmacy coverage Catastrophic only
Premium cost:
$
Premium frequency: (Check one.)
Weekly Every two weeks Twice a month Monthly Quarterly Yearly
26
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Appendix B: Absent Parent/Non-Custodial Parent Form
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Absent Parent/Non-Custodial Parent Form
Commonwealth of Massachusetts | EOHHS
Instructions
This form is being sent to you because you recently completed an application for certain state health plans such as MassHealth and indicated in that
application that one or more of the children in your household has a non-custodial parent. A non-custodial parent is a parent who does not live with
his or her child.
This form must be filled out and signed by the custodial parent or legal guardian of the children listed on the application for health care coverage.
You must provide the requested information for each child who has a non-custodial parent.
To get MassHealth, you agree to cooperate with MassHealth and the Child Support Enforcement Division of the Massachusetts Department of
Revenue (“DOR”) in collecting medical support from non-custodial parents. This means that you must fill out this form to help us identify the non-
custodial parent who has to pay for medical care for you and your children. Cooperation also means that you may have to, among other things:
• appear at a state or local oce to provide relevant information;
• appear as a witness at a court or other proceeding;
• provide information under penalty of perjury including information about the identity, location, and employment of a non-custodial parent;
• pay to MassHealth any support or medical care funds received that are covered by the assignment of rights; and
• take any other reasonable steps to assist in establishing paternity and securing medical support and payments and in identifying and
providing information to help us pursue liable third parties.
Your eligibility could be aected if you do not fill out this form in its entirety and do not meet the exceptions described below.
Please fax or mail to:
Electronic Document Management Center
P.O. Box 1231
Taunton, MA 02780
Fax: 617-887-8777
Important
MassHealth will not deny or terminate your child’s MassHealth benefits if you do not cooperate, but your eligibility will be impacted. Even if you
are not required to establish paternity, paternity establishment may result in financial benefits for the child such as Social Security dependents’
benets, pension benets,veterans benets, and possible rights of inheritance.You can ask for child-support-enforcement services if you want
help getting the absent parent to pay for health insurance or child support for the child. To do this, call DOR at 1-800-332-2733, or go to www.
mass.gov/dor and click on “Child Support.”The child’s MassHealth benets will not be aected if you choose to ask for these services or not. If you
ask for these services,you will have to cooperate with DOR.
Non-custodial-Parent Information
Please provide the following information for each child on the application who has a non-custodial parent. We have provided space for three
children and three non-custodial parents.If you need more room, please make a copy of this form or use a separate piece of paper.
If you are applying for benets for an unborn child, you do not need to give us information about the non-custodial parent of the unborn child at
this time.
NCP-1 (Rev. 10/13)
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Name of child #1:
First name Middle name Last name
Do any of the following apply to this child?
Adoption of this child is in process.
This child was a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child
(for example, cooperation could result in serious physical or emotional harm to me and/or the child).
I adopted this child as a single parent.
The non-custodial parent of this child is deceased.
I do not know who the non-custodial parent of this child is.
I am not married to the father of this child AND I am currently pregnant.
If you checked any of the boxes above, you do not have to provide information for this child’s non-custodial parent. Please provide non-custodial parent
information for any other child(ren) and sign at the end of this form.
Name of non-custodial parent for child #1:
I do not know
First name Middle name Last name
Non-custodial parent’s relationship to child:
mother father
Gender:
M F
Date of birth: (mm/dd/yyyy) I do not know
Social security number: I do not know Driver’s license number: I do not know Address: I do not know
Telephone number: I do not know Employer name and address: I do not know
Does the non-custodial parent have insurance that covers dependents? Ye s No I do not know
If yes, please provide the following information.
Policyholder name: Insurance company: Policy number: Group number:
Has a court issued an order for the non-custodial parent to provide health insurance for the child? Yes No I do not know
If yes, where and when was the order issued? I do not know
Has a court issued an order for the non-custodial parent to provide health insurance for you, the custodial parent? Ye s No I do not know
If yes, where and when was the order issued? I do not know
2
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
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Name of child #2:
First name Middle name Last name
Do any of the following apply to this child?
Adoption of this child is in process.
This child was a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child
(for example, cooperation could result in serious physical or emotional harm to me and/or the child).
I adopted this child as a single parent.
The non-custodial parent of this child is deceased.
I do not know who the non-custodial parent of this child is.
I am not married to the father of this child AND I am currently pregnant.
If you checked any of the boxes above, you do not have to provide information for this child’s non-custodial parent. Please provide non-custodial parent
information for any other child(ren) and sign at the end of this form.
Name of non-custodial parent for child #2:
I do not know
First name Middle name Last name
Is this the same non-custodial parent named for the rst child above? If so, check here and skip the rest of this section.
Make sure to sign this form.
Non-custodial parent’s relationship to child:
mother father
Gender:
M F
Date of birth: (mm/dd/yyyy) I do not know
Social security number: I do not know Driver’s license number: I do not know Address: I do not know
Telephone number: I do not know Employer name and address: I do not know
Does the non-custodial parent have insurance that covers dependents? Ye s No I do not know
If yes, please provide the following information.
Policyholder name: Insurance company: Policy number: Group number:
Has a court issued an order for the non-custodial parent to provide health insurance for the child? Yes No I do not know
If yes, where and when was the order issued? I do not know
Has a court issued an order for the non-custodial parent to provide health insurance for you, the custodial parent? Ye s No I do not know
If yes, where and when was the order issued? I do not know
3
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 
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Name of child #3:
First name Middle name Last name
Do any of the following apply to this child?
Adoption of this child is in process.
This child was a result of sexual abuse or assault.
Cooperation, as defined on page 1, is not in the best interest of this child
(for example, cooperation could result in serious physical or emotional harm to me and/or the child).
I adopted this child as a single parent.
The non-custodial parent of this child is deceased.
I do not know who the non-custodial parent of this child is.
I am not married to the father of this child AND I am currently pregnant.
If you checked any of the boxes above, you do not have to provide information for this child’s non-custodial parent. Please provide non-custodial parent
information for any other child(ren) and sign at the end of this form.
Name of non-custodial parent for child #3:
I do not know
First name Middle name Last name
Is this the same non-custodial parent named for the rst and/or second child above? If so,check here and skip the rest of this section.
Make sure to sign this form.
Non-custodial parent’s relationship to child:
mother father
Gender:
M F
Date of birth: (mm/dd/yyyy) I do not know
Social security number: I do not know Driver’s license number: I do not know Address: I do not know
Telephone number: I do not know Employer name and address: I do not know
Does the non-custodial parent have insurance that covers dependents? Ye s No I do not know
If yes, please provide the following information.
Policyholder name: Insurance company: Policy number: Group number:
Has a court issued an order for the non-custodial parent to provide health insurance for the child? Yes No I do not know
If yes, where and when was the order issued? I do not know
Has a court issued an order for the non-custodial parent to provide health insurance for you, the custodial parent? Ye s No I do not know
If yes, where and when was the order issued? I do not know
Signature
I certify under penalty of perjury that I am the custodial parent or legal guardian of the minor child(ren) listed on this form, that I have provided all the
information I have or can reasonably get, and that the information in this form is correct and complete to the best of my knowledge.
Signature of custodial parent or legal guardian Print name Date
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Ongoing Review Of Masshealth And Noncustodial Parents Health Insurance 2014 (Commonwealth of Massachusetts)

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Completed 26 July 2020

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