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Rights and Responsibilities

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This application will be used to determine eligibility for subsidized health care including MassHealth and Premium Tax Credits and state premium subsidies administered through the Commonwealth of Massachusetts. This application will also be used to determine eligibility for Health Safety Net.

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

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. Employers of eligible persons may be notified and billed in accordance with MassHealth regulations for any services that hospitals or community health centers provide to such persons that are paid for by the Health Safety Net. I may have to pay a premium for health coverage for myself and others listed on this application. Failure to pay any premium due may result in the State deducting the amount owed from the tax refunds of responsible persons. If I am a certain American Indian or Alaska Native, I may not have to pay premiums for MassHealth. MassHealth has the right to pursue and get money from third parties who may be obligated to pay for health services provided to eligible persons enrolled in MassHealth programs. Such third parties may include other health insurers, spouses, 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. A parent and/or guardian of minor children must agree to cooperate with state efforts to collect medical support from an absent parent unless they believe and tell MassHealth that cooperation will harm the children or the parent or guardian. 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. 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 lawsuit filed because of an accident or injury. 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. To the extent permitted by law, after notice and an opportunity to appeal, MassHealth may place a lien against any real estate owned by eligible MassHealth members or in which the member has a legal interest, if the individual is receiving long-term care in a nursing facility or other medical institution and MassHealth determines that the member is not reasonably expected to return home. If MassHealth puts a lien against such property and the property is later sold, money from the sale of that property may be used to repay MassHealth for medical services provided. To the extent permitted by law, and unless exceptions apply, for any eligible person age 55 or older, or any eligible person regardless of age for whom MassHealth helps pay for long-term care in a nursing home or other medical institution, MassHealth will seek money from the eligible person’s estate after death for the total cost of care. For more information on estate recovery, visit www.mass.gov/estaterecovery Opens a new window. 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 (800)-841-2900; TDD/TTY: 711 for people who are deaf, hard of hearing, or speech disabled. A change in information could affect eligibility for such persons or for persons in their household.

You can also be report changes in any of the following ways.

Sign onto your account at mahealthconnector.org. You can create an online account if you don’t already have one. Send the change information to Health Insurance Processing Center P O Box 4405 P O Box 4405Taunton, MA 02780. Fax the change information to (857)-323-8300. 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 such persons. MassHealth may share information about me and members of my household with my employer(s) and/or health insurer(s) to confirm this information. This includes, but is not limited to, information about policies, premiums, coinsurance, deductibles, and covered benefits that are, may be, or should have been available to such persons or members of their household. MassHealth, the Massachusetts Health Connector and the Health Safety Net may get records or data about persons listed on this application from federal and state data sources and programs, such as the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, the Department of Revenue, and the Registry of Motor Vehicles, as well as private data sources, including financial institutions 1) to prove any information given on this application and any supplements, or other information given once a person becomes a member, 2) to document medical services claimed or provided to such persons, and 3) to support continued eligibility. In connection with the eligibility and enrollment process, MassHealth, the Massachusetts Health Connector, and the Health Safety Net may send notices that contain personal information about persons listed on this application to other persons on this application, or otherwise communicate such information to such persons. 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/office/file Opens in a new window. I agree to allow the Massachusetts Health Connector to use income data, including information from tax returns, to determine my eligibility in future years. Review the Health Connector Privacy Policy Opens in a new window for more information about how the Health Connector uses tax information. The Massachusetts Health Connector will send me a notice and let me make changes to my eligibility application. I understand that if I am eligible for an Advance Premium Tax Credit (APTC) and/or ConnectorCare, these payments will be made directly to my selected insurance carrier(s). Acceptance of APTC and/or ConnectorCare may impact my annual tax liability. I will be given the option to apply all, some, or none of any APTC amount I may be eligible for to my monthly premium. I agree MassHealth or anyone acting on its behalf may contact me including via mail, email, call or text for any communications about my relationship with MassHealth or my healthcare needs, benefits, eligibility, or coverage using the contact information I provide, now or in the future, or information we obtain from a reliable data source. I also agree that MassHealth may use the same information to contact me to distribute information related to other health and welfare benefits I may be eligible to receive. These calls and texts may be made using automated technology, such as with an automatic telephone dialing system or artificial or pre-recorded voice messages. Standard message and data rates may apply.

I agree * Required I have read or have had read to me the information on this application, including any supplements and instruction pages, and I understand that the MassHealth Member Booklet contains important information and is available to me at https://www.mass.gov/service-details/member-booklet-and-application-for-health-and-dental-coverage-and-help-paying-costsOpens in a new window I have permission from all persons on this application (or their parent or other legally authorized representative) to submit this application, and to act on their behalf to complete this application and any ongoing or subsequent eligibility process and activity, including, for example: providing personal information about them, including health, health coverage, and income information, seeing such information as may be provided by the Massachusetts Health Connector, MassHealth, and the Health Safety Net, and providing consent on their behalf to the use and disclosure of their information as described in this application, or making choices about coverage options and methods of communication with the Massachusetts Health Connector, MassHealth, and the Health Safety Net, or making changes to the application or related eligibility documents and providing information about any change in their circumstances, or providing consent on their behalf to use government and private sources to verify information as described in this application. I understand my rights and responsibilities and the rights and responsibilities of all persons listed on this application, as explained on the Rights and Responsibilities page; I have told or will tell all such persons (or their parent or legally authorized representative, if applicable), about these rights and responsibilities so they understand them. I understand and agree that the Massachusetts Health Connector, MassHealth, and the Health Safety Net will treat electronic, faxed, or copies of signature(s) with the same force and effect as an original signature(s); The information I have supplied is correct and complete to the best of my knowledge about myself and others listed on this application; and I may be subject to penalties under federal law if I intentionally provide false or untrue information. I understand that MassHealth is allowed to ask for Social Security Numbers under federal and state law; uses SSNs to check income and other information to see who is eligible for help with health coverage costs; uses SSNs to detect fraud, to see if anyone is getting duplicate benefits, or to see if others should be paying for services; matches the SSN of anyone in the household who is applying and anyone who has or who can get health insurance for anyone in the household with the files of agencies and financial institutions. I understand that if MassHealth pays part of anyone’s health insurance premiums, MassHealth will add the SSN or the SSN of that policyholder to the State Comptroller’s vendor file. I understand that the policyholder in my household must have a valid SSN before getting a payment from MassHealth. The information I have supplied is correct and complete to the best of my knowledge about myself and other persons listed on this application. I may be subject to penalties under federal law if I intentionally provide false information. If someone does not have an SSN or needs help getting one, call the Social Security Administration at (800) 772-1213, TTY: (800) 325-0778, or go to www.socialsecurity.gov Opens in a new window. For a full explanation of on how we use your social security number, please refer to the Member Booklet for Health and Dental Coverage and Help Paying Costs.

I agree with the above statements.* Required By signing in this box, I hereby certify under the pains and penalties of perjury that the submissions and statements I have made in this Application are true and complete to the best of my knowledge and I agree to accept and comply with the above Rights and Responsibilities.

Electronic Signature *RequiredJohn Q. Public InformationInformation John Q. Public John Q. Public VOTER REGISTRATION Note:You can choose to change your selection for automatic voter registration at this time.

However, if you already registered automatically, you cannot undo your registration by opting out.

To check your voter registration status and make any further changes to your voting registration, please visit www.sec.state.ma.us Opens in a new window

Unless you check the box below, the information you entered for the Head of Household (or "Person 1") on this application will be sent to your local election official for voter registration. For people 16 or 17 years old, information will be sent for voting pre-registration. After your information is sent, your local election officials will tell you if your registration was accepted.

Voter registration will not affect your application or benefits.

IMPORTANT: If you are not a U.S. citizen, you must check the box below. Registering to vote when you are not eligible is illegal and could result in fines or jail time. Voter registration will not affect your application or benefits. To register or pre-register to vote in Massachusetts you must meet all of the following requirements:

U.S. citizen Massachusetts resident At least 16 years old Not under guardianship that prohibits registering to vote Not temporarily or permanently disqualified by law from voting Not currently incarcerated for a felony conviction If you do not meet all of the requirements above or you do not want us to share your information for voter registration, check the box below.

Do not use my information for voter registration.If you cannot answer Yes to all the items above or you do not want us to share your information for voter registration, check the checkbox. IMPORTANT: If you are not a U.S. citizen, you must check the checkbox. Registering to vote when you are not eligible is illegal and could result in fines or jail time. Voter registration will not affect your application or benefits. Information If I qualify for automatic voter registration and do not check the box above, I understand that this application will be my application to register to vote and this paragraph applies to me.

I authorize MassHealth and the Health Connector to make a one-time disclosure of the following information from this application: my name, date of birth, home and mailing addresses, citizenship, last four digits of your social security numbers, account reference ID, and electronic signature (collectively, "Applicant Information") through the Secretary of the Commonwealth to my local election official for voter registration. Following the disclosure, I understand that: the Secretary of the Commonwealth and/or the local election official are not subject to the same privacy laws as MassHealth and the Health Connector, and may be able to share my Applicant Information without my permission, and MassHealth and the Health Connector will not be able to take back any information once the information is transmitted. Register to vote by mail The form to register to vote is included with this application. More information on voting and registration can be found at www.sec.state.ma.us Opens in a new window. If you have any questions about the voter registration process, or if you need help filling out the form, please visit a local MassHealth Enrollment Center or call the MassHealth Customer Service Center at (800)-841-2900; TDD/TTY: 711. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency. If you would like help in filling out the voter registration application form, we will help you. The decision to seek or accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, with your right to privacy in deciding to register or in applying to register to vote, or with your right to choose your own political party or other political preference, you may file a complaint with:

Secretary of the Commonwealth, Elections Division One Ashburton Place, Room 1705, Boston, MA 02108 Tel: 617-727-2828 or 800-462-8683.

If you or anyone else in your application are not registered to vote where you live now, would you like to apply to register to vote today? * Required YesNo If you check Yes, we will send you a voter registration application through the mail.

If you do not check either box, you will be considered to have decided not to register to vote at this time, unless you qualify for automatic voter registration as described above and did not opt out.