AGENCIES
APPLICATIONS, FORMS AND WAIVERS
JOB AIDS AND TALKING POINTS
TRAININGS
SAMPLE NOTICES AND MEMBER COMMUNICATION
REGULATIONS AND POLICIES
- Mail/Fax Cover Sheet (May 2020)
- CAC Designation Form Fillable [English]
- CAC Designation Form Fillable [Spanish]
- Special Enrollment Period Form [English]
- Special Enrollment Period Form [Spanish]
- Fillable ACA-3 [English] (August 2023)
- Fillable ACA-3 [Spanish] (August 2023)
- SACA-2 [English] (August 2023) Fillable
- SACA-2 [Spanish] (March 2023) Fillable
- SACA-2 ERV [English] (March 2023) Fillable
- SACA-2 ERV [Spanish] (March 2023) Fillable
- SACA-2 UND [English] (June 2023) Fillable
- SACA-2 UND [Spanish] (October 2022) Fillable
- Fillable Additional Person(s) English ACA-3 (August 2023)
- Fillable Additional Person(s) Spanish ACA-3 (March 2023)
- MHBI/Medicare Savings Programs English (March 2024)
- MHBI/Medicare Savings Programs Spanish (March 2024)
- MHBI/Medicare Savings Programs Portuguese (March 2024)
- MHBI/Medicare Savings Programs Haitian Creole (March 2024)
- MHBI/Medicare Savings Programs Chinese (March 2024)
- MHBI/Medicare Savings Programs Vietnamese (March 2024)
- Residency Affidavit [English]
- Residency Affidavit [Spanish]
- Zero Income Affidavit [English]
- Zero Income Affidavit [Spanish]
- Attestation to Verify Income [English]
- Attestation to Verify Income [Spanish]
- Verification of Self-employment Income [English]
- Verification of Self-employment Income [Spanish]
- Incarceration Affidavit [English]
- Incarceration Affidavit [Spanish]
- Job Update Form [English]
- Jon Update Form [Spanish]
- Additional Information about Your Access to ESI (October 2018)
- Non-Custodial Parent Form [English]
- Non-Custodial Parent Form [Spanish]
- MassHealth Adult Disability Supplement [English]
- MassHealth Adult Disability Supplement [Spanish]
- MassHealth Child Disability Supplement [English]
- MassHealth Child Disability Supplement [Spanish]
- MassHealth Medical Release Form [English]
- MassHealth Medical Release Form [Spanish]
- Permission to Share Information (PSI) [English]
- Permission to Share Information (PSI) [Spanish]
- Authorized Representative Form (ARD) [English]
- Authorized Representative Form (ARD) [Spanish]
- Authorized Representative Form (ARD) [Portuguese]
- Authorized Representative Form (ARD) [Cape Verdean Creole]
- Authorized Representative Form (ARD) [Haitian Kreyol]
- Authorized Representative Form (ARD) [Chinese]
- Authorized Representative Form (ARD) [Vietnamese]
- Self-employment Income Proof [English]
- Self-employment Income Proof [Spanish]
- Letter for Tax Preparer [English]
- Letter For Tax Preparer [Spanish]
- Open Enrollment 2024
- MassHealth Redetermination Toolkit
- Over 65 Flyers (all available languages)
- Over 65 Flyer (English)
- Flyers for Individuals in LTC (all available languages)
- Flyer for Indivdiduals in LTC (English)
- Open Enrollment 2023
- Open Enrollment 2022
- Open Enrollment 2021
- Updates to Minimum Essential Coverage (August 2020)
- Health Reimbursement Arrangements (August 2020)
- System Update 21 (August 2020)
- MassHealth Eligibility Flexibility Overview (June 2020)
- Where Can I Send Documents (May 2020)
- Open Enrollment 2020
- Open Enrollment 2019:
- Open Enrollment Poster (English)
- Open Enrollment Poster (Spanish)
- New MassHealth Plan Options:
- ACO One-Pager (English)
- ACO One-Pager (Spanish)
- MassHealth Enrollment Guide (English)
- MassHealth Enrollment Guide (Spanish)
- ACO Notices At-a-Glance (An Assister Guide)
- ACO Letter A – ACO Partnership Plan Model (English)
- ACO Letter A – ACO Partnership Plan Model (Spanish)
- ACO Letter B – Primary Care ACO Model (English)
- ACO Letter B – Primary Care ACO Model (Spanish)
- ACO Letter C – MCO Administered ACO Model (English)
- ACO Letter C – MCO Administered ACO Model (Spanish)
- Letter AE – Auto-Assigned (English)
- Letter AE – Auto Assigned (Spanish)
- Letter PSP – Plan Selection Period (English)
- Letter PSP – Plan Selection Period (Spanish)
- Learn, Compare, Enroll Worksheet (English)
- Learn, Compare, Enroll Worksheet (Spanish)
- Enrollment Event Flyer (English)
- Enrollment Event Flyer (Spanish)
- Health Connector Applying and Shopping (11/2/2015)
- HIX Updates – Release 6.0 (July 17, 2015)
- Electronic Funds Transfer (Updated 7/15)
- System Issues Log (Updated 11/21)
Talking Points for Assisters:
ACA Learning Series:
MTF Meetings
- SACA-2 TRAINING
- SUMMER 2023
- Protecting Beneficiaries from Becoming Victims of Healthcare Errors, Fraud, and Abuse
- SPRING 2023
- SPRING 2022
- WINTER 2022
- WINTER 2021
- OCTOBER 2020
- JULY 2020
- APRIL 2020
- JANUARY 2020
- OCTOBER 2019
- JULY 2019
- APRIL 2019
- JANUARY 2019
- OCTOBER 2018
- JULY 2018
- APRIL 2018
- JANUARY 2018
- OCTOBER 2017
- JULY 2017
- APRIL 2017
- OCTOBER 2016
- JULY 2016
- APRIL 2016
- JANUARY 2016
- JULY 2015
- JANUARY 2015
Sample Notices:
Member Communication: