Massachusetts Health Connector
You hereby authorize Stride Health, Inc. to act as your Broker of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on the Massachusetts Health Connector. By submitting your application, you agree to the Massachusetts Health Connector Privacy Policy, Terms of Use, Disclaimer and Accessibility Statement. You also acknowledge and agree to the following:
All of the material posted on this website and accessible to the public without use of an authenticating and authorizing mechanism (such as a “PIN” or password) is public record. Most of the public record posted on Commonwealth websites can be copied and used for any purpose. For example, all regulations and all laws and regulations are public record.
With respect to material copyrighted by the Commonwealth, including the design, layout, and other features of this website, the Massachusetts Health Connector forbids any copying or use other than “fair use” under the Copyright Act. “Fair use” includes activities such as criticism, comment, news reporting, teaching, research, and other related activities. In addition, please be advised that the Massachusetts Health Connector makes use of materials (including, but not limited to, photographs) copyrighted by third parties, which also cannot be copied or used for use other than “fair use” without permission of the copyright owner. If you want to make use other than “fair use” of any copyrighted information on this website, you must seek permission directly from the copyright owner.
The Massachusetts Health Connector makes no warranty that the materials contained within this website are free from copyright claims, or other restrictions or limitations on free use or display. The Massachusetts Health Connector disclaims any liability for the improper or incorrect use of information obtained from this website. You agree that your use of this Site and any disputes relating thereto shall be governed in all respects by the laws of the Commonwealth of Massachusetts. Any dispute relating to this Agreement shall be resolved solely in the state courts located in Boston, Massachusetts.
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.
Eligible persons may have to pay a premium for health coverage for themselves 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 an eligible person is a certain American Indian or Alaska Native, such person 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, 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.
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 lawsuits 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, 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 such property and it is 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 55 years of age or older, or any eligible person for whom MassHealth helps pay for care in a nursing home, MassHealth will seek money from the eligible person’s estate after death.
MassHealth, the 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. 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 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.
I agree to the following statements:
I have read or have had read to me the information on this application, including any supplements and instruction pages, and I understand that the Member Booklet contains important information.
I have permission from all persons listed on this application (or their parent or other legally authorized representative) to submit this application and to act on their behalf to complete this application and any ongoing or subsequent eligibility process and activity, including, for example:
providing personal information about them, including health, health coverage, and income information, seeing such information as may be provided by the Health Connector, MassHealth, and the Health Safety Net, and providing consent on their behalf to the use and disclosure of their information as described in this application;
making choices about coverage options and methods of communication with the Health Connector, MassHealth, and the Health Safety Net;
making changes to the application or related eligibility documents and providing information about any change in their circumstances; and
providing consent on their behalf to use government and private sources to verify information as described in this application.
I understand my rights and responsibilities and the rights and responsibilities of all persons listed on this application as explained in this Step 6.
I have told or will tell all such persons (or their parent or legally authorized representative, if applicable) about these rights and responsibilities so they understand them.
I understand and agree that MassHealth, the Health Safety Net, and the Health Connector will treat electronic, faxed, or copies of signatures with the same force and effect as an original signature(s).
The information I have supplied is correct and complete to the best of my knowledge about myself and other persons listed on this application.
I may be subject to penalties under federal law if I intentionally provide false or untrue information.