Get MA SACA-2 2018

MAGI rules to determine eligibility. See the Senior Guide for more information. APPLICATION FOR HEALTH COVERAGE FOR SENIORS AND PEOPLE NEEDING LONG-TERM-CARE SERVICES SACA-2 Rev. 06/16 WHAT YOU NEED WHEN YOU APPLY The following MUST be sent with the application when applying for MassHealth the Health Safety Net and the Massachusetts Health Connector SOCIAL SECURITY NUMBER SSN PROOF OF CITIZENSHIP/NATIONAL STATUS 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. Application for Health Coverage for Seniors and People Needing Long-Term-Care Services HOW TO APPLY Please identify which program each household member is applying for on page 1 of the application* You can submit your application in any of the following ways. Mail or fax your filled-out signed application to Hand deliver your filled-out signed application to MassHealth Enrollment Center Central Processing Unit P. O. Box 290794 The Schrafft Center Charlestown MA 02129-0214 529 Main Street Suite 1M Fax 617-887-8799 MASSHEALTH and the HEALTH SAFETY NET Who Can Use This Application This is your application for health coverage if you live in Massachusetts and are an individual 65 years of age or older and living at home You are the parent of a child under 19 years of age who and lives with you or not the parent of a child under 19 years of age who lives You are an adult relative living with and taking care of a with you or child younger than 19 years of age when neither parent is not an adult relative living with and taking care of a child living in the home or younger than 19 years of age when neither parent is You are disabled and are either working 40 or more hours a month or are currently working and have worked at least an individual of any age and need long-term-care services 240 hours in the six months immediately before the month in a medical institution or nursing facility of the application You will also need to fill out a Long-Term-Care Supplement long-term-care services to live at home or if you are a member of a married couple living with your spouse and in an institution such as a nursing home chronic hospital both you and your spouse are applying for health or other medical institution You may have to pay a monthly coverage payment called a patient-paid amount to the long-term there are no children under 19 years of age living with care facility. For more information see page 14 in the you and Senior Guide. one spouse is 65 years of age or older and the other in an acute hospital waiting for placement in a long-termspouse is under 65 years of age. Please see Part 8 of the application* living in your home and applying for or getting longIf you meet any of the following exceptions you should complete term-care services under a Home- and Community-Based the Application for Health and Dental Coverage and Help Paying Services Waiver. Costs ACA-3. To obtain a copy of this application call us at If someone is helping you fill out this application you may need 1-800-841-2900 TTY 1-800-497-4648 for people who are deaf to fill out a separate form that gives that person permission to hard of hearing or speech disabled.