MassHealth has released criteria and a specific form to use to request an exemption from the requirement to pay a premium. The check-off options on the form are:

• I am homeless, or am more than 30 days behind in rent or mortgage payments, or have received an eviction or foreclosure notice.
• I have a shut-off notice from my utility company (gas, electric, oil, water, or telephone), OR one or more of my utilities has been shut off, OR one or more of my utility companies is refusing to deliver services because I cannot pay. (Members with a large or long overdue utility bill, but who are protected from shutoff because of disability or because it is winter, should check this section.)
• I have high medical and/or dental bills that MassHealth or another insurance does not pay for. These bills may be for me or for someone else in my immediate family (such as a child or a spouse).
• I have had a large unexpected increase in expenses within the last six months.

The form will be posted shortly on the staff access area of the department's webpage, in the MassHealth section.

06/2004