UMASS-Worcester New Students
Student Health Insurance Plan
MassHealth Premium Assistance Form

2018-2019 Policy Year

In order to qualify for MassHealth Premium Assistance, the SHIP plan must be cost effective for MassHealth to purchase. Whether it is cost effective depends on what MassHealth coverage type you have and what the SHIP premium is. Given the SHIP premium for the 2018-2019 academic year, if you are in MassHealth Standard for non-disabled members or in Family Assistance, you will not qualify for premium assistance for the SHIP plan and will not be required to enroll. However, you may still use your MassHealth coverage to waive the SHIP requirement and keep MassHealth coverage as your primary coverage. Although a check to determine if you qualify for MassHealth Premium Assistance will still occur, we wanted to let you know you may not be approved for the MHPA program due to the cost of the 2018-2019 SHIP premium.

MassHealth members who are eligible will be enrolled in the Student Health Insurance Plan (SHIP), the premium will be paid by MassHealth and waived from your student account. The benefits include access to a larger network of in-state providers as well as out-of-state and out-of-country coverage.

The MassHealth Premium Assistance program for students is not voluntary. If you are eligible for Premium Assistance, then you are expected to complete this process. If you fail to complete the form and therefore not enroll in SHIP you may lose your MassHealth benefits.

Upon approval of your request, your coverage under MassHealth will remain active and you must show both your MassHealth ID and Student Blue Cross Blue Shield ID for providers to coordinate your benefits. To learn more about the program click on the following links:FAQs and Coordination of Benefits.

 

COMPLETE THE FIELDS BELOW TO CONTINUE:

First Name:
Last Name:
Date of Birth:  (MM/DD/YYYY)
Last 4 Digits of Social Security Number: