Becker College
MassHealth Premium Assistance Form
2018-2019 Policy Year

YOU HAVE REACHED THE MASSHEALTH PREMIUM ASSISTANCE FORM

The MassHealth Premium Assistance program is not voluntary. If you are eligible for Premium Assistance, then you are expected to complete this form. To learn more about the application process, please click here. If you fail to complete the form, you jeopardize your MassHealth benefits.

Upon approval, you will be enrolled in the Student Blue Cross Blue Shield (BCBS) plan and this will replace your MCO/ACO. Your coverage under MassHealth will remain active. The Student BCBS premium is paid for by MassHealth and the insurance charge will be removed from your student account. You must show both your BCBS ID and MassHealth ID for providers to coordinate your benefits. For additional information about MHPA, please click here.

 

COMPLETE THE FIELDS BELOW TO CONTINUE:

First Name:
Last Name:
Student ID:  (7 digits including leading zeros)