Fitchburg State University
Student Health Insurance Plan
MassHealth Premium Assistance Form

2017/2018 Policy Year

MassHealth members 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)
Student ID: