Enroll in or change your health plan

Use this form to choose your MassHealth health plans.

You have a 90-day Plan Selection Period each year. You can change your health plan during this time. MassHealth will tell you when your new Plan Selection Period starts and ends. During that period, you can change health plans for any reason.

If you are in an ACO or MCO, when your Plan Selection Period ends you will enter your Fixed Enrollment Period. During this time you cannot change your health plan, except for certain reasons.

To learn more about health plan choices available, go to www.masshealthchoices.com.

Is this form for you?

Certain members in the MassHealth program will need to enroll in a health plan. Use this form to choose your MassHealth health plans if you:

Are under 65
Do not have other insurance (including Medicare)
Live in a community (for example, not in a nursing facility), and
Are in MassHealth Standard, CommonHealth, CarePlus, or Family Assistance.

If you have questions about your plan options or to check if you are in a Plan Selection Period, please call MassHealth Customer Service 1-800-841-2900 (TTY: 1-800-497-4848), Monday through Friday between the hours of 8:00 a.m. and 5:00 p.m.

This is NOT an application to apply for MassHealth. If you need to apply for MassHealth, go to www.MAhealthconnector.org.

Step 1: Enter your member information

First Name

Last Name

Street Address

MassHealth Member ID (12-digit member identification number)

Street Address - Apartment or Additional Address

Last 4 digits of Social Security Number

City

State

ZIP Code

Best number to reach you

E-Mail Address

Please indicate the best time to reach you.

Step 2: Choose your health plan

To compare health plan options available, go to www.masshealthchoices.com/compare.

Based on your zip code, you will need a Service Area exception to enroll in any plans that are not on this list.
Do you think you meet one of the following Service Area exceptions? Please tell us why:

I have an established relationship with a provider who participates in a health plan that is not listed.
I am homeless and a specific Accountable Care Partnership Plan would better support my needs
The Accountable Care Partnership Plan would significantly support my

- language, communication, or cultural needs;

- specialized health care needs; or

- other accessibility needs.

Tell us in more detail about why you are making this request and which plan you would like to select

500 characters remaining **

Let us know which health plan you want

Step 3: Tell us about your primary care provider (PCP)

You must choose a primary care provider (PCP).

To search for a PCP or Primary Care site (ex. health center) that accepts MassHealth health plans, go to www.masshealthchoices.com/compare/find-primary-care-provider.

Please note: If you do not choose a MassHealth health plan, MassHealth will pick a MassHealth health plan for you. If you pick a MassHealth health plan, but not a PCP, the MassHealth health plan will assign a PCP to you.

PCP / Primary Care Site Name

PCP / Primary Care Site Street Address

City

State

ZIP Code

Phone Number

Step 4: Tell us if you have other health care coverage

Name of your plan

Policy Holder

Policy ID

Step 5: Submit the form

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