Navigator Designation Form

Use this form to choose a Navigator to help you with applying for or getting health benefits.

Navigators help you apply for or enroll in health benefits through cost savings programs. The programs are available through MassHealth (Medicaid) and the Massachusetts Health Connector. The HealthConnector is Massachusetts’ health insurance Marketplace.

Fill out and submit your application and other forms related to eligibility and enrollment Give proof of information from eligibility and enrollment forms, such as proof of identity Report changes in your income, address, or other circumstances Get copies of notices sent to you Your Navigator must give you a copy, or read you the terms, of any application or form they submit for you. Your Navigator will use the information you give them only to help you apply for or get benefits. The Navigator must keep your information private.

Each adult member of your household who wants help from a Navigator must fill out a separate form. You can send us your completed forms in one of these ways:

Call: 1-800-841-2900 (TTY: 1-800-466-7566) Fax: 1-617-887-8777 Health Insurance Processing Center Mail: P.O. Box 4405 Taunton, MA 02780

Visit MAhealthconnector.org or call 1-800-841-2900 (TTY: 1-800-497-4648) Fax: 1-617-887-8777. Monday to Friday, 8 a.m. to 5 p.m. The call is free.

Navigator Program Information (continued)

What is the Navigator Program?

The Navigator Program is an education and enrollment program. The federal Patient Protection and Affordable Care Act (ACA) requires every Health Insurance Marketplace to have a Navigator Program.

In Massachusetts, Navigators help individuals, families and small businesses:

Learn about health care coverage choices Enroll in a health plan Get help paying for coverage through federal tax credits and other state and federal programs

Can I choose a different Navigator or stop using a Navigator?

Yes. Tell your Navigator you want a different Navigator or you no longer want a Navigator’s help.

If you want a different Navigator, you will need to fill out this form again with your new Navigator’s information.

Visit MAhealthconnector.org or call 1-800-841-2900 (TTY: 1-800-497-4648) Fax: 1-617-887-8777. Monday to Friday, 8 a.m. to 5 p.m. The call is free.

I certify that I have chosen the following person or organization to be my Navigator, that I understand the duties and responsibilities this person or organization will have (as explained earlier in this form), and that by signing this Navigator Designation Form I am authorizing this person or organization to take any of the actions (including receiving notices) on my behalf that are described in the first paragraph of this form.

I further certify under the pains and penalties of perjury that the information that I provide to the person or organization named below in connection with the application, eligibility and enrollment processes is true and complete to the best of my knowledge. I understand that the information that I provide to my Navigator will be used in connection with applying for or getting health benefits, and that such information may be shared with and/or used by other organizations, including the Health Connector and MassHealth, in connection with determining my qualification for such benefits. Recipients of such information, including the person or organization named below, the Health Connector and MassHealth, will maintain the confidentiality of such information in accordance with applicable law.

This designation will not end until I revoke it (as explained earlier in this form

Visit MAhealthconnector.org or call 1-800-841-2900 (TTY: 1-800-497-4648) Fax: 1-617-887-8777. Monday to Friday, 8 a.m. to 5 p.m. The call is free.

I will at all times during the enrollment process accurately write the information given by the applicant or member named above. I will complete my duties, as described in the first paragraph of this form, unless my designation as this person’s Navigator is revoked (ended I have verified the applicant’s identity with proper proof presented by the applicant, if applicable. I will not submit any applications, forms or proof of information on behalf of an applicant or member, or report changes in an applicant’s or member’s circumstances, unless authorized by the applicant or member to do so. I understand my duties and responsibilities as this person’s Navigator, as explained earlier in this form.

Visit MAhealthconnector.org or call 1-800-841-2900 (TTY: 1-800-497-4648) Fax: 1-617-887-8777. Monday to Friday, 8 a.m. to 5 p.m. The call is free.