MassHealth
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth

For office use only

Customer account #:


Date received: 

Application for Waiver 
or Reduction of 
MassHealth Premium

Return this form to: 
MassHealth Customer Service, Attn: Premium Billing, P.O. Box 120049, Boston, MA 
02112

To get a MassHealth Premium Hardship Waiver, you must meet one of the hardships 
described below. You must give MassHealth 
proof of your financial hardship. Hardship waivers are good for six months. You 
will not get billed for premiums during the 
approved hardship period.

The start date cannot be more than three months before the date that MassHealth 
gets your waiver application.

If you have any questions about this form or a premium billing payment plan or 
if you need a new hardship waiver application, 
please call MassHealth Customer Service at 1-800-841-2900 (TTY: 1-800-497-4648 
for people with partial or total hearing 
loss).

Applicant information

Last name First name Middle initial

MassHealth ID no. Daytime phone no.

Street address 

City State Zip

Details of hardship

Please check all of the boxes below that relate to your or your family’s extreme 
financial hardship.

 I am more than 30 days late paying my rent or mortgage, have an eviction 
notice, or am homeless. Please send in a 
copy of any notices from your landlord, bank or mortgage company, or court as 
proof.

 I have a shut-off notice from a utility company (gas, electric, oil, water, or 
telephone), one or more of my utilities has 
been shut off, or one or more of my utility companies will not deliver services 
because I cannot pay. (If you have a 
large or long-overdue utility bill, but you cannot be shutoff because you are 
disabled or it is winter, check this section.) 
Please send in a copy of your shut-off notice or overdue bill as proof.

 I have high medical and/or dental bills. These bills are more than 7.5% of my 
gross annual income. The bills may be 
for me or for someone else in my immediate family (such as a child or a spouse). 
They cannot be paid for by Health 
Safety Net or any other health insurance, including MassHealth. Please send in 
copies of these medical bills as proof.

 In the past six months, I have had a large, unexpected increase in basic 
expenses. Please tell us about the expenses in 
the Comments section and send proof of the amount.

HW (Rev. 10/09) over 





If your hardship waiver is approved and your account has a past-due balance, 
MassHealth will start a payment plan for you 
for the past-due amount. You will get a separate premium billing statement. If 
you do not make payments according to the 
payment plan, you will lose your hardship waiver. 

At the end of the six months of the hardship waiver, you can ask for another 
hardship waiver if you think you are still eligible.

Comments

If you need more space, please attach a separate sheet.

I certify that I have read or had read to me the information on this 
application. I understand my rights and responsibilities. 
I certify under the penalty of perjury that the information on this application 
and any papers added to it is correct and 
complete to the best of my knowledge.

If you are acting for someone in filling out this form, you must be active on 
our computer system as a MassHealth Eligibility 
Representative (ERD). If you are not, you must fill out an ERD form and send it 
back with this application.

Your signature or the signature of your eligibility representative on this 
application certifies that the information on this 
form is correct and complete to the best of your knowledge.

Signature of member Date

Signature of eligibility representative Date

X

X