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The Commonwealth of Massachusetts Executive Office of Health and Human Services MassHealth Premium Assistance Program PO Box 9212, Chelsea, MA 02150

****IMPORTANT NOTICE**** 03/31/2011 STEVEN PERRY 18 SHIPS WHEEL DR MASHPEE, MA 02649

Dear STEVEN PERRY, You and/or one of your family members are currently receiving MassHealth benefits. MassHealth eligibility laws require every member to obtain and maintain available health insurance. Failure to do so may result in a denial of your MassHealth benefits. MassHealth has a program that may assist you in obtaining health insurance through your employer. For individuals and families who get MassHealth benefits, the MassHealth Premium Assistance program helps pay the cost of employer health insurance when cost effective. If your employer sponsored health insurance meets the Premium Assistance program standards, the following may apply: • The Premium Assistance program may assist in paying for your health insurance premiums for a family plan which may include members of your family that are not covered by MassHealth. • Your employer sponsored health insurance may cover more services than your current MassHealth. Please fill out the enclosed forms and return both forms together within 15 days to the address or fax number provided at the top of this letter to avoid changes in your MassHealth eligibility. In order to process your application both forms need to be returned. Your employer needs to comply with all MassHealth regulations and should complete the information on Form #2. If you are not already enrolled in a health plan please do not enroll in any health plan until we have reviewed the plan to meet the Premium Assistance program standards. If we find that it is a qualified plan we will send you a letter. If you have any questions, please call the Premium Assistance Team at the toll-free phone number listed below. Sincerely,

The MSCPA Team Phone: (800) 862-4840 Fax: (617) 451-1332

(888) 291-4464 | Fax (617)...