Please be sure to enter your Member ID WITHOUT
the NSA prefix—only the numbers, no letters.
- Complete Schedule HC when filing your taxes and request an appeal.
- You will receive a Statement of Grounds for Appeal from the MA Department of Revenue. Please complete that when you receive it.
- Submit this Notice from the Plan with your Statement of Grounds for Appeal to the MA Department of Revenue.
- If the MA Department of Revenue or MA Connector request additional information about your coverage, log into Benefits Manager and send the Plan an email (preferred) or email [email protected] and include your first and last name and HCID. Please either include a copy of the request from the MA Department of Revenue or MA Connector or a detailed description of what information is being requested.