DHS-6939-ENG 1-26 (1.1.0)

Medical Assistance for Employed Persons with Disabilities (MA‑EPD) Good Cause Application

MA-EPD ENROLLEE NAME

DATE OF BIRTH

CASE NUMBER or MHCP MEMBER NUMBER

PHONE NUMBER

EMAIL ADDRESS

STREET ADDRESS

CITY

STATE

ZIP CODE

Good cause for non-payment of your MA-EPD premium may be approved if something happened that was beyond your control or that you could not reasonably foresee.

Answer all questions on this form and give as much detail as possible. If we do not have enough information we will not be able to approve your good cause request.

Your unexpected life event or circumstance may result in a lower MA-EPD premium. Report changes in circumstance that could affect your MA-EPD eligibility or premium amount, like changes in income, job loss or moving to a new address. You must call your county or tribal agency to report the change within 30 days.

Please tell us:

1. Why can't you pay your MA-EPD premium? What was beyond your control or something you could not reasonably foresee?

2. When did this unexpected event occur?

3. What month(s) are you asking for good cause? Good cause cannot be granted for an initial premium or for a month in which a premium was already paid.

4. Is there anything else you would like to tell us to help us understand your good cause request?

Submitted by

Submitter is the MA-EPD Enrollee

NAME

PHONE NUMBER

EMAIL ADDRESS

ROLE/AGENCY

TODAY'S DATE

I certify that all information provided on this form is true and correct.