Client Questionnaire (Page 4 of 4) in pdf

Client Questionnaire Page 4

HEALTH INSURANCE MARKETPLACE EXEMPTIONS

1. Exemption for members of a recognized religious sect

2. Exemption for members of a healthcare sharing ministry

3. Exemption for members of a federally recognized Indian Tribe

4. Exemption for individuals who have been incarcerated

5. Hardship exemptions if:



You were homeless



You were evicted in the past 6 months or were facing eviction or foreclosure



You received a shut-off notice from a utility company



You recently experienced domestic violence



You recently experienced the death of a close family member



You experienced a fire, flood, or other natural or human caused disaster that caused

substantial damage to your property



You filed for bankruptcy in the last 6 months



You had medical expenses you couldn’t pay in the last 24 months



You experienced unexpected increases in necessary expenses due to caring for an ill,

disabled, or aging family member



You expect to claim a child as a tax dependent who has been denied coverage in

Medicaid and the Children’s Health Insurance Program (CHIP), and another person is

required by court order to medical support to the child



As a result of an eligibility appeals decision, you are eligible for enrollment in a qualified

health plan (QHP) through the Marketplace, or lower costs on your monthly premiums,

or cost sharing reductions, for a time period when you were not enrolled in a QHP

through the Marketplace



You were determined ineligible for Medicaid because your state didn’t expand eligibility

for Medicaid under the Affordable Care Act



You received a notice saying that your current health insurance plan is being cancelled,

and you consider the other plans available unaffordable



You experienced another hardship in obtaining health insurance

YOU MUST COMPLETE AN APPLICATION TO APPLY FOR AN EXEMPTION IN WRITING TO THE HEALTH INSURANCE

MARKETPLACE-EXEMPTION PROCESSING. YOU CAN DOWNLOAD APPLICATIONS AT HEALTHCARE.GOV

Client Questionnaire Page 4

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