Application For Health Coverage & Help Paying Costs

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09/2017

Application for Health Coverage & Help Paying Costs

Form Approved

OMB No. 0938-1213

Apply faster online at HealthCare.gov

Affordable private health insurance plans that offer comprehensive coverage to

•

Use this application

help you stay well.

to see what coverage

A new tax credit that can immediately help pay your premiums for

•

you qualify for

health coverage.

Free or low-cost coverage from Medicaid or the Children’s Health Insurance

•

Program (CHIP).

You may qualify for a free or low-cost program, even if you earn as much as

$98,400 a year (for a family of 4).

Use this application to apply for anyone in your family.

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Who can use this

Apply even if you or your child already has health coverage. You could

•

application?

be eligible for lower-cost or free coverage.

If you’re single, you may be able to use a short form. Visit HealthCare.gov.

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Families that include immigrants can apply. You can apply for your child even if

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you aren’t eligible for coverage. Applying won’t affect your immigration status

or chances of becoming a permanent resident or citizen.

If someone is helping you fill out this application, you may need to complete

•

Appendix C.

Social Security Numbers (or document numbers for any eligible immigrants

•

What you may

who need coverage).

need to apply

Employer and income information for everyone in your family (for example,

•

from pay stubs, W-2 forms, or wage and tax statements).

Policy numbers for any current health insurance.

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Information about any job-related health insurance available to your family.

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We ask about income and other information to let you know what coverage

Why do we ask for

you qualify for and if you can get any help paying for it. We’ll keep all the

this information?

information you provide private and secure, as required by law. To view the

Privacy Act Statement, visit

HealthCare.gov

or see instructions.

Send your complete, signed application to the address on page 7. If you don’t

What happens

have all the information we ask for, sign and submit your application

next?

anyway. We’ll follow up with you within 1–2 weeks, and you may receive a call

from the Marketplace if we need more information. You’ll get an eligibility

determination letter in the mail after your application is processed. If you don’t

hear from us, contact the Marketplace Call Center. Filling out this application

doesn’t mean you have to buy health coverage.

Online: HealthCare.gov.

•

Get help with this

Phone: Call the Marketplace Call Center at 1-800-318-2596. TTY users should

•

application

call 1-855-889-4325.

In person: There may be counselors in your area who can help. Visit

•

HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for

more information.

En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.

•

Other languages: If you need help in a language other than English, call

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1-800-318-2596 and tell the customer service representative the language you

need. We’ll get you help at no cost to you.

You have the right to get the information in this product in an alternate format.

You also have the right to file a complaint if you feel you’ve been discriminated

against. Visit

cmsnondiscriminationnotice.html, or call the Marketplace Call Center at

1-800-318-2596 for more information. TTY users should call 1-855-889-4325.

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control

number. The valid OMB control number for this information collection is 0938-1191. The time required to complete this information collection is estimated to average 45 minutes per

response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments

concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop

C4-26-05, Baltimore, Maryland 21244-1850.