Application For Health Coverage & Help Paying Costs Page 8

Download a blank fillable Application For Health Coverage & Help Paying Costs in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Application For Health Coverage & Help Paying Costs with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

Page 7 of 7

STEP 5:

Your agreement & signature

1. Do you agree to allow the Marketplace to use income data, including information from tax returns,

for the next 5 years? ..........................................................................................................................................................................................

Yes

To make it easier to determine your eligibility for help paying for coverage in future years, you can agree to allow the Marketplace to use updated income data,

including information from tax returns. The Marketplace will send a notice and let you make any changes. The Marketplace will check to make sure you’re still

eligible, and may have to ask you to prove that your income still qualifies. You can opt out at any time.

If no, automatically update my information for the next:

4 years

2 years

Don’t use my tax data to renew my eligibility for help paying for health coverage

(selecting this option may impact your ability to get help paying for coverage at renewal.)

3 years

1 year

2. Is anyone applying for health insurance on this application incarcerated (detained or jailed)? ..................................................................

Yes

If yes, tell us the person’s name. The name of the incarcerated person is:

Fill in here if this person is facing

disposition of charges.

If anyone on this application is eligible for Medicaid:

•

I’m giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third

parties. I’m also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

•

Does any child on this application have a parent living outside of the home? .................................................................................................

Yes

•

If yes, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to

collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.

•

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my

knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

• I know that I must tell the Health Insurance Marketplace within 30 days if anything changes (and is different than) what I wrote on this

application. I can visit

HealthCare.gov

or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect

my eligibility as well as eligibility for member(s) of my household.

• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender

identity, or disability. I can file a complaint of discrimination by visiting

•

I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for

lawful purposes of the Marketplace and programs that help pay for coverage.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using

information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland

Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

What should I do if I think my eligibility results are wrong?

If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to find appeals

instructions specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here’s

important information to consider when requesting an appeal:

•

You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual.

Or, you can request and participate in your appeal on your own.

•

If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.

•

The outcome of an appeal could change the eligibility of other members of your household.

To appeal your Marketplace eligibility results, visit HealthCare.gov/marketplace-appeals/. Or call the Marketplace Call Center at 1-800-318-2596.

TTY users should call 1-855-889-4325. You can also mail an appeal request form or your own letter requesting an appeal to Health Insurance

Marketplace, Dept. of Health and Human Services, 465 Industrial Blvd., London, KY 40750-0001. You can appeal eligibility for purchasing health

coverage through the Marketplace, enrollment periods, tax credits, cost-sharing reductions, Medicaid, and CHIP, if you were denied these. If you

qualify for tax credits or cost-sharing reductions, you can appeal the amount we determined you’re eligible for. Depending on your state, you may be

able to appeal through the Marketplace or you may have to request an appeal with the state Medicaid or CHIP agency.

PERSON 1 should sign this application. If you’re an authorized representative, you may sign here as long as PERSON 1 signed Appendix C.

Signature

Date signed (mm/dd/yyyy)

If you’re signing this application outside of Open Enrollment (between November 1 and December 15), make sure you review Appendix D

(“Questions about life changes”).

STEP 6:

Mail completed application

Mail your signed application to:

If you want to register to vote, you can complete a

Health Insurance Marketplace

voter registration form at

Dept. of Health and Human Services

465 Industrial Blvd.

London, KY 40750-0001

NEED HELP WITH YOUR APPLICATION?

Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a

language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325.