Client Self Attestation Form - Delaware Health And Social Services printable pdf download

Client Self-Attestation Form

Ineligible for Health Insurance Coverage or Exempt from the Federal Insurance Mandate

With insurance opportunities under the Affordable Care Act, Delaware’s Community Healthcare Access

Program (CHAP) has fulfilled its original purpose to link low-income people to needed health care

services and closed February 1, 2015 for individuals who are eligible for Medicaid or required by law to

have health care coverage.

CHAP has evolved and changed its name to Health Care Connection (HCC). HCC will focus on those

ineligible to purchase health insurance or exempt from the federal insurance mandate. To continue to

receive services, low-income individuals in this category are required to provide proof of their

ineligibility or exemption.

If you are either a U.S. citizen or U.S. national, or an alien lawfully present in the United States, the

Individual Responsibility Provision of the Affordable Care Act requires you and each member of your

family to have basic health insurance coverage, qualify for an exemption or make an individual shared

responsibility payment when you file your federal income tax return. How you get the exemption

depends upon the type of exemption for which you are eligible. You can obtain some exemptions only

from the Health Insurance Marketplace in the area where you live, others only from the IRS, and yet

others from either the Marketplace or IRS.

If you are claiming that you are ineligible or exempt from the federal requirement to have health

insurance, and the option to obtain proof of that exemption from the Marketplace is not available or

required, please check the first item listed in the form below. Although optional, it also would be

helpful if you would indicate the circumstance that makes you exempt or ineligible.

To attest to your ineligibility or exemption, please read and complete this form, provide your contact

information where indicated and sign and return.

Required:

I attest that I am exempt from the federal mandate to have health insurance or ineligible to

____

obtain Medicaid coverage or purchase insurance on the Health Insurance Marketplace.

Optional:

Please indicate the circumstance that makes you ineligible or exempt (optional):

____Coverage is unaffordable, in accordance with the IRS definition of “unaffordable”. This will

be claimed on my tax return.

___My household income is below the return filing threshold, as determined by the IRS.

___Two or more family members’ aggregate cost of self-only employer-sponsored coverage

exceeds 8 percent of household income, as does the cost of any available employer-sponsored

coverage for the entire family. This may only be claimed on tax return.

Client Self-Attestation Form

Delaware Department of Health and Social Services-Division of Public Health

Page 1

Revised June 25, 2015

Client Self Attestation Form - Delaware Health And Social Services