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? …………………………
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
3 years 1 year
(selecting this option may impact your ability to get help paying for coverage at renewal.)
2. Is anyone applying for health insurance on this application incarcerated (detained or jailed)?………………….
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 No
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 www.hhs.gov/ocr/office/file.
willbeusedonlytodetermineeligi bilityforhealthcoverage, helppayingforcoverage( ifrequested),andfor 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.
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”).