Form CMS-10440 AttachmentC-Application for Health Coverage & Help Payin

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and Children's Health Insurance Program Agencies

CMS-10440.AttachmentC-Application for Health Coverage & Help Paying Costs

Individual Application

OMB: 0938-1191

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1191 can be found here:

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04.24.13

Application for Health Coverage & Help Paying Costs
Use this application
to see what
coverage choices
you qualify for

•

Who can use this
application?

•
•

THINgS To kNoW

•
•

•

Apply faster
online
What you may
need to apply

Use this application to apply for anyone in your family.
Apply even if you or your child already has health coverage. You could
be eligible for lower-cost or free coverage.
If you’re single, you may be able to use a short form. Visit HealthCare.gov.
Families that include immigrants can apply. You can apply for your
child even if 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.

Apply faster online at HealthCare.gov.

•
•
•
•

Why do we ask for
this information?

Affordable private health insurance plans that offer comprehensive
coverage to help you stay well
A new tax credit that can immediately help pay your premiums for
health coverage
Free or low-cost insurance 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 $94,000 a year (for a family of 4).

Social Security Numbers (or document numbers for any legal immigrants
who need insurance)
Employer and income information for everyone in your family (for
example, from paystubs, W-2 forms, or wage and tax statements)
Policy numbers for any current health insurance
Information about any job-related health insurance available to your family

We ask about income and other information to let you know what coverage
you qualify for and if you can get any help paying for it. We’ll keep all the
information you provide private and secure, as required by law.

What happens next?

Send your complete, signed application to the address on page 7. If you
don’t have all the information we ask for, sign and submit your application
anyway. We’ll follow-up with you within 1–2 weeks. You’ll get instructions
on the next steps to complete your health coverage. If you don’t hear from
us, visit HealthCare.gov or call 1-800-XXX-XXXX. Filling out this application
doesn’t mean you have to buy health coverage.

Get help with this
application

•
•
•

•

Online: HealthCare.gov
Phone: Call our Help Center at 1-800-XXX-XXXX.
In person: There may be counselors in your area who can help.
Visit our website or call 1-800-XXX-XXXX for more information.
En Español: Llame a nuestro centro de ayuda gratis al 1-800-XXX-XXXX.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX, and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

STEP 1

Tell us about yourself.

(We need one adult in the family to be the contact person for your application.)
1. First name, Middle name, Last name, & Suffix
2. Home address (Leave blank if you don’t have one.)
4. City

3. Apartment or suite number
5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)
10. City

9. Apartment or suite number
11. State

14. Phone number

(

)

12. ZIP code

13. County

15. other phone number

–

(

16. Do you want to get information about this application by email?

)
Yes

–
No

Email address:
17. Preferred spoken or written language (if not English)

STEP 2

Tell us about your family.

Who do you need to include on this application?
Tell us about all the family members who live with you. If you file taxes, we need to know about everyone on your tax
return. (You don’t need to file taxes to get health coverage).
DO Include:
• Yourself
• Your spouse
• Your children under 21 who live with you
• Your unmarried partner who needs health coverage
• Anyone you include on your tax return, even if they
don’t live with you
• Anyone else under 21 who you take care of and lives
with you

You DON’T have to include:
• Your unmarried partner who doesn’t need health
coverage
• Your unmarried partner’s children
• Your parents who live with you, but file their own tax
return (if you’re over 21)
• other adult relatives who file their own tax return

The amount of assistance or type of program you qualify for depends on the number of people in your family and their
incomes. This information helps us make sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have
more than 2 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide
immigration status or a Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all
the information you provide private and secure as required by law. We’ll use personal information only to check if you’re
eligible for health coverage.

STEP 2: PERSON 1 (Start with yourself)
Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax
return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add family
members who live with you.
1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

SELF
3. Date of birth (mm/dd/yyyy)

Male

4. Sex

Female

5. Social Security number (SSN)
We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too
since it can speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with
health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call
1-800-325-0778.
6. Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)

YES. If yes, please answer questions a–c.
a. Will you file jointly with a spouse?

NO. If no, skip to question c.

Yes

If yes, name of spouse:
b. Will you claim any dependents on your tax return?

Yes

If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return?

Yes

If yes, please list the name of the tax filer:
How are you related to the tax filer?
7. Are you pregnant?

No a. If yes, how many babies are expected during this pregnacy?

Yes

8. Do you need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.

NO. If no, SkIP to the income questions on page 3.
Leave the rest of this page blank.

9. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily
chores, etc) or live in a medical facility or nursing home?
10. Are you a U.S. citizen or U.S. national?

Yes

11. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Yes. Fill in your document type and ID number below.
a. Immigration document type

b. Document ID number

c. Have you lived in the U.S. since 1996?

Yes

d. Are you, or your spouse or parent a veteran or an active-duty
member of the U.S. military?
Yes
No

12. Do you want help paying for medical bills from the last 3 months?

Yes

13. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?
14. Are you a full-time student?

Yes

15. Were you in foster care at age 18 or older?

Yes

16. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

other

17. Race (OPTIONAL—check all that apply.)
White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
korean

Vietnamese
other Asian
Native Hawaiian

guamanian or Chamorro
Samoan
other Pacific Islander
other

STEP 2: PERSON 1 (Continue with yourself)
Current Job & Income Information
Employed
If you’re currently employed, tell
us about your income. Start with
question 18..

Not employed
Skip to question 28.

Self-employed
Skip to question 27.

CURRENT JOB 1:
18. Employer name and address

19. Employer phone number

(
20. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

)

Monthly

–
Yearly

$
21. Average hours worked each WEEk

CURRENT JOB 2:

(If you have more jobs and need more space, attach another sheet of paper.)

22. Employer name and address

23. Employer phone number

(
24. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

)

Monthly

–
Yearly

$
25. Average hours worked each WEEk

26. In the past year, did you:

Change jobs

Stop working

Start working fewer hours

None of these

27. If self-employed, answer the following questions:
a. Type of work

b. How much net income (profits once business expenses are
paid) will you get from this self-employment this month?

$
28. OTHER

INCOmE THIS mONTH: Check all that apply, and give the amount and how often you get it.

NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None
Unemployment

How often?

Pensions

How often?

Net farming/fishing

Social Security

How often?

Net rental/royalty

How often?

other income

How often?

Retirement accounts

How often?

Alimony received

How often?

Type:

29. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.
If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health
coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 27b).
Alimony paid

How often?

other deductions

Student loan interest

How often?

Type:

30.

How often?

YEARLY INCOmE: Complete only if your income changes from month to month.

If you don’t expect changes to your monthly income, skip to the next person.
Your total income this year

Your total income next year (if you think it will be different)

THANKS! This is all we need to know about you.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX, and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.
Page 3 of 7

STEP 2: PERSON 2
Complete Step 2 for yourself, your spouse/partner, and children who live with you and/or anyone on your same federal income tax
return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add family
members who live with you.
1. First name, Middle name, Last name, & Suffix

2. Relationship to you?

3. Date of birth (mm/dd/yyyy)

4. Sex

Male

Female

5. Social Security number (SSN)
We need this if you want health coverage and have an SSN.
6. Does PERSoN 2 live at the same address as you?

Yes

If no, list address:
7. Does PERSON 2 plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)

Yes. If yes, please answer questions a–c.
a. Will PERSoN 2 file jointly with a spouse?

Yes

No. If no, skip to question c.
No

If yes, name of spouse:
b. Will PERSoN 2 claim any dependents on his or her tax return?

Yes

c. Will PERSoN 2 be claimed as a dependent on someone’s tax return?

Yes

If yes, list name(s) of dependents:
No

If yes, please list the name of the tax filer:
How is PERSoN 2 related to the tax filer?

8. Is PERSoN 2 pregnant?

No a. If yes, how many babies are expected during this pregnacy?

Yes

9. Does PERSON 2 need health coverage?
(Even if they have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.

NO. If no, SkIP to the income questions on page 5.
Leave the rest of this page blank.

10. Does PERSoN 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing,
daily chores, etc) or live in a medical facility or nursing home?
Yes
No
11. Is PERSoN 2 a U.S. citizen or U.S. national?

Yes

12. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Yes. Fill in their document type and ID number below.
a. Document type

b. Document ID number

c. Has PERSoN 2 lived in the U.S. since 1996?
13. Does PERSoN 2 want help paying for
medical bills from the last 3 months?
Yes

Yes

d. Is PERSoN 2, or their spouse or parent a veteran or an activeduty member in the U.S. military?
Yes
No

14. Does PERSoN 2 live with at least one child
under the age of 19, and are they the main
person taking care of this child?
Yes
No

15. Was PERSoN 2 in foster care at
age 18 0r older?
Yes

Please answer the following questions if PERSON 2 is 22 or younger:
16. Did PERSoN 2 have insurance through a job and lose it within the past 3 months?
a. If yes, end date:

Yes

b. Reason the insurance ended:

17. Is PERSoN 2 a full-time student?

Yes

18. If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

other

19. Race (OPTIONAL—check all that apply.)
White
Black or African
American

American Indian or
Alaska Native
Asian Indian
Chinese

Filipino
Japanese
korean

Vietnamese
other Asian
Native Hawaiian

guamanian or Chamorro
Samoan
other Pacific Islander
other

Now, tell us about any income from PERSON 2 on the back.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX, and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.
Page 4 of 7

STEP 2: PERSON 2
Current Job & Income Information

CURRENT JOB 1:
20. Employer name and address

21. Employer phone number

(
22. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

)

Monthly

–
Yearly

$
23. Average hours worked each WEEk

CURRENT JOB 2:

(If you have more jobs and need more space, attach another sheet of paper.)

24. Employer name and address

25. Employer phone number

(
26. Wages/tips (before taxes)

Hourly

Weekly

Every 2 weeks

Twice a month

)

Monthly

–
Yearly

$
27. Average hours worked each WEEk

28. In the past year, did PERSON 2:

Change jobs

Stop working

Start working fewer hours

None of these

29. If self-employed, answer the following questions:
a. Type of work

b. How much net income (profits once business expenses are
paid) will you get from this self-employment this month?

$
30. OTHER

INCOmE THIS mONTH: Check all that apply, and give the amount and how often you get it.

NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None
Unemployment

How often?

Pensions

How often?

Net farming/fishing

Social Security

How often?

Net rental/royalty

How often?

Retirement accounts

How often?

other income

Alimony received

How often?

Type:

How often?

31. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.
If PERSoN 2 pays for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of
health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).
Alimony paid

How often?

other deductions

Student loan interest

How often?

Type:

32.

How often?

YEARLY INCOmE: Complete only if PERSON 2’s income changes from month to month.

If you do not expect changes to PERSoN 2 (pages 4 and 5) and complete.
PERSoN 2’s total income this year

PERSoN 2’s total income next year (if you think it will be different)

THANKS! This is all we need to know about PERSON 2. If you have more than two
people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX, and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.
Page
Page 5
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STEP 3

American Indian or Alaska Native (AI/AN) family member(s)

1. Are you or is anyone in your family American Indian or Alaska Native?
If No, skip to Step 4.
Yes. If yes, go to Appendix B.

STEP 4

Your Family’s Health Coverage

Answer these questions for anyone who needs health coverage.

1. Is anyone enrolled in health coverage now from the following?
Yes. If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.

Medicaid

Employer insurance

CHIP

Name of health insurance:

Medicare
TRICARE (Don’t check if you have direct care or Line of Duty)

VA health care programs
Peace Corps

No.

Policy number:
Is this CoBRA coverage?
Is this a retiree health plan?

Yes
Yes

No
No

other
Name of health insurance:
Policy number:
Is this a limited-benefit plan (like a school accident policy)?
Yes

2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s
job, such as a parent or spouse. Check yes even if you are not enrolled in the plan.
YES. If yes, you’ll need to complete and include Appendix A. Is this a state employee benefit plan?

Yes

NO. If no, continue to Step 5.

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-XXXX. The time required
to complete this information collection is estimated to average [Insert Time (hours or 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.

STEP 5

Read & sign this application.

•

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 penalities under federal law if I provide false
and or untrue information.

•

I know that I must tell the Health Insurance Marketplace if anything changes (and is different than) what I wrote
on this application. I can visit HealthCare.gov or call 1-800-XXX-XXXX to report any changes. I understand that a
change in my information could affect the 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.
I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,
is incarcerated.

•

(name of person)

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.

Renewal of coverage in future years
To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the
Marketplace to use income data, including information from tax returns. The Marketplace will send me a notice, let me
make any changes, and I can opt out at any time.
Yes, renew my eligibility automatically for the next
5 years (the maximum number of years allowed), or for a shorter number of years:
4 years

3 years

2 years

1 year

Don’t use information from tax returns to renew my coverage.

If anyone on this application is eligible for medicaid:
•

I am giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal
settlements, or other third parties. I am 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?

•

If yes, I know I will 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.

Yes

my right to appeal:
•

If I think the Health Insurance Marketplace or Medicaid/Children’s Health Insurance Program (CHIP) has made a
mistake, I can appeal its decision. To appeal means to tell someone at the Health Insurance Marketplace or Medicaid/
CHIP that I think the action is wrong, and ask for a fair review of the action. I know that I can find out how to appeal
by contacting the Marketplace at 1-800-XXX-XXXX. I know that I can be represented in the process by someone other
than myself. My eligibility and other important information will be explained to me.

Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized representative
you may sign here, as long as you have provided the information required in Appendix C.
Signature

STEP 6

Date (mm/dd/yyyy)

mail completed application.

Mail your signed application to:

Health Insurance marketplace
1005 XYZ Drive
Washington, DC 20005
If you want to register to vote, you can complete a voter registration form at XXXXX.gov.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX, and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.
Page 7 of 7

04.24.13

APPENDIX A
Health Coverage from Jobs
You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job.
Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.
Take the Employer Coverage Tool on the next page to the employer who offers coverage to help you answer
these questions. You only need to include this page when you send in your application, not the Employer Coverage
Tool.

EMPLOYEE Information
1. Employee name (First, Middle, Last)

2. Employee Social Security number
-

EMPLOYER Information
3. Employer name

4. Employer Identification Number (EIN)

5. Employer address

6. Employer phone number

(
7. City

)

–

8. State

9. ZIP code

10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above)

(

)

12. Email address

–

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you’re in a waiting or probationary period, when can you enroll in coverage?

(mm/dd/yyyy)

List the names of anyone else who is eligible for coverage from this job.
Name:

Name:

No (Stop here and go to Step 5 in the application)

Tell us about the health plan offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?

Yes

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans):
If the employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum
discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

16. What change will the employer make for the new plan year (if known)?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to
the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See
question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

Date of change (mm/dd/yyyy):

* An employer-sponsored health plan meets the “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the
plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

04.24.13

EMPLOYER COVERAGE TOOL
Use this tool to help answer questions in Appendix A about any employer health coverage that you’re eligible for (even
if it’s from another person’s job, like a parent or spouse). The information in the numbered boxes below match the boxes
on Appendix A. For example, the answer to question 14 on this page should match question 14 on Appendix A.
Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form.
Complete one tool for each employer that offers health coverage.

EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last)

2. Social Security Number
-

EMPLOYER Information

Ask the employer for this information.
3. Employer name

4. Employer Identification Number (EIN)

5. Employer address (the Marketplace will send notices to this address)

6. Employer phone number

(
7. City

)

8. State

–
9. ZIP code

10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address

(

)

–

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible
for coverage?
(mm/dd/yyyy) (Continue)
No (STOP and return this form to employee)

Tell us about the health plan offered by this employer.
Does the employer offer a health plan that covers an employee’s spouse or dependent?
Yes. Which people?

Spouse

Dependent(s)

No
(Go to question 14)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15)

No (STOP and return form to employee)

15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the
employer has wellness programs, provide the premium that the employee would pay if he/ she received the maximum discount
for any tobacco cessation programs, and didn’t receive any other discounts based on wellness programs.

a. How much would the employee have to pay in premiums for this plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and
return form to employee.
16. What change will the employer make for the new plan year?
Employer won’t offer health coverage
Employer will start offering health coverage to employees or change the premium for the lowest-cost plan available only to
the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See
question 15.)

a. How much will the employee have to pay in premiums for that plan? $

b. How often?

Weekly

Every 2 weeks

Twice a month

Quarterly

Yearly

Date of change (mm/dd/yyyy):

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

04.24.13

APPENDIX B
American Indian or Alaska Native Family Member (AI/AN)
Complete this appendix if you or a family member are American Indian or Alaska Native. Submit this with your
Application for Health Coverage & Help Paying Costs.

Tell us about your American Indian or Alaska Native family member(s).
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods.
Answer the following questions to make sure your family gets the most help possible.
NOTE: If you have more people to include, make a copy of this page and attach.
AI/AN PERSON 1
1. Name
(First name, Middle name, Last name)

First

Middle

Last

2. Member of a federally recognized tribe?

AI/AN PERSON 2
First

Last

Yes
If yes, tribe name

No
3. Has this person ever gotten a service
from the Indian Health Service, a tribal
health program, or urban Indian health
program, or through a referral from one
of these programs?

4. Certain money received may not be
counted for Medicaid or the Children’s
Health Insurance Program (CHIP). List
any income (amount and how often)
reported on your application that
includes money from these sources:
• Per capita payments from a tribe that
come from natural resources, usage
rights, leases, or royalties
• Payments from natural resources,
farming, ranching, fishing, leases, or
royalties from land designated as
Indian trust land by the Department
of Interior (including reservations and
former reservations)
• Money from selling things that have
cultural significance

Middle

Yes

If no, is this person eligible to get
services from the Indian Health Service,
tribal health programs, or urban Indian
health programs, or through a referral
from one of these programs?

Yes

How often?

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

04.24.13

APPENDIX C
Assistance with Completing this Application
You can choose an authorized representative.
You can give a trusted person permission to talk about this application with us, see your information, and act for you on
matters related to this application, including getting information about your application and signing your application
on your behalf. This person is called an “authorized representative.” If you ever need to change your authorized
representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application,
submit proof with the application.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address

3. Apartment or suite number

4. City

5. State

7. Phone number

(

)

6. ZIP code

–

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you
on all future matters with this agency.
10. Your signature

11. Date (mm/dd/yyyy)

For certified application counselors, navigators, agents, and brokers only.
Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for
somebody else.
1. Application start date (mm/dd/yyyy)
2. First name, Middle name, Last name, & Suffix
3. Organization name

4. ID number (if applicable)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov or call us at 1-800-XXX-XXXX. Para obtener una copia de este
formulario en Español, llame 1-800-XXX-XXXX. If you need help in a language other than English, call 1-800-XXX-XXXX and tell the
customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-800-XXX-XXXX.

File Type	application/pdf
File Title	Draft of the Application for Health Coverage and Help Paying Costs
Subject	Read only. This is not intended to be filled out. Draft of the Application for Health Coverage and Help Paying Costs., Plus the
Author	CMS
File Modified	2013-04-24
File Created	2013-04-23