CMS-10440 Attachment C-Paper Application - FA Family, plus appendi

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 Attachment C Paper Application - FA Family, plus appendices 30 Day Clean 508 3.7.16

Individual Application

OMB: 0938-1191

⚠️ Notice: This form may be outdated.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

Document [pdf]

Download: pdf | pdf

09/2015

Application for Health Coverage & Help Paying Costs

Form Approved
OMB No. 0938-1191

Apply faster online

Apply faster online at HealthCare.gov.

Use this application
to see what coverage
you qualify for

• 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 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 $95,400 a year (for a family of 4).

Who can use this
application?

• 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.

What you may
need to apply

• Social Security Numbers (or document numbers for any eligible immigrants

who need coverage).

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

Why do we ask for
this information?

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. To view
the Privacy Act Statement, visit HealthCare.gov or see instructions.

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, 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.

Get help with this
application

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

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

1-800-318-2596 and tell the customer service representative the language
you need. We’ll get you help at no cost to you.

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.

Page 1 of 7

Please print in capital letters using black or dark blue ink only.
Fill in the circles (
) like this
.

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

3. Apartment or suite number

2. Home address (Leave blank if you don’t have one.)

4. City

5. State

6. ZIP code

7. County, parish, or township

8. Mailing address (if different from home address)

10. City

11. State

14. Daytime phone number

(

9. Apartment or suite number

)

–

12. ZIP code

13. County, parish, or township

15. Evening phone number

(

)

–

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

Yes

Email address:
17. What’s your preferred spoken language? What’s your preferred written language?

STEP 2: Tell us about your family.
Who do you need to include on this application?
Complete the Step 2 pages for every person in your family and household, even if the person has health coverage already. The information in
this application helps us make sure everyone gets the best coverage they can. The amount of help or type of program you qualify for is based on
the number of people in your family and their incomes. If you don’t include someone, even if they already have health coverage, your eligibility
results could be affected.

For adults who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

• Any spouse
• Any son or daughter under age 21 they live with, including stepchildren
• Any other person on the same federal income tax return (including any children over age 21 who are claimed on a parent’s tax return). You
don’t need to file taxes to get health coverage.

For children under age 21 who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

• Any parent (or stepparent) they live with
• Any sibling they live with
• Any son or daughter they live with, including stepchildren
• Any other person on the same federal income tax return. You don’t need to file taxes to get health coverage.

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.

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.

Page 2 of 7

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

3. Are you married?

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

2. Relationship to PERSON 1?

SELF

Yes

–

6. Social Security Number (SSN)

Suffix

5. Sex
Female

Male

–

We need a Social Security number (SSN) if you want health coverage and have an SSN or can get one. We use SSNs to check income and other
information to see who’s eligible for help paying for health coverage. If you need help getting an SSN, visit socialsecurity.gov, or call Social Security at
1-800-772-1213. TTY users should call 1-800-325-0778.
7. Do you plan to file a federal income tax return NEXT YEAR? You can still apply for coverage even if you don’t file a federal income tax return.
YES. If yes, please answer questions a–c.
NO. If no, skip to question c.
a. Will you file jointly with a spouse? ................................................................................................................................................................

Yes

If yes, write name of spouse:
b. Will you claim any dependents on your tax return?........................................................................................................................................
If yes, list name(s) of dependents:
c. Will you be claimed as a dependent on someone’s tax return? .....................................................................................................................
If yes, please list the name of the tax filer:

How are you related to the tax filer?

8. Are you pregnant? .......................................................................................

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

Yes

9. Do you need health coverage? Even if you have coverage, 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.

10. 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? ......................................................................................................................................................

Yes

11. Are you a U.S. citizen or U.S. national? ...............................................................................................................................................................................

Yes

12. Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.)
YES. If yes, complete a and b.
NO. If no, continue to question 13.
a. Alien number:
b. Certificate number:

13. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Immigration document type

Status type (optional)

After you complete a and b,
SKIP to question 14.
YES. Enter document type and ID number. See instructions.

Write your name as it appears on your immigration document.

Alien or I-94 number

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

a. Have you lived in the U.S. since 1996? ...................................................................................................................................................................................
b. Are you, or your spouse or parent, a veteran or an active-duty member of the U.S. military? .....................................................................................

Yes
Yes

No
No

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

Yes

15. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?
(Select “yes” if you or your spouse takes care of this child.) ............................................................................................................................................................

Yes

16. Tell us the names and relationships of any children under 19 that live with you in your household:

17. Are you a full-time student?....................

Yes

Optional: 19. If Hispanic/Latino, ethnicity:

No
Mexican

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

(Fill in all that 20. Race:
White
Black or African American
apply.)
Vietnamese
Other Asian
Native Hawaiian

Chicano/a

Puerto Rican

Cuban

Other

American Indian or Alaska Native
Filipino
Japanese
Korean
Asian Indian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

Chinese

Page 3 of 7

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 21..

Not employed:
Skip to question 31.

Self-employed:
Skip to question 30.

Current job 1:
21. Employer name

a. Employer address

b. City

c. State

23. Wages/tips (before taxes)

d. ZIP code

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

22. Employer phone number

(

)

–

24. Average hours worked each WEEK

Current job 2: (If you have additional jobs and need more space, attach another sheet of paper.)
25. Employer name

a. Employer address

b. City

c. State

27. Wages/tips (before taxes)

$
29. In the past year, did you:

d. ZIP code

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Change jobs

Stop working

26. Employer phone number

(

)

–

28. Average hours worked each WEEK

Start working fewer hours

None of these

30. If self-employed, answer a and b:
a. Type of work:
b. How much net income (profits once business expenses are paid) will you get from this
self-employment this month? See instructions.

31. Other income you get this month: Fill in all that apply, and give the amount and how often you get it. Fill in here if none.
NOTE: You don’t need to tell us about income from child support, veteran’s payments, or Supplemental Security Income (SSI).
Unemployment

How often?

Alimony received

How often?

Pension

How often?

Net farming/fishing

How often?

Social Security

How often?

Net rental/royalty

How often?

Retirement
accounts

How often?

Other income
Type:

How often?

32. Deductions: Fill in all that apply, and give the amount and how often you pay 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 child support that you pay, or a cost already considered in your answer to net self-employment (question 30b).
Alimony paid

How often?

Other deductions
Type:

How often?

Student loan
How often?
$
interest
33. Complete this question if your income changes during the year, like if you only work at a job for part of the year or receive a benefit for certain
months. 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.

Page 4 of 7

STEP 2: PERSON 2

Note: If this person doesn’t need health coverage, just answer questions 1–11 on this
page. Make a copy of pages 4–5 if there are more than 2 people in your household.

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

Middle name

2. Relationship to PERSON 1? See instructions.

3. Is PERSON 2 married?
Yes

–

6. Social Security Number (SSN)

Last name

Suffix
5. Sex

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

Male

Female

We need this if you want health coverage for PERSON 2,
and PERSON 2 has an SSN.

–

7. Does PERSON 2 live at the same address as PERSON 1? ....................................................................................................................................

Yes

If no, list address:
8. Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for coverage even if PERSON 2 doesn’t file a federal income tax return.)
YES. If yes, please answer questions a–c.
NO. If no, skip to question c.
a. Will PERSON 2 file jointly with a spouse? ......................................................................................................................................................

Yes

If yes, write name of spouse:
b. Will PERSON 2 claim any dependents on his or her tax return? ......................................................................................................................
If yes, list name(s) of dependents:
c. Will PERSON 2 be claimed as a dependent on someone’s tax return? ...........................................................................................................
If yes, please list the name of the tax filer:
How is PERSON 2 related to the tax filer?

9. Is PERSON 2 pregnant? .................................................................................

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

Yes

10. Does PERSON 2 need health coverage? (Even if PERSON 2 has coverage, 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.
11. 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

12. Is PERSON 2 a U.S. citizen or U.S. national? ......................................................................................................................................................................

Yes

13. Is PERSON 2 a naturalized or derived citizen? (This usually means they were born outside the U.S.)
YES. If yes, complete a and b.
NO. If no, continue to question 14.
a. Alien number
b. Certificate number

After you complete a and b,
SKIP to question 15.

YES. Enter document type and ID number. See instructions.
14. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?
Immigration document type:
Status type (optional):
Write PERSON 2’s name as it appears on their immigration document.
Alien or I-94 number

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

a. Has PERSON 2 lived in the U.S. since 1996? ........................................................................................................................................................................
b. Is PERSON 2, or PERSON 2’s spouse or parent, a veteran or an active-duty member of the U.S. military? ...............................................................

Yes
Yes

No
No

15. Does PERSON 2 want help paying for medical bills from the last 3 months? ..............................................................................................................

Yes

16. Does PERSON 2 live with at least one child under the age of 19, and is PERSON 2 the main person taking care of this child?
(Select “yes” if PERSON 2 or their spouse takes care of this child.) ...............................................................................................................................................

Yes

17. Tell us the names and relationships of any children under 19 that live with PERSON 2 in their household: (These can be the same children listed on page 2.)
18. Was PERSON 2 in foster care at age 18 or older? ...............................................................................................................................................................

Yes

Please answer these questions if PERSON 2 is 22 or younger:
19. Did PERSON 2 have insurance through a job and lose it within the past 3 months?......................................................................................................

Yes

a. If yes, end date:

b. Reason the insurance ended:

20. Is PERSON 2 a full-time student? ...........................................................................................................................................................................................

Optional: 21. If Hispanic/Latino, ethnicity:
(Fill in all that 22. Race:
apply.)

Mexican

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

White
Black or African American
American Indian or Alaska Native
Filipino
Japanese
Korean
Asian Indian
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other

Chinese

Page 5 of 7

STEP 2: PERSON 2

Tell us about any income PERSON 2 gets.
Complete this page even if PERSON 2 doesn’t need health coverage.

Current job & income information
Employed: If PERSON 2 is currently employed,
tell us about his/her income. Start with question 23..

Not employed:
Skip to question 33.

Self-employed:
Skip to question 32.

Current job 1:
23. Employer name

a. Employer address

b. City

c. State

25. Wages/tips (before taxes)

d. ZIP code

24. Employer phone number

(

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

)

–

26. Average hours worked each WEEK

Current job 2: (If PERSON 2 has more jobs, attach another sheet of paper.)
27. Employer name

a. Employer address

b. City

c. State

29. Wages/tips (before taxes)

$
31. In the past year, did PERSON 2:

d. ZIP code

28. Employer phone number

(

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Change jobs

Stop working

)

–

30. Average hours worked each WEEK

Start working fewer hours

None of these

32. If PERSON 2 is self-employed, answer the following questions:
a. Type of work:
b. How much net income (profits once business expenses are paid) will PERSON 2 get from this
self-employment this month? See instructions.

33. Other income PERSON 2 gets this month: Fill in all that apply, and give the amount and how often PERSON 2 gets it. Fill in here if none.
NOTE: You don’t need to tell us about PERSON 2’s income from child support, veteran’s payments, or Supplemental Security Income (SSI).
Unemployment

How often?

Alimony received

How often?

Pension

How often?

Net farming/fishing

How often?

Social Security

How often?

Net rental/royalty

How often?

Retirement
accounts

How often?

Other income
Type:

How often?

34. Deductions: Fill in all that apply, and give the amount and how often PERSON 2 gets 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 child support that PERSON 2 pays, or a cost already considered in the answer to net self-employment (question 32b).
Alimony paid

How often?

Other deductions
Type:

How often?

Student loan
How often?
$
interest
35. Complete only if PERSON 2’s income changes during the year, like if PERSON 2 only works at a job for part of the year or receives a
benefit for certain months. If you don’t expect changes to PERSON 2’s monthly income, skip to the next person.
PERSON 2’s total income this year

PERSON 2’s total income next year

$
Thanks! This is all we need to know about PERSON 2.

Page 6 of 7

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?
NO. If no, continue to Step 4.

YES. If yes, continue to Step 4, plus complete Appendix B and include with application.

STEP 4: Your family’s health coverage
1. For every year that you got a premium tax credit, did your household file a tax return and reconcile any premium tax credit you used?
YES, premium tax credits were reconciled. Fill in the circle only if ALL of these apply to you:
• You used advance payments of premium tax credits (APTC) in one or more past years to help lower your costs for Marketplace coverage.
• The tax filer for your household filed a federal income tax return for each of these years.
• The tax return filed compared the amount of APTC used to the rest of the tax return information for each year.
2. Was anyone on this application found not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in the
past 90 days? (Select yes only if someone was found not eligible for this coverage by your state, not by the Marketplace.)...............................................

Yes

Who?
Or, was anyone on this application found not eligible for Medicaid or CHIP due to their immigration status since October 1, 2013? .......
Who?
3. Did anyone on this application apply for coverage during the Marketplace open enrollment period? ..............................................................
Who?
4. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else’s job, like a parent or spouse, even
if they don’t accept the coverage.
YES. Continue and then complete Appendix A. Is this a state employee benefit plan? ..............................................................................................

Yes

NO.
5. Is anyone enrolled in health coverage now?
YES. If yes, continue to question 6.

NO. If no, SKIP to Step 5.

6. Information about current health coverage. (Make a copy of this page if more than 2 people have health coverage now.)
Write the type of coverage, like employer insurance, COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, or other.
(Don’t tell us about TRICARE if you have Direct Care or Line of Duty.)
Name of person enrolled in health coverage

Type of coverage:

PERSON 1:

Employer insurance

COBRA

Medicaid

CHIP

Medicare

TRICARE

VA health care program

If it’s employer insurance: (You’ll also need to complete Appendix A.)
Name of health insurance company

Policy/ID number

If it’s another kind of coverage:
Name of health insurance company

Policy/ID number

Peace Corps

Is this a limited-benefit plan, like a school accident policy? ............................................................................................................................................

Other

Yes

Name of person enrolled in health coverage

Type of coverage:

PERSON 2:

Employer insurance

COBRA

Medicaid

CHIP

Medicare

TRICARE

VA health care program

If it’s employer insurance: (You’ll also need to complete Appendix A.)
Name of health insurance company

Policy/ID number

If it’s another kind of coverage:
Name of health insurance company

Policy/ID number

Peace Corps

Other

Yes

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
No
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

3 years

1 year

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.)

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
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.

• 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 January 31), make sure you review Appendix D
(“Questions about life changes”).

STEP 6: Mail completed application

✉

Mail your signed application to:

Health Insurance Marketplace
Dept. of Health and Human Services
465 Industrial Blvd.
London, KY 40750-0001

If you want to register to vote, you can complete a
voter registration form at www.eac.gov.

Form Approved
OMB No. 0938-1191

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, even if they don’t accept
the coverage. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Make a copy of this page and take it to the employer who offers coverage to help you answer these questions.

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?

12. Email address

11. Phone number (if different from above)

(

)

–

13. Is the employee currently eligible for coverage offered by this employer, or will the employee become eligible in the next 3 months?
NO (Stop here, and return to Step 5 in the application.)

YES (Continue)
a. 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

Name

Tell us about the lowest-cost 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
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

Once a month

Quarterly

Yearly

(Go to next question.)

16. What change, if any, 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 that meets the minimum value standard* and
is available to the employee only. (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

c. Date of change: (mm/dd/yyyy)

Twice a month

Once a month

Quarterly

Yearly

* A health plan meets the minimum value standard if pays at least 60% of the total cost of medical services for a standard population and offers substantial coverage of hospital and
doctor services. In other words, in most cases a plan that meets minimum value will cover 60% of covered medical costs. You’d pay 40%. Most job-based plans meet the minimum
value standard.

Form Approved
OMB No. 0938-1191

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 and are applying for coverage. 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 questions below 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.
1. Name (First name, Middle name, Last name)

2. Member of a federally recognized tribe? .........................................................................................................................................................................

Yes

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?................................................................................................

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

AI/AN PERSON 1:

If yes, Tribe name:

State tribe is located in:

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
How often?

$
1. Name (First name, Middle name, Last name)

Yes

AI/AN PERSON 2:

If yes, Tribe name:

State tribe is located in:

Per capita payments from a tribe that come from natural resources, usage rights, leases, or royalties

•

Money from selling things that have cultural significance
How often?

Form Approved
OMB No. 0938-1191

Appendix C
Assistance with completing this application
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)

5. Agents/Brokers only: NPN number

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 or remove 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

7. Phone number

(

5. State

)

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
related to this application.
10. Signature of PERSON 1 listed on this application

11. Date signed (mm/dd/yyyy)

Form Approved
OMB No. 0938-1191

Appendix D
Questions about life changes
(You must complete the rest of this application along with this page. Don’t submit this page by itself.)

If anyone on this application experienced certain life changes in the past 60 days, fill out the following questions. Certain life changes allow
your coverage through the Marketplace to start right away. We also recommend you answer these questions if you’re applying after the annual
Open Enrollment Period ends and before the next annual Open Enrollment Period starts.
These questions are optional. If your life circumstances haven’t changed, you can leave the answers blank. You can enroll in Medicaid and the
Children’s Health Insurance Program (CHIP) any time of the year, even if you didn’t experience life changes. Members of federally recognized
tribes and Alaska Native shareholders can enroll in coverage through the Marketplace any time of the year.

Tell us about changes in your household.
1. Someone lost health coverage in the last 60 days, or expects to lose coverage in the next 60 days.
Names

Date coverage ended or will end (mm/dd/yyyy)

Check here if coverage ended because not paying premiums.
2. Someone got married in the last 60 days.
Names

Date (mm/dd/yyyy)

3. Someone was released from incarceration, detention, or jail in the last 60 days.
Names

Date (mm/dd/yyyy)

4. Someone gained eligible immigration status in the last 60 days.
Names

Date (mm/dd/yyyy)

5. Someone was born, adopted, placed for adoption, or placed for foster care in the last 60 days.
Names

Date (mm/dd/yyyy)

6. Someone moved in the last 60 days.
Names

Date of move (mm/dd/yyyy)

What is the zip code of your previous address?

File Type	application/pdf
File Title	Application for Health Coverage and Help Paying Costs
File Modified	2015-10-29
File Created	2015-09-29