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pdf09/2015
Application for Health Coverage
Apply faster online
Form Approved
OMB No. 0938-1191
Apply faster online at HealthCare.gov.
Who can use this
application?
Anyone who needs health coverage can use this application.
What happens
next?
Send your complete, signed application to the address on page 4. If you don’t
have all the information we ask for, sign and submit your application
anyway.
If someone is helping you fill out this application, you may need to complete
Appendix C.
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 notice in the mail after your application is processed.
Filling out this application doesn’t mean you have to buy health coverage.
Get help with costs
You need to use a different application to get help with costs. You could
qualify for:
• A 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). Visit HealthCare.gov or call the
Marketplace Call Center to learn more.
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 20 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 3
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)
9. Apartment or suite number
10. City
11. State
14. Daytime phone 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
No
Email address:
17. What’s your preferred spoken language? What’s your preferred written language?
18. Do you need health coverage for yourself?
YES. If yes, answer all the questions below.
NO. If no, skip to Step 2 on page 2. (Leave the rest of this page blank)
–
19. Social Security Number (SSN)
–
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.
20. Sex
Male
21. Date of birth (mm/dd/yyyy)
Female
/
/
22. Are you a U.S. citizen or U.S. national? ...............................................................................................................................................................................
Yes
No
23. 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 24.
a. Alien number:
b. Certificate number:
After you complete a and b,
SKIP to question 25.
24. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Immigration document type
Status type (optional)
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)
Optional: 25. If Hispanic/Latino, ethnicity:
(Fill in all that 26. Race:
apply.)
White
Vietnamese
Mexican
Mexican American
Black or African American
Other Asian
Native Hawaiian
Chicano/a
Puerto Rican
American Indian or Alaska Native
Guamanian or Chamorro
Filipino
Samoan
Cuban
Japanese
Other
Korean
Other Pacific Islander
Asian Indian
Chinese
Other
NOW, tell us who else needs 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 3
STEP 2: Tell us about anyone who needs health coverage.
(If you have more people to include, make a copy of this page and attach.)
Person 2
1. First name
Middle name
Last name
Suffix
2. Relationship to PERSON 1?
3. Social Security Number (SSN)
–
4. Date of birth (mm/dd/yyyy)
–
/
5. Sex
Male
/
Female
6. Does PERSON 2 live at the same address as PERSON 1? ...................................................................................................................................................
Yes
No
Yes
No
If no, list address:
7. Is PERSON 2 U.S. citizen or U.S. national? ..........................................................................................................................................................................
8. 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 9.
a. Alien number:
b. Certificate number:
After you complete a and b,
SKIP to question 10.
9. 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)
YES. Enter document type and ID number. See instructions.
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 their spouse or parent, a veteran or an active-duty member of the U.S. military? ............................................................................
Optional: 10. If Hispanic/Latino, ethnicity:
(Fill in all that 11. Race:
apply.)
White
Vietnamese
Mexican
Mexican American
Black or African American
Other Asian
Native Hawaiian
Chicano/a
Puerto Rican
American Indian or Alaska Native
Guamanian or Chamorro
Filipino
Samoan
Cuban
Japanese
Yes
Yes
No
No
Other
Korean
Other Pacific Islander
Asian Indian
Chinese
Other
STEP 3: American Indians/Alaska Natives
American Indians and Alaska Natives can get services from the Indian Health Service, 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.
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. If you have more people to include, make a copy of this page and attach.
2. Name (First name, Middle name, Last name)
3. Member of a federally recognized tribe? .............................................................................................................................................................................
If yes, Tribe name:
Yes
No
State tribe is located in:
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 3 of 3
STEP 4: Your agreement & signature
Is anyone applying for health insurance on this application incarcerated (detained or jailed)?....................................................................
Yes
No
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 health coverage. 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 5: 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.
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.
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)
/
/
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.
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 later in the year.
These questions are optional. If your life circumstances haven’t changed, you can leave the answers blank. 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 born, adopted, or placed for foster care 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 moved in the last 60 days.
Names
Date of move (mm/dd/yyyy)
/
/
What is the zip code of your previous address?
6. Someone was released from incarceration, detention, or jail in the last 60 days.
Names
Date (mm/dd/yyyy)
/
/
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.
| File Type | application/pdf |
| File Title | Application for Health Coverage |
| Subject | Application for Health Coverage, Health insurance Marketplace, Non Financial Assistance |
| File Modified | 2015-10-06 |
| File Created | 2015-10-06 |