CMS-10440 Electronic Questionnaire Additional Items

OMB No. 0938-1191
Expires: XX/XXXX

Appendix A, Attachment 1:
Additional Electronic Application Items to Support
Eligibility Determinations for Enrollment through the
Health Insurance Marketplace and for Medicaid and the
Children’s Health Insurance Program

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 (expires XX/XXXX). The time required to complete this information collection is estimated to average 15
minutes, 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. ****CMS Disclosure**** Please do not send applications, claims, payments, medical
records or any documents containing sensitive information to the PRA Reports Clearance Office. Please note that any
correspondence not pertaining to the information collection burden approved under the associated OMB control number
listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding where to submit
your documents, please contact the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).

Annotated outline: Additional electronic application questions
I.
II.

Before you get started: Collects basic household and income information to guide
consumers to the “help paying for coverage” application as appropriate.
Questions about […]: Collects household information to guide consumers to the correct
series of Marketplace application questions for their household circumstances.

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Contents
I.

Before you get started ..................................................................................................................... 4

II.

Questions about [Everyone in the household] ................................................................................ 5
A.

Questions about [People applying for coverage] ................................................................. 6

B.

Questions about your [#] dependents .................................................................................. 7

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I.

Before you get started

(Note to reviewers: Section I [“Before you get started”] gathers information about consumers’ household
composition, tax filing status, and income and informs consumers whether their household is likely to be
eligible to get help paying for health coverage. The household composition information is also used to
determine the questions asked in Section II [“Questions about…”].)
1. I live in [Select your state]
2. Fill in the information below about your household. Not applying for coverage in [state]?
[Change your state.] (If selected, display a.)
a. What state are you applying for coverage in? (Display dropdown list of states.)
3. Are you single or married?
a. Single (Display option button.)
b. Married (Display option button.)
4. How many tax dependents, like your children, will you claim on your [coverage year] tax return?
Include all of your dependents on your [coverage year] tax return, even those not applying for
coverage. Don’t include yourself or your spouse.
a. (Display number drop down values, e.g., 0-9)
5. Of the [total number of people from question 3 and 4 above], who are you applying for coverage
for? Select all that apply.
If you're applying for someone other than yourself, your spouse, or your dependents, [click
here](URL) to continue your application.
a. Me (Display option button.)
b. My spouse (Display option button if “b” was selected in item 3.)
c. My dependent (Display option button.)
d. Neither of my dependents (Display option button.)
e. Both of my dependents (Display option button.)
f. All [number] of my dependents (Display option button.)
6. How much income will your household make this year? (optional)
(The income threshold amount displayed below is based on the family size and the applicable
federal poverty level.)
a. [$income threshold] or less (Display option button.)
b. More than [$income threshold] (Display option button.)
7. (Display if no income range is selected.) Do you want to answer additional questions to see if
you qualify for help paying for coverage?
a. Yes (Display option button.)
b. No (Display option button.)

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8. (Display if likely eligible for help paying for coverage.)
Based on your estimated household income in [coverage year] of less than [$income], you may
get help paying for coverage. Do you want to answer additional questions to see if you qualify
for help paying for coverage?
a. Yes (Display option button. Selecting “Yes” directs the individual to the application for
help paying for coverage.)
b. No (Display option button. Selecting “No” directs the individual to an application for
Marketplace coverage in a Qualified Health plan with no financial assistance.)
9. (Display if not likely eligible for help paying for coverage.)
Based on your estimated household income in [coverage year] of more than [$income], you
most likely won’t get help paying for coverage. Do you still want to answer extra questions to
see if you qualify for help paying for coverage?
a. Yes (Display option button. Selecting “Yes” directs the individual to the application for
help paying for coverage.)
b. No (Display option button. Selecting “No” directs the individual to an application for
Marketplace coverage in a Qualified Health plan with no financial assistance.)

(Note to reviewers: Section II [“Questions about [you, your spouse, and [number] dependents],
subsection A [“Questions about people applying for coverage”], and subsection B [“Questions about your
[number] dependents”] collect information about the applicant’s household to guide them to the most
appropriate series of Marketplace application questions for their household. This is intended to provide a
more efficient consumer experience applying for health coverage through the Marketplace.)
(These questions are grouped according to the user’s indications of household composition and who is
applying for health coverage. For each question, pronouns vary based on whether the applicants are
single, married, with or without dependents, and also based on cases where the household contact (also
known as the application filer) isn’t applying for coverage for himself or herself. All questions are
displayed here. For the purposes of this document, pronoun variables are for a married couple with 2
children.)

II. Questions about [you, your spouse, and [number] dependents]
(Everyone in the household)
(Note to reviewers: Section II [“Questions about you, your spouse, and [number] dependents”] collects
information on everyone in household, regardless of whether they are applying for health coverage.)
(Display variable header based on household composition [“Questions about you, your spouse, and 2
dependents”], and the following questions for everyone in the household.)
1. Does everyone have the same permanent home address AND currently live in [state]?
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a. Yes (Display option button.)
b. No (Display option button.)
2. Do you plan to file a joint federal income tax return with your spouse for [coverage year]? You
don’t have to file taxes to apply for coverage, but you’ll need to file next year if you want to get
a premium tax credit to help pay for coverage now.
a. Yes (Display option button.)
b. No (Display option button.)
3. Are you and your spouse responsible for a child 18 or younger who lives with you, but isn't on
your tax return?
a. Yes (Display option button.)
b. No (Display option button.)
4. Is anyone a full-time student aged 18-22?
a. Yes (Display option button.)
b. No (Display option button.)
5. Is anyone pregnant, or has anyone had a child in the last 60 days?
a. Yes (Display option button.)
b. No (Display option button.)

A. Questions about [people applying for coverage] (People applying for
coverage)

Note to reviewers: Subsection A [“Questions about people applying for coverage”] collects information
on those people who are applying for health coverage.
(Display variable header based on household composition [“Questions about you, your spouse, and 2
dependents”], and the following questions for people applying for coverage.)
1. Are all of you U.S. citizen[s]?
a. Yes (Display option button.)
b. No (Display option button.)
2. Can you enter Social Security Numbers (SSN) for each of you?
a. Yes (Display option button.)
b. No (Display option button.)
3. Are any of you applying under a name that’s different than the one on your Social Security card?
a. Yes (Display option button.)
b. No (Display option button.)

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4. Are any of you naturalized or derived citizens? (This usually means a U.S. citizen who was born
outside the U.S.)
a. Yes (Display option button.)
b. No (Display option button.)
5. Are any of you currently incarcerated (detained or jailed)?
a. Yes (Display option button.)
b. No (Display option button.)
6. Are any of you an American Indian or Alaska Native?
a. Yes (Display option button.)
b. No (Display option button.)
7. Are any of you offered health coverage through your job, someone else's job, or COBRA? (Select
ʺYesʺ even if any of you didn’t enroll, or the enrollment period is over.)
a. Yes (Display option button.)
b. No (Display option button.)
8. Were any of you in foster care at 18 AND are currently 25 or younger?
a. Yes (Display option button.)
b. No (Display option button.)

B. Questions about your [number] dependents

(Note to reviewers: Subsection B [“Questions about your [number] dependents”] collects information
about dependents.)
(If the application includes dependents, display variable header based on household composition
[“Questions about your 2 dependents”], and the following questions.)
1. Will you claim both of them as dependents on your federal income tax return for [coverage
year]?
a. Yes (Display option button.)
b. No (Display option button.)
2. Are both of them your children who are single (not married) and 25 or younger?
a. Yes (Display option button.)
b. No (Display option button.)
3. Are either of them your stepchildren or grandchildren?
a. Yes (Display option button.)
b. No (Display option button.)
4. Do either of them live with a parent who’s not on your tax return?
a. Yes (Display option button.)
b. No (Display option button.)
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