| Section | Item # | Question |
Answer Options and Format | Who sees this question | Required/Option for the consumer to answer | Why this information is collected |
| 01 - Account Creation/Identity | 1 | Pick the state you live in. | Dropdown, single-selection: All states and territories |
All application filers | Required | This information is used to determine whether the consumer is able to apply on HealthCare.gov, or whether they should be directed to their SBE. |
| 01 - Account Creation/Identity | 2 | Set up your login information: 1. First name 2. Last name 3. Email address 4. Password |
Open text fields | All application filers | Required | This information is used to set up the application filer's account. Their name will be used as part of the RIDP process, and they will receive a confirmation email at the address provided in order to activate their account. |
| 01 - Account Creation/Identity | 3 | Pick 3 questions only you can answer: Question #1: 1. Pick a question 2. Enter an answer Question #2: 1. Pick a question 2. Enter an answer Question #3: 1. Pick a question 2. Enter an answer |
1. Dropdown, single-selection: - What is your favorite radio station? - What was your favorite toy when you were a child? - What is your favorite cuisine? - What is the first name of your oldest niece? - What is a relative's telephone number that is not your own? - What is the name of your favorite pet? - Type a significant date in your life? - In what city was your mother born? - What is the name of your favorite childhood friend? - What is your parents' wedding anniversary date? - What is the name of the manager at your first job? - What is the nick name of your grandmother? 2. Open text field |
All application filers | Required | These questions are used to help application filers who forget their password to access their account. |
| 01 - Account Creation/Identity | 4 | Verify your identity and contact information: 1. First name 2. Middle 3. Last name 4. Suffix 5. Phone number 6. Phone type 7. Date of birth 8. Street address 9. Apt./Ste. # 10. City 11. State 12. ZIP code 13. Social Security Number (SSN) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single-selection: - Jr. - Sr. - II - III - IV - V 5. Open text field 6. Dropdown, single-selection: - Home - Cell - Work 7. Open text field: MM / DD / YYYY 8. Open text field 9. Open text field 10. Open text field 11. Dropdown, single-selection: all U.S. states 12. Open text field 13. Open text field |
All application filers | 1. Required 2. Optional 3. Required 4. Optional 5. Required 6. Required 7. Required 8. Required 9. Optional 10. Required 11. Required 12. Required 13. Optional |
This information is used to generate questions that are used to verify the application filer's identity through trusted data sources. Relevant contact information is also used to pre-fill relevant fields later in the eligibility application. |
| 01 - Account Creation/Identity | 5 | Answer these questions so we can verify your identity: (Examples of the kinds of questions that may be generated by Equifax) - You may have opened a mortgage loan in or around March 2020. Please select the lender to whom you currently make your mortgage payments. If you do not have a mortgage, select 'NONE OF THE ABOVE/DOES NOT APPLY'. - Which of the following is a current or previous employer? If there is not a matched employer name, please select 'NONE OF THE ABOVE'. - According to our records, you graduated from which of the following High Schools? - According to our records, you may have resided or currently reside on one of the following streets. Please select your street name from the choices listed below. |
Varies | All application filers | Required | These questions are generated by trusted data sources, based on the contact information that the application filer provided. This process enables the Exchange to verify the identity of application filers. Application filers who are unable to verify their identity through this process are able to either call the trusted data sources or submit other identifying documentation in order to fulfill the identity proofing requirement. |
| 02 - Application Creation/HH Contact | 6 | Get coverage for: select year | Dropdown, single selection: - Current year (if before 11/30) - Upcoming coverage year (if during Open Enrollment) |
All application filers | Required | During OE, individuals have the ability to enroll in coverage for the current year (if applying before 11/30) or the following year. This is collected so that the application processes for the proper coverage start date. |
| 02 - Application Creation/Household Contact | 7 | Get coverage for: select state | Dropdown, single selection: All states on the federal platform |
All application filers | Required | The application state is used to determine what plans applicants are eligible for, and which unique Medicaid and CHIP eligibility rules should apply. |
| 02 - Application Creation/Household Contact | 8 | I agree to have my information used and retrieved from data sources for this application. I have consent for all people I'll list on the application for their information to be retrieved and used from data sources. I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period, if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage. |
Checkbox next to each statement | All application filers | Required | Privacy agreements with SSA, IRS, and DHS require that this permission be granted. It is necessary under the PPACA to use these data sources to confirm eligibility information in the application before the system can access data from outside sources. The application filer must actively affirm that he or she has consent from all the people who will be on the application before continuing with the application. |
| 02 - Application Creation/Household Contact | 9 | How many people do you report on your tax return, including yourself? | Open text field (numbers only) | All application filers | Required | This information, along with the information in Item 10, is used to provide the application filer with information about cost savings programs their household may qualify for. It helps the application filer choose whether they want to apply for financial assistance. |
| 02 - Application Creation/Household Contact | 10 | In [coverage year], what do you estimate your household's income range will be? | Radio buttons: - $XX,XXX or less - More than $XX,XXX - I choose not to answer |
All application filers | Required | The income amounts used in this question are dynamic depending on the application filer's household size and the FPL. Application filers that indicate that they make less than this amount will be told they are likely to qualify for savings. Application filers who indicate that they make more than this amount, or who choose not to answer, will be told they may still qualify for savings. This item along with Item 9 provides the consumer with information regarding cost savings programs they might qualify for, so they can choose whether they want to apply for financial assistance. |
| 02 - Application Creation/Household Contact | 11 | Choose a savings option | Radio buttons: - Check for all savings options - Continue without checking for savings options |
All application filers | Required | Per PPACA Sections 1411 and 1413, application filers must have the opportunity to choose between applying for financial assistance (APTC, CSR, Medicaid and CHIP) or applying to enroll in a full-price QHP. Application filers seeking full-cost QHP only will not be asked questions about their household and income that are not relevant for QHP eligibility. |
| 02 - Application Creation/Household Contact | 12 | Do you need coverage for yourself? | Radio buttons: - Yes - No |
All application filers | Required | The application filer must indicate whether they are seeking coverage for themselves, or applying on someone else's behalf. |
| 02 - Application Creation/Household Contact | 13 | 1. First name 2. Middle name 3. Last name 4. Suffix |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: - Jr. - Sr. - II - III - IV - V |
All application filers | 1. Required 2. Optional 3. Required 4. Optional |
The application filer must include their first and last name. The application filer's name will be used when attempting to verify information told to the Exchange, such as when attempting to verify the household's income with trusted data sources. It will also be used so that the application can direct questions to the application filer by name. |
| 02 - Application Creation/Household Contact | 14 | Date of birth | Open text field: MM / DD / YYYY | All application filers | Required | The application filer must be 18 years of age or older. If the application filer is seeking coverage, their age may impact eligibility for insurance affordability programs and their QHP premiums. |
| 02 - Application Creation/Household Contact | 15 | Sex | Radio buttons: - Female - Male |
All application filers | Required | The Exchange collects sex for all application filers. The Exchange does not currently permit an attestation of "X," nor do we distinguish between current sex and sex assigned at birth, but may add options pending any future federal guidance. Section 4302 of the PPACA requires that all federally conducted health programs collect applicants' sex. |
| 02 - Application Creation/Household Contact | 16 | Sexual orientation and gender identity | To be determined | To be determined | Optional | The Exchange does not currently collect information about sexual orientation or gender identity. The Exchange may collect this information pending any future federal guidance, in accordance with Section 4302 of the PPACA, which requires the collection of information about sex in order to detect and monitor trends in health disparities at the Federal and State levels. |
| 02 - Application Creation/Household Contact | 17 | Home address: 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) 7. Or: I don't have a home address |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: all U.S. states and territories 5. Open text field 6. Radio buttons: counties within the ZIP code 7. Checkbox |
All application filers | 1. Required 2. Optional 3. Required 4. Required 5. Required 6. Required 7. Required if no home address is provided |
Home address, when provided, is used for determining state residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as for rating for QHP premiums. Application filers who told the Exchange that they have no home address will have their mailing address used to establish their residency instead. |
| 02 - Application Creation/Household Contact | 18 | Is this also your mailing address? [Display previously entered home address.] |
Radio buttons: - Yes - No |
Application filers who provided a home address | Required | Mailing addresses are used to send communications by mail. |
| 02 - Application Creation/Household Contact | 19 | Mailing address: 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: all U.S. states and territories 5. Open text field 6. Radio buttons: counties within the ZIP code |
Application filers who selected no home address OR application filers who selected having a mailing address different from their home address | Required | Mailing address is collected so that the Exchange, and the applicant filer's plan or SMA, as appropriate, can send communications to the enrollees by mail. In the case of consumers who have no home address, this information is used to determine their residency for the purpose of eligibility for Medicaid, CHIP and QHP, as well as for rating for QHP premiums. |
| 02 - Application Creation/Household Contact | 20 | Are you living outside [application state] temporarily? | Radio buttons: - Yes - No |
Application filers who select in Item 17 a home address in a state other than the state in which they're applying for coverage | Required | This item and Item 21 are used to establish whether application filers who are living outside of the state in which they're applying for coverage temporarily can still establish residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as for rating for QHP premiums. |
| 02 - Application Creation/Household Contact | 21 | Where will you live when you move back to [application state]? 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: only the application state 5. Open text field 6. Radio buttons: counties within the ZIP code |
Application filers who select that they are living outside the application state temporarily in Item 20 | 1. Optional 2. Optional 3. Required 4. Required 5. Required 6. Required |
This item and Item 20 are used to establish whether application filers who are living outside of the state in which they're applying for coverage temporarily can still establish residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as for rating for QHP premiums. |
| 02 - Application Creation/Household Contact | 22 | Contact information: 1. Email address 2. Phone number 3. Extension 4. Phone type |
1. Open text field 2. Open text field 3. Open text field 4. Radio buttons: - Mobile - Home - Work |
All application filers | 1. Required 2. Required 3. Optional 4. Required |
Email address is collected for notifications by email. At least one phone number must be collected for the application. Phone number type is collected so that the Exchange knows whether the phone number can be used for SMS communications, if the consumer selects SMS as their communications preference in Item 25. |
| 02 - Application Creation/Household Contact | 23 | Preferred language: 1. Preferred written language 2. Preferred spoken language |
For each field, dropdown, single selection: - English - Spanish - Arabic - Chinese - French - French Creole - German - Gujarati - Hindi - Korean - Polish - Portuguese - Russian - Tagalog - Urdu - Vietnamese - Other |
All application filers | Required | This information is collected to populate the correct language, if available, in notice content and communications. |
| 02 - Application Creation/Household Contact | 24 | How would you like to get notices about your application? | Radio buttons: -Email or text me when there's a new notice in my Marketplace account. -Send me paper notices in the mail. |
All application filers | Required | The application must provide the application filer an option to receive their notices by mail. Notices will always be available through the online account. |
| 02 - Application Creation/Household Contact | 25 | How should we let you know when there's a new notice in your account? | Checkboxes, multi-selection: - Email me at [email address] - Text me. Text STOP to cancel. Text HELP for help. Message frequency varies, but you may receive 1-3 reminder messages per week during Open Enrollment (Nov. 1 - Jan. 15). Message and data rates may apply. |
All application filers who select "email or text me when there's a new notice in my Marketplace account" | Required | This information is used to determine how to notify application filers when there are new notices in their Exchange account. |
| 02 - Application Creation/Household Contact | 26 | Is a professional helping you complete your application? If a family member or friend is helping you, select "No." | Radio buttons: - Yes - No |
All application filers | Required | This information is used to track information about use of agents, brokers, navigators, and certified application counselors. |
| 02 - Application Creation/Household Contact | 27 | Which type of professional is helping you? | Checkboxes, multi-selection: - Navigator - Certified application counselor - Agent or broker - Other assister |
All application filers who select that a professional helping them complete their application in Item 26 | Required | This information is used to track information about use of agents, brokers, navigators, and certified application counselors |
| 02 - Application Creation/Household Contact | 28 | Tell us about the navigator/certified application counselor/assister: 1. First name 2. Middle initial 3. Last name 4. Suffix 5. Organization name 6. ID number |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field 6. Open text field |
All application filers who select that a navigator, certified application counselor, or other assister helping them complete their application in Item 27 | 1. Required 2. Optional 3. Required 4. Optional 5. Optional 6. Optional |
This information is used to track information about use of agents, brokers, navigators, and certified application counselors. |
| 02 - Application Creation/Household Contact | 29 | Tell us about the Agent or Broker: 1. First name 2. Middle initial 3. Last name 4. Suffix 5. National Producer Number (NPN) |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field |
All application filers who select that an agent or broker helping them complete their application in Item 27 | 1. Required 2. Optional 3. Required 4. Optional 5. Required |
This information is used to track information about use of agents, brokers, navigators, and certified application counselors. |
| 03 - Who Needs Coverage | 30 | Who needs health coverage? | List of known consumers Button: Add a person applying for coverage |
All application filers | Required | Application filers must have the opportunity to indicate which members of their household are applying for health coverage, so that the application can ask the necessary follow-up questions to determine applicants' eligibility to enroll in a plan or for insurance affordability programs. |
| 03 - Who Needs Coverage | 31 | 1. First name 2. Middle name 3. Last name 4. Suffix |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: - Jr. - Sr. - II - III - IV - V |
All applicants added in Item 30 | 1. Required 2. Optional 3. Required 4. Optional |
Applicants must include their first and last name. Applicants' names will be used when attempting to verify information told to the Exchange, such as when attempting to verify the household's income with trusted data sources. Names will also be used so that the application can direct questions to applicants by name. |
| 03 - Who Needs Coverage | 32 | Date of birth | Open text field: MM / DD / YYYY | All applicants added in Item 30 | Required | Age is used to help determine which questions should display for applicants, can impact eligibility for Medicaid and CHIP programs, and can impact premiums for Marketplace plans. |
| 03 - Who Needs Coverage | 33 | Sex | Radio buttons: - Female - Male |
All applicants added in Item 30 | Required | The Exchange collects sex for all applicants. The Exchange does not currently permit an attestation of "X," nor do we distinguish between current sex and sex assigned at birth, but may add options pending any future federal guidance. Section 4302 of the PPACA requires that all federally conducted health programs collect applicants' sex. |
| 03 - Who Needs Coverage | 34 | Sexual orientation and gender identity | To be determined | All applicants added in Item 30 | Optional | The Exchange does not currently collect information about sexual orientation or gender identity. The Exchange may collect this information pending any future federal guidance, in accordance with Section 4302 of the PPACA, which requires the collection of information about sex in order to detect and monitor trends in health disparities at the Federal and State levels. |
| 03 - Who Needs Coverage | 35 | 1. How is [applicant] related to [application filer]? 2. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) |
Dropdown, single selection: [applicant] is [application filer]/[other applicant]'s: - Spouse - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) |
All applicants added in Item 30 | Required | The Exchange collects relationships between all applicants to help determine who is able to enroll in an Exchange plan together. This information is also used to determine Medicaid eligibility when an adult must have an allowable "parent or caretaker-relative" relationship with a child, or for Medicaid and CHIP eligibility when an applicant qualifies to use familial relationships rather than tax filing relationships to construct their household. |
| 03 - Who Needs Coverage | 36 | Choose the statement that best describes the legal relationship between [applicant] and [application filer]. Choose the statement that best describes the legal relationship between [applicant] and [other applicant]. |
Dropdown, single selection: [applicant] is [application filer]/[other applicant]'s, OR [application filer]/[other applicant] is [applicant]'s: - foster child - collateral dependent - sponsored dependent - ward - guardian - court-appointed guardian - former spouse - None of these relationships |
Applicants who are the grandparent, grandchild, uncle/aunt, niece/nephew, first cousin, brother/sister, domestic partner, parent's domestic partner, or child's domestic partner of another applicant, AND Applicants who are the other relative OR are the son/daughter or stepson/stepdaughter of the application filer and are at least 25 years old OR are the parent or stepparent of another applicant who is at least 25 years old |
Optional | The Exchange gives applicants who selected familial relationships that may not qualify them to enroll in a plan together the opportunity to also provide a legal relationship that may allow them to enroll in a plan together. |
| 03 - Who Needs Coverage | 37 | Remove member | Button | All consumers except for the application filer | Optional | Application filers must have the option to remove a consumer that they no longer wish to include on their application. |
| 03 - Who Needs Coverage | 38 | Remove [applicant], or change their coverage needs? | Radio buttons: - Remove [applicant] from the application - Change [applicant]'s status to "Doesn't need coverage" and keep them on the application |
All applicants for whom the "Remove" button is selected | Required | Application filers who select to remove an applicant must choose between removing the applicant from the application altogether, or keeping them on the application as a consumer who is not seeking coverage. |
| 03 - Who Needs Coverage | 39 | Why are you removing [consumer]? | Radio buttons: - [consumer] is deceased - [consumer] has gotten divorced - A different reason |
All consumers for whom the "Remove [consumer] from the application" in Item 38 was selected AND the consumer was added on a previously submitted version of the application | Required | Application filers who choose to remove an consumer who was added on a previous version of the application must select a reason for removal. Knowing the reason helps the Exchange determine whether retroactive termination of the consumer's coverage is warranted. For example, if the consumer has died in the past, the Exchange needs to know the date of death in order to terminate coverage after that date. |
| 03 - Who Needs Coverage | 40 | Date [consumer] became deceased | Open text field: MM / DD / YYYY | All consumers for whom "[consumer] is deceased" in Item 39 was selected | Required | Collecting the date of death allows the Exchange to terminate a consumer's coverage retroactive to the date of death. |
| 03 - Who Needs Coverage | 41 | Date [consumer] became divorced | Open text field: MM / DD / YYYY | All consumers for whom "[consumer] has gotten divorced" in Item 39 was selected | Optional | Providing the date of divorce may help the Exchange terminate a consumer's coverage retroactive to the date of divorce, if the consumer wishes. |
| 04 - Household Composition | 42 | What is [applicant]'s marital status? | Radio buttons: - Single - Married |
All applicants age 15 or older on applications seeking financial assistance | Required | Marital status is used to determine an applicant's household for APTC, Medicaid, and CHIP purposes. Applicants who are married generally must file a joint return in order to be eligible for APTC. Married applicants who are victims of domestic abuse or spousal abandonment are advised by application help text to select "single" here, so that they can remain eligible for APTC even if they do not file a joint return with their spouse. |
| 04 - Household Composition | 43 | Tell us about [applicant]'s spouse: 1. First name 2. Middle name 3. Last name 4. Suffix 5. Date of birth 6. Sex |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field: MM / DD / YYYY 6. Radio buttons: - Female - Male |
All applicants requesting financial assistance who select "Married" in Item 42, and whose spouse is not already applying for coverage | 1. Required 2. Optional 3. Required 4. Optional 5. Required 6. Required |
Basic demographic information about an applicant's non-applicant spouse is collected to build the applicant's household for APTC, Medicaid, and CHIP purposes. The Exchange does not currently permit a sex attestation of "X," nor do we distinguish between current sex and sex assigned at birth, but may add options pending any future federal guidance. |
| 04 - Household Composition | 44 | Will [applicant] file a [coverage year] joint federal income tax return with [spouse]? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who selected a relationship of "Spouse" in Item 35 or to a status of "Married" in Item 42 | Required | Tax filing status is used to determine an applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 45 | Will [applicant] file a [coverage year] federal income tax return? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who selected a status of "Single" in Item 42 or who select "No" to filing a joint return in Item 44 | Required | Tax filing status is used to determine an applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 46 | Will [applicant] [and spouse if filing jointly] claim any dependents on their [coverage year] federal income tax return? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select that they will file a joint tax return in Item 44 or their own tax return in Item 45 | Required | Who an applicant will claim on their tax return, and whether an applicant will be claimed as a tax dependent on someone else's return, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. Applicants must file a tax return for the coverage year, or be claimed as a tax dependent, in order to be eligible for APTC. |
| 04 - Household Composition | 47 | Who will [applicant] [and spouse if filing jointly] claim as a dependent on their [coverage year] federal income tax return? | Checkboxes, multi-selection: All other applicants who are not already in a tax household Button: Add a dependent |
All applicants requesting financial assistance who select that they will claim dependents in Item 46 | Required | Who an applicant will claim on their tax return, and whether an applicant will be claimed as a tax dependent on someone else's return, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 48 | Tell us about [applicant] [and spouse if filing jointly]'s dependent: 1. How is this person related to [application filer]? 2. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) 3. First name 4. Middle name 5. Last name 6. Suffix 7. Date of birth 8. Sex |
1 + 2. Dropdown, single selection: - Spouse - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) 3. Open text field 4. Open text field 5. Open text field 6. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 7. Open text field: MM / DD / YYYY 8. Radio buttons: - Female - Male |
All applicants requesting financial assistance who select "Add a dependent" in Item 47 | 1. Required 2. Required 3. Required 4. Optional 5. Required 6. Optional 7. Required 8. Required |
Non-applicant dependents must provide basic demographic information. This allows the application to direct questions at the consumer by name, to verify information told to the Exchange with trusted data sources as needed, and to apply eligibility rules that vary depending on the consumer's age. The Exchange does not currently permit a sex attestation of "X," nor do we distinguish between current sex and sex assigned at birth, but may add options pending any future federal guidance. |
| 04 - Household Composition | 49 | Will someone else claim [applicant] as a dependent on their [coverage year] federal tax return? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select "No" to filing a tax return in Item 45, OR "Yes" to filing a tax return in Item 45, and "No" to claiming dependents in Item 46. | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 50 | Who will claim [applicant] on their [coverage year] federal tax return? | Checkboxes, single-selection: All other known applicants or couples filing jointly Button: Add a person who will claim [applicant] |
All applicants requesting financial assistance who select "Yes" to being claimed as a dependent in Item 49 | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 51 | How is this person related to [applicant]? | Dropdown, single selection: - Spouse - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) |
All applicants requesting financial assistance who select "Add a person who will claim [applicant]" in Item 50 | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 52 | Does [applicant] live with this parent? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who are children under state Medicaid age and who select "Parent" or "Stepparent" in Item 51 | Required | This question is used to establish whether the dependent is claimed by a parent who they don't live with. If the dependent is claimed by a parent who they don't live with, and the dependent has another parent who they do live with, the dependent meets the criteria to have their household for purposes of Medicaid and CHIP constructed based on family members that they live with, instead of who else is on their tax return. |
| 04 - Household Composition | 53 | Does [applicant] live with any parent or stepparent? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select "No" to living with their claiming tax filer parent or stepparent in Item 52 | Required | This question is used to establish whether the dependent is claimed by a parent who they don't live with. If the dependent is claimed by a parent who they don't live with, and the dependent has another parent who they do live with, the dependent meets the criteria to have their household for purposes of Medicaid and CHIP constructed based on family members that they live with, instead of who else is on their tax return. |
| 04 - Household Composition | 54 | Can you provide more information about the person who claims [applicant], and any other people on their tax return? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select "Yes" to living with any parent or stepparent in Item 53, OR who are children under state Medicaid age and who select that their claiming tax filer is not a "Parent" or "Stepparent" in Item 51 | Required | This information is collected to determine whether we can evaluate the applicant's eligibility for APTC. Applicants for whom we can evaluate eligibility for Medicaid and CHIP based on their answers in Item 51, Item 52, and Item 53 can in some cases opt out of providing information about their claiming tax filer. Applicants who answer "no" to this question will not have their eligibility for APTC evaluated. |
| 04 - Household Composition | 55 | Tell us about the person who claims [applicant]: 1. How is this person related to [application filer]? 2. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new claiming tax filer) 3. First name 4. Middle name 5. Last name 6. Suffix 7. Date of birth 8. Sex |
1 + 2. Dropdown, single selection: - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) 3. Open text field 4. Open text field 5. Open text field 6. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 7. Open text field: MM / DD / YYYY 8. Radio buttons: - Female - Male |
All applicants requesting financial assistance who select "Add a person who will claim [applicant]" in Item 50 AND Are over state Medicaid child age, OR Select that they are claimed by a parent or stepparent who they live with in Item 51 and Item 52 OR Select that they are claimed by a parent or stepparent who they do not live with, and that they do not live with any parent or stepparent in Item 52 and Item 53 OR Select "Yes" when asked if they can provide information about their claiming tax filer |
1. Required 2. Required 3. Required 4. Optional 5. Required 6. Optional 7. Required 8. Required |
Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 56 | Is this person married? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who add or select a claiming tax filer in Item 50 or Item 51, and it is not already known whether the claiming tax filer is married | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 57 | Will this person file a [coverage year] joint federal tax return with their spouse? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select "Yes" to their claiming tax filer being married in Item 56, or it is already known that their claiming tax filer is married from Item 50 or Item 51 | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 58 | Tell us about [claiming tax filer]'s spouse: 1. How is this person related to applicant? 2. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) 3. First name 4. Middle name 5. Last name 6. Suffix 7. Date of birth 8. Sex |
1 + 2. Dropdown, single selection: - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) 3. Open text field 4. Open text field 5. Open text field 6. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 7. Open text field: MM / DD / YYYY 8. Radio buttons: - Female - Male |
All applicants requesting financial assistance who select "Yes" to their claiming tax filer filing a joint return with their spouse in Item 57 | 1. Required 2. Required 3. Required 4. Optional 5. Required 6. Optional 7. Required 8. Required |
Whether an applicant will be claimed as a tax dependent on someone else's return, and who they will be claimed by, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 59 | Will [claiming tax filer] [and spouse if filing jointly] claim any other dependents on their [coverage year] federal tax return? | Radio buttons: - Yes - No |
All applicants requesting financial assistance who select or provide a claiming tax filer in Item 50 or Item 51 | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, who they will be claimed by, and whether their claiming tax filers will also claim other dependents, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 60 | Who will [claiming tax filer] [and spouse if filing jointly] claim as a dependent on their [year] federal tax return? | Checkboxes, multi-selection: All other applicants who are not already in a tax household Button: Add a dependent |
All applicants requesting financial assistance who select "Yes" to whether their claiming tax filer will claim other dependents in Item 59 | Required | Whether an applicant will be claimed as a tax dependent on someone else's return, who they will be claimed by, and whether their claiming tax filers will also claim other dependents, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 04 - Household Composition | 61 | Tell us about [claiming tax filer] [and spouse if filing jointly]'s dependent: 1. How is this person related to applicant? 2. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) 3. First name 4. Middle name 5. Last name 6. Suffix 7. Date of birth 8. Sex |
1 + 2. Dropdown, single selection: - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) 3. Open text field 4. Open text field 5. Open text field 6. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 7. Open text field: MM / DD / YYYY 8. Radio buttons: - Female - Male |
All applicants requesting financial assistance who select "Add a dependent" in Item 60 | 1. Required 2. Required 3. Required 4. Optional 5. Required 6. Optional 7. Required 8. Required |
Whether an applicant will be claimed as a tax dependent on someone else's return, who they will be claimed by, and whether their claiming tax filers will also claim other dependents, is used to determine the applicant's household for APTC, Medicaid, and CHIP purposes. |
| 05 - Living Situation | 62 | What is [consumer]'s home address? | Radio buttons: - Application filer's home address - Other applicants addresses, if known - A different address - No home address |
All applicants or non-applicants filing a tax return | Required | Home address is used for determining state residency, which is a criteria of eligibility for Medicaid, CHIP, and QHP, as well as to determine which QHPs are available in the applicant's area. Non-applicants are also asked to provide their address so the Exchange can determine which applicants they live with, which is a criteria for building applicants' households for Medicaid and CHIP eligibility. |
| 05 - Living Situation | 63 | Enter [applicant]'s home address. 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: all U.S. states and territories 5. Open text field 6. Radio buttons: counties within the ZIP code |
All applicants or non-applicants filing a tax return who select "A different address" in Item 62 | 1. Required 2. Optional 3. Required 4. Required 5. Required 6. Required |
Home address is used for determining state residency, which is a criteria of eligibility for Medicaid, CHIP, and QHP, as well as to determine which QHPs are available in the applicant's area. Non-applicants are also asked to provide their address so the Exchange can determine which applicants they live with, which is a criteria for building applicants' households for Medicaid and CHIP eligibility. |
| 05 - Living Situation | 64 | Enter [applicant]'s mailing address. |
Radio buttons: - Application filer's home address - Other applicants' addresses, if known - A different address |
All applicants or non-applicants filing a tax return who select "No home address" in Item 62 | Required | In the case of applicants who have no home address, mailing address is used to determine their residency for the purpose of eligibility for Medicaid, CHIP, and QHP, as well as to determine which QHPs are available in the applicant's area |
| 05 - Living Situation | 65 | Enter [applicant]'s mailing address. 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: all U.S. states and territories 5. Open text field 6. Radio buttons: counties within the ZIP code |
All applicants or non-applicants filing a tax return who select "A different address" in Item 62 | 1. Required 2. Optional 3. Required 4. Required 5. Required 6. Required |
In the case of applicants who have no home address, mailing address is used to determine their residency for the purpose of eligibility for Medicaid, CHIP and QHP, as well as to determine which QHPs are available in the applicant's area. |
| 05 - Living Situation | 66 | Is [applicant] living outside [application state] temporarily? | Radio buttons: - Yes - No |
All applicants who select or add a home address that is not in the application state | Required | Applicants who are living outside of the state in which they're applying for coverage temporarily may still be able to establish residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as to determine which QHPs are available in the applicant's area, in the state in which they're applying for coverage. |
| 05 - Living Situation | 67 | Where will [applicant] live when they move back to [application state]? | Radio buttons: - Application filer's home address - Other applicants addresses, if known - A different address - No home address |
Applicants who select "Yes" to living outside of the state temporarily in Item 66 | Required | Applicants who are living outside of the state in which they're applying for coverage temporarily may still be able to establish residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as to determine which QHPs are available in the applicant's area, in the state in which they're applying for coverage. |
| 05 - Living Situation | 68 | Enter [applicant]'s address in [application state]. 1. Street address 2. Street address 2 3. City 4. State 5. ZIP code 6. County (if ZIP code crosses multiple counties) |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: all U.S. states and territories 5. Open text field 6. Radio buttons: counties within the ZIP code |
Applicants who selected "A different address" in Item 67 | 1. Optional 2. Optional 3. Required 4. Required 5. Required 6. Required |
Applicants who are living outside of the state in which they're applying for coverage temporarily may still be able to establish residency, which is a criteria of eligibility for Medicaid, CHIP and QHP, as well as to determine which QHPs are available in the applicant's area, in the state in which they're applying for coverage. |
| 05 - Living Situation | 69 | Will [applicant] file as Head of Household on their 2022 federal income tax return? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and are married, who will not file a joint return with their spouse, who do not live with their spouse, and who will claim a tax dependent who they live with | Required | Applicants who are married and will not file a joint return may still qualify for APTC if they will file using the Head of Household status. This status is available to tax filers who do not live with their spouse, and who provide support to a dependent who they live with. |
| 05 - Living Situation | 70 | You told us that [applicant] lives with [parent]. Does [applicant] also live with another parent at this address? (Display attested address) | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and are under state Medicaid child age and are claimed as a tax dependent by a parent who they live with, and it is unknown whether they live with another parent | Required | Children who live with two parents who won't file a joint tax return qualify to have their Medicaid and CHIP household constructed on the basis of who they live with, rather than who else is on their tax return. This question establishes whether the child lives with two parents who won't file jointly. |
| 05 - Living Situation | 71 | Does [applicant] live with a parent at this address? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and are under state Medicaid child age and are claimed as a tax dependent by a parent who they do not live with, and it is unknown whether they live with a parent | Required | Children who are claimed by a parent who they don't live with, and who have another parent they do live with, qualify to have their Medicaid and CHIP household constructed on the basis of who they live with, rather than who else is on their tax return. This question establishes whether the child qualifies for this exception. |
| 05 - Living Situation | 72 | Can you provide more information about [applicant]'s parent? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and are under state Medicaid child age and are claimed as a tax dependent by a parent who they do not live with, and they selected living with another parent in Item 53 and did not opt out of providing information on their claiming tax filer parent in Item 54 | Required | If a child is claimed by a parent who they don't live with, and has a parent who they do live with, the Exchange can in some cases determine the dependent's eligibility for APTC without collecting information about the child's custodial parent. The Exchange gives the application filer the opportunity to continue without providing the child's custodial parent information, since it's reasonable they may not have it in these family situations. Dependents who answer "no" will not be evaluated for Medicaid or CHIP eligibility. |
| 05 - Living Situation | 73 | Tell us about [applicant]'s parent: 1. First name 2. Middle name 3. Last name 4. Suffix 5. Date of birth 6. Sex 7. How is this person related to applicant? 8. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field: MM / DD / YYYY 6. Radio buttons: - Female - Male 7 + 8. Dropdown, single selection: - Spouse - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) |
Applicants who select "Yes" to living with a another parent in Item 70 or Item 71, or who select "Yes" to being able to provide more information in Item 72 | 1. Required 2. Optional 3. Required 4. Optional 5. Required 6. Required 7. Required 8. Required |
Children who live with two parents who won't file a joint tax return or who are claimed by a parent they don't live with and have a parent they do live with, qualify to have their Medicaid or CHIP household constructed on the basis of who they live with, rather than who else is on their tax return. This parent is therefore part of the child's household for purposes of Medicaid and CHIP eligibility. Collecting this demographic information allows the application to direct questions at the applicant by name, and to verify information told to the Exchange with trusted data sources as needed. |
| 06 - Non-Filer Households | 74 | Does [applicant] live with any other parents, sisters/brothers under [state Medicaid child age], or daughters/sons under [state Medicaid child age]? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and won't file a tax return or be claimed OR Applicants who are requesting financial assistance and claimed as a tax dependent by a non-parent or stepparent OR Applicants who are requesting financial assistance and under the state Medicaid child age and live with two parents who won't file a joint tax return OR Applicants who are requesting financial assistance and under the state Medicaid child age and are claimed as a dependent by a non-custodial parent |
Required | This information is collected to determine eligibility for Medicaid and CHIP. Applicants who see this question meet the criteria to have their household for purposes of Medicaid and CHIP constructed based on family members that they live with, instead of who else is on their tax return. This question collects information about all consumers who may be relevant to the applicant's Medicaid and CHIP household. The application will tailor which family members are asked about based on the applicant's age, and whether it is already known that the applicant lives with parents, siblings, or children. |
| 06 - Non-Filer Households | 75 | Can you provide information about the family members who live with [applicant]? | Radio buttons: - Yes - No |
Applicants who requesting financial assistance and selected "Yes" to living with other parents, siblings, or children in Item 74, AND who are claimed as a tax dependent by a non-parent OR who are claimed as a tax dependent by a non-custodial parent and provided that parent's information in Item 55 | Required | This information is collected to determine whether we can evaluate the applicant's eligibility for Medicaid and CHIP. Applicants for whom we can evaluate eligibility for APTC because they provided full information about their tax household can in some cases opt out of providing information about other family members they live with. Applicants who answer "No" to this question will not have their eligibility for Medicaid and CHIP evaluated. |
| 06 - Non-Filer Households | 76 | Enter [applicant]'s family members who live with them: 1. First name 2. Middle name 3. Last name 4. Suffix 5. Date of birth 6. Sex 7. How is this person related to applicant? 8. How is [applicant] related to [other applicant]? (repeat as needed for each applicant with unknown relationship to new applicant) |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field: MM / DD / YYYY 6. Radio buttons: - Female - Male 7 + 8. Dropdown, single selection: - Domestic Partner - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted & step child) - Sibling (including half & step sibling) - Parent (including adoptive parent) - Stepparent - Parent's domestic partner - Grandparent - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Mother-in-law or father-in-law - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (by blood or marriage) - Unrelated (not by blood or marriage) |
Applicants requesting financial assistance and selected "Yes" to living with other parents, siblings, or children in Item 74 and did not meet the criteria to see the "opt out" question in Item 75, OR who saw the "opt out" question and selected "Yes" in Item 75 | 1. Required 2. Optional 3. Required 4. Optional 5. Required 6. Required 7. Required 8. Required |
Applicants who see this question meet the criteria to have their household for purposes of Medicaid and CHIP constructed based on family members that they live with, instead of who else is on their tax return. This question collects information about all consumers who may be relevant to the applicant's Medicaid and CHIP household. Collecting this demographic information allows the application to verify information told to the Exchange with trusted data sources, and to direct questions at the applicant by name. |
| 07 - Parent/Caretaker Relative (PCR) | 77 | Is [applicant] the main caretaker of a child? Select "Yes" if both of these apply: They live with any children 18 or younger They're the main person taking care of at least one of those children |
Radio Buttons: - Yes - No |
Applicants who are requesting financial assistance and who are age 19 or older, and who have not yet told the Exchange they live with a child to whom they are either the parent or claiming tax filer | Required | This information is used to determine Medicaid eligibility for adults who qualify for the Parent/Caretaker Relative Medicaid category. |
| 07 - Parent/Caretaker Relative (PCR) | 78 | Select and/or add each child [applicant] is the main caretaker for. | Checkboxes, multi-selection: - Display names of applicants and non-applicants under 19 [applicant] lives with - Add a child |
Applicants who select "Yes" to being the main caretaker of a child in Item 77 | Required | This information is used to determine Medicaid eligibility for adults who qualify for the Parent/Caretaker Relative Medicaid category. |
| 07 - Parent/Caretaker Relative (PCR) | 79 | Tell us about the child [applicant] takes care of: | Answer Fields: 1. First Name: [Open text field] 2. Middle Name: [Open text field] 3. Last Name: [Open text field] 4. Suffix: [drop-down, single selection]: - Jr. - Sr. - II - III - IV - V 5. DOB: [Open text field]: MM-DD-YYYY 6. Sex [Radio buttons]: - Female - Male 7. How is this person related to [applicant]? [Drop-down, single-selection] - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted and step child) - Sibling (including half and stepsibling) - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (including by marriage and adoption) - Unrelated (not by blood or marriage) 8. How is this person related to [spouse of applicant]? - Child (including adopted child) - Stepchild - Child of domestic partner (including adopted and step child) - Sibling (including half and stepsibling) - Grandchild - Niece or nephew - Aunt or uncle - First cousin - Daughter-in-law or son-in-law - Sister-in-law or brother-in-law - Other relative (including by marriage and adoption) - Unrelated (not by blood or marriage) |
Applicants who select "Yes" to being the main caretaker of a child in Item 77 and select "Add a child" in Item 78 | 1. Required 2. Optional 3. Required 4. Optional 5. Required 6. Required 7. Required 8. Required (If spouse of main applicant taking care of the child is also applying for coverage) |
The child's information is used to determine whether the adult parent or caretaker can qualify for Medicaid under the Parent/Caretaker Relative Medicaid category. |
| 08 - More About Household | 80 | Do any of these situations apply to any household members? | Checkboxes, multi-selection: - Is pregnant - Is American Indian or Alaska Native - Is 18-25 years old and was ever in foster care - Is currently incarcerated (detained or jailed) - None of these apply to the people in the household |
The "Is pregnant" checkbox displays on applications seeking financial assistance, and a household member is female and between 9 and 66 years of age. The "Is American Indian or Alaska Native" checkbox always displays. The "Is 18-25 years old and was ever in foster care" question displays whenever the applicant is seeking financial assistance, and an applicant is between 18-25 years old. The "Is currently incarcerated" checkbox always displays. |
Required | Pregnancy: Collected to determine eligibility for Medicaid and CHIP. Pregnancy can impact eligibility for Medicaid and CHIP, and can impact the size of the household used to calculate Medicaid and CHIP eligibility for other applicants. AI/AN: Collected to determine eligibility for Medicaid, CHIP, Exchange CSRs, and Exchange SEPs. The application collects information on whether someone identifies as AI/AN in order to trigger additional questions in the application to appear related to receipt of tribal income for Medicaid and CHIP eligibility purposes, or asking whether someone is a member of a federally-recognized tribe for purposes of determining special benefits available through the Exchange for tribal members. Foster care: Collected to determine eligibility for Medicaid. Former foster care youth may be Medicaid eligible regardless of current income. Incarceration: Collected to determine eligibility for CHIP and to enroll in a QHP. Whether a consumer is incarcerated can impact their eligibility for CHIP and their eligibility to enroll in a QHP. |
| 08 - More About Household | 81 | Which of these people are pregnant? Optional. Select all that apply. Pregnant women and their household members may be eligible for free or low-cost coverage through Medicaid or CHIP. If a pregnant woman is already enrolled in Marketplace coverage and wants to keep her current coverage, don't select her name here. |
Checkboxes, multi-selection: - All female applicants and non-applicants between 9 and 66 years of age - None of these people |
Female consumers between 9 and 66 years of age, who checked "Is pregnant" in Item 80 | Optional | Pregnancy can impact eligibility for Medicaid and CHIP, and can impact the size of the household used to calculate Medicaid and CHIP eligibility for other applicants. |
| 08 - More About Household | 82 | How many babies is [consumer] expecting during this pregnancy? | Dropdown, single-selection: - 1 - 2 - 3 - 4 - 5 - 6 - 7 - 8 |
Female consumers between 9 and 66 years of age, who selected being pregnant in Item 81 | Required | How many babies a pregnant consumer is expecting can impact the size of the household used to determine eligibility for Medicaid and CHIP. All states increase the pregnant woman's household size by the number of babies she's expecting. Some states also increase the household size of other household members by the number of babies she's expecting, and others opt to only increase other household members' household size by 1 regardless of how many babies she's expecting. |
| 08 - More About Household | 83 | Which of these people are American Indians or Alaska Natives? | Checkboxes, multi-selection: - All consumers - None of these people |
All consumers who checked "Is American Indian or Alaska Native" in Item 80. | Required | This information is collected to determine eligibility for Medicaid, CHIP, Exchange CSRs, and Exchange SEPs. The application collects information on whether someone identifies as AI/AN in order to trigger additional questions in the application to appear related to receipt of tribal income for Medicaid and CHIP eligibility purposes, or asking whether someone is a member of a federally-recognized tribe for purposes of determining special benefits available through the Exchange for tribal members. |
| 08 - More About Household | 84 | Which of these people were in foster care? | Checkboxes, multi-selection: - All applicants age 18-25 - None of these people |
All applicants age 18-25 who checked "Is 18-25 years old and was ever in foster care" | Required | This information is collected to determine eligibility for Medicaid. Former foster care youth may be Medicaid eligible regardless of current income. |
| 08 - More About Household | 85 | In what state was [applicant] in the foster care system? | Dropdown, single-selection: All states |
All applicants age 18-25 who selected being in foster care in Item 84 | Required | This information is collected to determine eligibility for Medicaid. Different states have different rules for whether former foster children can qualify, depending on the age at which they left the system, and whether they were previously enrolled in Medicaid. |
| 08 - More About Household | 86 | Was [applicant] getting health care through [state Medicaid program] (Medicaid)? | Radio buttons: - Yes - No |
All applicants age 18-25 who selected being in foster care in Item 84 | Required | This information is collected to determine eligibility for Medicaid. Different states have different rules for whether former foster children can qualify, depending on the age at which they left the system, and whether they were previously enrolled in Medicaid. |
| 08 - More About Household | 87 | Which of these people are incarcerated? | Checkboxes, multi-selection: - All applicants - None of these people |
All applicants who checked "Is currently incarcerated (detained or jailed)" in Item 80 | Required | This information is collected to determine eligibility for CHIP and to enroll in a QHP. Whether a consumer is incarcerated can impact their eligibility for CHIP and their eligibility to enroll in a QHP. |
| 08 - More About Household | 88 | Is [applicant] only incarcerated pending disposition of charges? | Radio buttons: - Yes - No |
All applicants who selected being incarcerated in Item 87 | Required | If a consumer is incarcerated pending disposition of charges, meaning that they are in jail but have not yet been convicted of a crime, they may still be eligible to enroll in a QHP. |
| 08 - More About Household | 89 | Is [consumer] a full-time student? | Radio buttons: - Yes - No |
Applicant is age 18-22 in a state that considers student status when applying Medicaid and CHIP residency rules, OR Consumer is age 18 and has a parent caretaker (a. parent that lives with the child, b. claiming tax filer that lives with the child, or c. selected parent caretaker of the child) OR Consumer is age 19 or 20 in a state that considers full-time students who are age 19 or 20 children for Medicaid and CHIP household composition purposes |
Required | Full-time student status can affect whether a student's parent qualifies for the Parent/Caretaker-Relative Medicaid category, whether the applicant can be considered a resident of the state for Medicaid and CHIP, and what set of household composition rules should apply to an applicant or nonapplicant. |
| 08 - More About Household | 90 | Do one or more of [applicant]'s parents or guardians live in [application state]? | Radio buttons: - Yes - No |
Applicants age 18-22, who selected "Yes" to being a full-time student in Item 89, are tax dependents, and who are applying for coverage in a state that considers student status when applying Medicaid or CHIP residency rules | Required | Medicaid and CHIP residency rules in some states require full-time students age 18-22 who are going to school in the state in which they're applying for Medicaid or CHIP coverage to have parents or guardians living in the application state. |
| 08 - More About Household | 91 | Does [applicant] go to school in [application state]? | Radio buttons: - Yes - No |
Applicants who select "No" to having parents or guardians living in the state where they're applying for coverage | Required | Medicaid and CHIP residency rules in some states require full-time students age 18-22 who are going to school in the state in which they're applying for Medicaid or CHIP coverage to have parents or guardians living in the application state. |
| 09 - Race and Ethnicity | 92 | Is [consumer] of Hispanic, Latino, or Spanish origin? | Radio buttons: - Yes - No |
All consumers | Optional | Section 4302 of the PPACA requires that application collect demographic information on race and ethnicity. The question format aligns with 2011 HHS guidance on the collection of race and ethnicity. |
| 09 - Race and Ethnicity | 93 | What is [consumer]'s ethnicity? | Checkboxes, multi-selection: - Cuban - Mexican, Mexican American, Chicano/a - Puerto Rican - An ethnicity not listed above [Open text field] |
All consumers who select "Yes" to Hispanic, Latino, or Spanish origin in Item 92 | Optional | Section 4302 of the PPACA requires that application collect demographic information on race and ethnicity. The question format aligns with 2011 HHS guidance on the collection of race and ethnicity. |
| 09 - Race and Ethnicity | 94 | What is [consumer]'s race? | Checkboxes, multi-selection: - American Indian or Alaska Native - Asian Indian - Black or African American - Chinese - Filipino - Guamanian or Chamorro - Japanese - Korean - Native Hawaiian - Other Asian - Pacific Islander - Samoan - Vietnamese - White - Another race not listed above |
All consumers | Optional | Section 4302 of the PPACA requires that application collect demographic information on race and ethnicity. The question format aligns with 2011 HHS guidance on the collection of race and ethnicity. |
| 10 - SSN, Citizenship, Immigration | 95 | What is [applicant]'s Social Security Number (SSN)? | Open text field Checkbox: [applicant] doesn't have an SSN |
All applicants | Required | Applicants must provide their SSNs, if they have one. SSNs are used as an input to verify consumer information, including citizenship and income, through trusted data sources. If consumers do not provide an SSN, they will need to submit additional documentation after submitting their application in order to verify their eligibility. |
| 10 - SSN, Citizenship, Immigration | 96 | What is [non-applicant]'s Social Security Number (SSN)? | Open text field |
All non-applicants | Optional | Non-applicants are generally not required to provide their SSN, however they are strongly encouraged to provide their SSN in order to use for verification of income. |
| 10 - SSN, Citizenship, Immigration | 97 | Does the name below match the name on [applicant]'s Social Security card? (Display applicant's name as attested on the application). | Radio buttons: - Yes - No |
All consumers who provide an SSN in Item 95 or 96 | Required | Consumers whose name on the application does not match the name on their SSN must provide the name on their Social Security card so the Exchange can verify their information with trusted data sources. |
| 10 - SSN, Citizenship, Immigration | 98 | Enter this person's information exactly as it appears on their Social Security card: 1. First name 2. Middle name 3. Last name 4. Suffix |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: Jr., Sr., II, III, IV, V |
All consumers who select "No" to their name matching their Social Security card in Item 97 | 1. Required 2. Optional 3. Required 4. Optional |
Consumers whose name on the application does not match the name on their Social Security card must provide the name on their Social Security card so the Exchange can verify their information with trusted data sources. |
| 10 - SSN, Citizenship, Immigration | 99 | Is [applicant] a U.S. citizen or U.S. national? | Radio buttons: - Yes - No |
All applicants | Required | In order to be eligible to enroll in a QHP or be eligible for Medicaid or CHIP coverage an applicant must be a U.S. citizen or national or have an eligible immigration status. |
| 10 - SSN, Citizenship, Immigration | 100 | We weren't able to verify [consumer]'s information. Please confirm the information below is correct and try again. Does this match the name and date of birth on [consumer]'s Social Security card? | Radio buttons: - Yes - No |
All consumers who provided an SSN and a call was made to the SSA to verify citizenship and SSA indicated a "mismatch" | Required | Consumers whose name or DOB on the application is not able to be matched to the SSN provided by SSA must edit their information so the Exchange can verify their information with trusted data sources. |
| 10 - SSN, Citizenship, Immigration | 101 | Enter this person's information exactly as it appears on their Social Security card: 1. First name 2. Middle name 3. Last name 4. Suffix 5. Date of birth |
1. Open text field 2. Open text field 3. Open text field 4. Drop-down, single selection: - Jr. - Sr. - II - III - IV - V 5. Open text field: MM / DD / YYYY |
All consumers who select "No" to their name matching their Social Security card in Item 97 | 1. Required 2. Optional 3. Required 4. Optional 5. Required |
Consumers whose name or DOB on the application is not able to be matched to the SSN provided by SSA must edit their information so the Exchange can verify their information with trusted data sources. |
| 10 - SSN, Citizenship, Immigration | 102 | Re-enter [consumer]'s Social Security Number (SSN). | Open text field | All applicants who provided an SSN, who selected "Yes" to being a U.S. citizen or U.S. national, and a call was made to the SSA to verify citizenship, and SSA indicated a "mismatch" | Optional | Applicants whose name or DOB on the application is not able to be matched to the SSN provided by SSA must edit their information so the Exchange can verify their information with trusted data sources. |
| 10 - SSN, Citizenship, Immigration | 103 | Is [applicant] a naturalized or derived citizen? | Radio buttons: - Yes - No |
All applicants who provided an SSN, who selected "Yes" to being a U.S. citizen or U.S. national, and a call was made to SSA to verify citizenship, but SSA was unable to verify their citizenship | Required | Applicants who are naturalized or derived citizens are eligible to enroll in a QHP, and for other financial assistance programs, if otherwise eligible. Naturalized and derived citizen status may not be verified through SSA. For this reason, additional information is collected in order to verify applicants' status through the DHS. |
| 10 - SSN, Citizenship, Immigration | 104 | Does [applicant] have one of these documents? | Radio buttons: - Naturalization Certificate - Certificate of Citizenship - None of these |
All applicants who selected"Yes" to being a naturalized or derived citizen in Item 103 | Optional | Applicants who are naturalized or derived citizens are eligible to enroll in a QHP, and for other financial assistance programs, if otherwise eligible. Naturalized and derived citizen status may not be verified through SSA. For this reason, additional information is collected in order to verify applicants' status through the DHS. This information is optional for the applicant to provide at the time of application. Appliants who do not provide this information may need to submit additional documentation later to verify citizenship status. |
| 10 - SSN, Citizenship, Immigration | 105 | 1. [applicant]'s Naturalization Certificate number 2. [applicant]'s alien number |
1. Open text field 2. Open text field |
All applicants who select "Naturalization Certificate" in Item 104 | Optional | Applicants who are naturalized or derived citizens are eligible to enroll in a QHP, and for other financial assistance programs, if otherwise eligible. Naturalized and derived citizen status may not be verified through SSA. For this reason, the Naturalization Certificate number or alien number is collected in order to attempt to verify applicants' status through the DHS. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later to verify citizenship status. |
| 10 - SSN, Citizenship, Immigration | 106 | 1. [applicant]'s Certificate of Citizenship number 2. [applicant]'s alien number |
1. Open text field 2. Open text field |
All applicants who select "Certificate of Citizenship" in Item 104 | Optional | Applicants who are naturalized or derived citizens are eligible to enroll in a QHP, and for other financial assistance programs, if otherwise eligible. Naturalized and derived citizen status may not be verified through SSA. For this reason, Certificate of Citizenship information or alien number is collected in order to attempt to verify applicants' status through DHS. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later to verify citizenship status. |
| 10 - SSN, Citizenship, Immigration | 107 | Does [applicant] have eligible immigration status? | Radio buttons: -Yes, [applicant] has eligible immigration status -I would like to continue through the application without answering this question. I understand that if I don't answer it, [applicant] won’t be eligible for full Medicaid or Marketplace coverage and will be considered for only coverage of emergency services, including labor and delivery services. |
All applicants who select "No" to being a U.S. citizen or national | Required | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP with or without APTC/CSRs, Medicaid and CHIP. |
| 10 - SSN, Citizenship, Immigration | 108 | Select the document type that corresponds with [applicant]'s most current documentation and status | Radio buttons: - Permanent Resident Card (Green Card) or Reentry Permit (I-551, temporary I-551 stamp, I-327) - Machine Readable Immigrant Visa with temporary I-551 language - Employment Authorization Card (I-766) - Arrival/Departure Record (I-94, I-94A) - Refugee Travel Document (I-571) - Nonimmigrant Student or Exchange Visitor Status (I-20, DS2019) - Notice of Action (I-797) - Other document or status - Unexpired foreign passport - None of these |
All applicants who select "Yes" to having eligible immigration status in Item 107 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 109 | Select an option | Dropdown, single selection: - I-551 (Permanent Resident Card, "Green Card") - Temporary I-551 Stamp (on passport or I-94/I-94A) - I-327 (Reentry Permit) |
All applicants who select "Permanent Resident Card (Green Card) or Reentry Permit (I-551, temporary I-551 stamp, I-327)" in Item 108 | Required for applicants who attest to "Permanent Resident Card (Green Card) or Reentry Permit (I-551, temporary I-551 stamp, I-327)" in Item 108 | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 110 | Select an option | Dropdown, single selection: - Arrival/Departure Record (I-94/I-94A) - Arrival/Departure Record in unexpired foreign passport (I-94) |
All applicants who select "Arrival/Departure Record (I-94, I-94A)" in Item 108 | Required for applicants who select "Arrival/Departure Record (I-94, I-94A)" in Item 108 | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 111 | Select an option | Dropdown, single selection: - Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20) - Certificate of Eligibility for Exchange Visitor (J-1) Status |
All applicants who select "Nonimmigrant Student or Exchange Visitor Status (I-20, DS2019)" in Item 108 | Required for applicants who select Nonimmigrant Student or Exchange Visitor Status (I-20, DS2019) in Item 108 | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 112 | 1. [applicant]'s alien number 2. [applicant]'s card number 3. Document expiration date 4. Does the name below match the name on the I-551? (Display attested name) |
1. Open text field 2. Open text field 3. Open text field: MM / DD / YYYY 4. Radio buttons: - Yes - No |
All applicants who select "I-551 (Permanent Resident Card, "Green Card")" in Item 109 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 113 | 1. [applicant]'s alien number 2. [applicant]'s passport number 3. Select the country that issued [applicant]'s passport 4. Document expiration date |
1. Open text field 2. Open text field 3. Dropdown, single-selection: list of passport-issuing countries 4. Open text field: MM / DD / YYYY |
All applicants who select "Temporary I-551 Stamp (on passport or I-94/I-94A)" in Item 109 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 114 | 1. [applicant]'s alien number 2. Document expiration date |
1. Open text field 2. Open text field: MM / DD / YYYY |
All applicants who select "I-327 (Reentry Permit)" or "Refugee Travel Document (I-571)" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 115 | 1. [applicant]'s alien number 2. [applicant]'s passport number 3. Select the country that issued [applicant]'s passport 4. Document expiration date 5. Does the name below match the name on the I-551? (Display attested name) |
1. Open text field 2. Open text field 3. Dropdown, single-selection: list of passport-issuing countries 4. Open text field: MM / DD / YYYY 5. Radio buttons: - Yes - No |
All applicants who select "Machine Readable Immigrant Visa with temporary I-551 language" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 116 | 1. [applicant]'s alien number 2. [applicant]'s card number 3. Document expiration date 4. Category code 5. Does the name below match the name on the card? (Display attested name) |
1. Open text field 2. Open text field 3. Open text field: MM / DD / YYYY 4. Open text field 5. Radio buttons: - Yes - No |
All applicants who select "Employment Authorization Card (I-766)" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 117 | 1. Document expiration date 2. [applicant]'s I-94 number 3. [applicant]'s SEVIS ID number |
1. Open text field: MM / DD / YYYY 2. Open text field 3. Open text field |
All applicants who select "Arrival/Departure Record (I-94/I-94A)" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 118 | 1. [applicant]'s passport number 2. Select the country that issued [applicant]'s passport 3. Document expiration date 4. [applicant]'s I-94 number 5. [applicant]'s SEVIS ID number 6. Does the name below match the name on the card? (Display attested name) |
1. Open text field 2. Dropdown, single-selection: list of passport-issuing countries 3. Open text field: MM / DD / YYYY 4. Open text field 5. Open text field 6. Radio buttons: - Yes - No |
All applicants who select "Arrival/Departure Record in unexpired foreign passport (I-94)" or "Unexpired foreign passport" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 119 | 1. [applicant]'s passport number 2. Select the country that issued [applicant]'s passport 3. Document expiration date 4. [applicant]'s I-94 number 5. [applicant]'s SEVIS ID number |
1. Open text field 2. Dropdown, single-selection: list of passport-issuing countries 3. Open text field: MM / DD / YYYY 4. Open text field 5. Open text field |
All applicants who select "Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)" or "Certificate of Eligibility for Exchange Visitor (J-1) Status" in Item 111 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 120 | 1. [applicant]'s alien number 2. [applicant]'s I-94 number |
1. Open text field 2. Open text field |
All applicants who select "Notice of Action (I-797)" in Item 108 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 121 | Update [applicant]'s information so that it matches their [document type]. 1. First name 2. Middle name 3. Last name 4. Suffix |
1. Open text field 2. Open text field 3. Open text field 4. Dropdown, single selection: - Jr. - Sr. - II - III - IV - V |
All applicants who select "No" when asked "Does the name below match the name on the [document type]?" in Items 112, 115, 116, 118 | 1. Required 2. Optional 3. Required 4. Optional |
Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 122 | Does [applicant] have one of these document types or statuses? | Checkboxes, multi-selection: - Document indicating member of a federally recognized Indian tribe or American Indian born in Canada - Certification from HHS ORR - ORR eligibility letter (if under 18) - Cuban/Haitian Entrant - Resident of American Samoa - Battered spouse, child, or parent under the Violence Against Women Act - Other document or [applicant]'s alien number/I-94 number - None of these (Select this if this person doesn't have a listed document. You can continue the application without selecting a document or status type.) |
All applicants who select "Yes" to having eligible immigration status in Item 107 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, and for other financial assistance programs. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information provided by the consumer in this section is used to try to verify the consumer's immigration status, to the extent needed to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 123 | 1. Enter a description of the document Enter either [applicant]'s alien number or I-94 number: 2. [applicant]'s alien number 3. [applicant]'s I-94 number |
1. Open text field 2. Open text field 3. Open text field |
All applicants who select "Other document or [applicant]'s alien number/I-94 number" in Item 122 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, Medicaid or CHIP. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. Immigration documentation information is used to verify the applicant's immigration status with DHS to determine program eligibility. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 124 | When did [applicant] get their current immigration status? Optional | Open text field: MM / DD / YYYY | All applicants who provide immigration documentation information, and a call is made to DHS, and DHS is unable to provide the applicant's grant date | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, and for other financial assistance programs. In some cases, noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP. The date entered here is used to determine whether the applicant meets those requirements. This information is optional for the applicant to provide at the time of application. Applicants who do not provide this information may need to submit additional documentation later. |
| 10 - SSN, Citizenship, Immigration | 125 | Has [applicant] lived in the U.S. since 1996? | Radio buttons: - Yes - No |
All applicants who select "Yes" to having eligible immigration status in Item 107 and who have a DOB before 8/22/1996 | Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, and for other financial assistance programs. Noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP; these requirements differ for applicants who have lived in the U.S. since 1996. This information is optional for applicants to provide at the time of application. |
| 10 - SSN, Citizenship, Immigration | 126 | Are any of these people an honorably discharged Veteran or active-duty member of the U.S. military? | Checkboxes, multi-selection: If Applicant is age 17 or older: [applicant] If Applicant is married: [applicant's spouse] If Applicant is not married, and is a tax dependent of their parent(s): [applicant's parent 1] If Applicant is not married, and is a tax dependent of 2 parents filing jointly: [applicant's parent 2] If Applicant is not married and over age 14: [applicant]'s deceased spouse None of these people |
All applicants who select "Yes" to having eligible immigration status in Item 107 AND who were born after 8/22/1996 OR selected "No" to having lived in the U.S. since 1996 in Item 125 AND meet one of the following conditions: Applicant is age 17 or older Applicant is married Applicant is not married and over age 14 Applicant is a tax dependent and has relationship of child to their tax filer |
Optional | Applicants who are not U.S. citizens must have eligible immigration status in order to qualify to enroll in a QHP, and for other financial assistance programs. Noncitizen applicants must meet additional requirements to qualify for Medicaid and CHIP; these requirements differ for applicants when they or their family members have qualifying military service. This information is optional for the applicant to provide at the time of application. |
| 11 - Non-MAGI (income) based Medicaid | 127 | Does [applicant] have a special health care need, physical disability, or mental health condition that limits their ability to work, attend school, or take care of their daily needs? | Radio buttons: - Yes - No |
All applicants seeking financial assistance | Optional | This information is collected to refer applicants to Medicaid for a full determination on a basis other than income for disability programs. |
| 12 - Non-MAGI (income) based Medicaid | 128 | Does [applicant] need help with daily activities (like dressing or using the bathroom), or live in a medical facility or nursing home? | Radio buttons: - Yes - No |
All applicants seeking financial assistance | Optional | This information is collected to refer applicants to Medicaid for a full determination on a basis other than income for disability programs. |
| 12 - Medicaid transfer | 129 | Did [applicant] have Medicaid or CHIP that recently ended or will end soon because they're no longer eligible? | Radio buttons: - Yes - No |
Applicants seeking financial assistance | Required | Applicants for whom Medicaid or CHIP coverage has ended may qualify for a SEP to enroll in a QHP. Applicants may also respond in such a way that the Exchange will not revisit Medicaid and CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs. This is to prevent them from being sent back to their SMA after losing coverage. |
| 12 - Medicaid transfer | 130 | Has the household income or size changed since [applicant(s)] was/were found ineligible by the state? | Radio buttons: - Yes - No |
Applicants who selected having Medicaid or CHIP ending in Item 129 | Required | Applicants for whom Medicaid or CHIP coverage has ended but who selected having household size or income changes will be evaluated for Medicaid and CHIP coverage, along with eligibility for a QHP and APTC/CSRs, and their information will be sent to their SMA if otherwise eligible. |
| 12 - Medicaid transfer | 131 | What's the last day of [applicant]'s Medicaid or CHIP coverage? | Open text field: MM / DD / YYYY | Applicants who selected having Medicaid or CHIP ending in Item 129 | Required | Applicants for whom Medicaid or CHIP coverage has ended may qualify for a SEP to enroll in a QHP if their coverage is ending within +/- 60 days. If their coverage ended in the last 90 days or is ending in the next 60 days, and they do not select household or income size changes, the Exchange will not revisit their Medicaid and CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs. This is to prevent them from being sent back to their SMA after having been recently denied coverage. |
| 12 - Medicaid transfer | 132 | Was [applicant] found not eligible for Medicaid or CHIP since [90 days ago]? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and who did not select having Medicaid or CHIP ending in Item 129 | Required | Applicants who applied during an OEP and were denied Medicaid or CHIP after the end of the OEP, may qualify for an SEP. Applicants may also qualify for a SEP if they applied for Exchange coverage after an SEP qualifying event, were referred to Medicaid or CHIP, and then were determined Medicaid or CHIP ineligible after their original SEP window ended because more than 60 days passed since their original qualifying event. Applicants may respond in such a way that the Exchange will not revisit Medicaid or CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs. This is to prevent them from being sent back to their SMA after having been recently denied coverage. |
| 12 - Medicaid transfer | 133 | When did [applicant] get their Medicaid or CHIP denial from [application state]? | Open text field: MM / DD / YYYY | Applicants who select that they were found not eligible for Medicaid in Item 132 | Required | Consumers who have a Medicaid or CHIP denial may qualify for a SEP to enroll in a QHP if their denial is within +/- 60 days. If their denial is in the last 90 days or the next 60 days, we will not revisit Medicaid and CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs. This is to prevent them from being sent back to their SMA after having been recently denied coverage. |
| 12 - Medicaid transfer | 134 | Did [applicant] apply for health coverage between [dates of the most recent OEP]? | Radio buttons: - Yes - No |
Applicants who select that they were found not eligible for Medicaid in Item 132 | Required | Consumers who applied during an OEP and were denied Medicaid or CHIP after the end of the OEP, may qualify for an SEP. |
| 12 - Medicaid transfer | 135 | Did [applicant] apply through the Health Insurance Marketplace after a qualifying life event? Qualifying life changes include moving, marriage, birth, adoption, and loss of coverage. |
Radio buttons: - Yes - No |
Applicants who select "No" to having applied during the most recent OEP in Item 134 | Required | Applicants may qualify for a SEP if they applied for Exchange coverage after an SEP qualifying event, were referred to Medicaid or CHIP, and then were determined Medicaid or CHIP ineligible after their original SEP window ended because more than 60 days passed since their original qualifying event. |
| 12 - Medicaid transfer | 136 | Was [applicant] found not eligible for Medicaid or CHIP based on their immigration status since [five years ago]? | Radio buttons: - Yes - No |
Applicants who are requesting financial assistance and selected having eligible immigration status in Item 107 | Required | Applicants are generally ineligible for Medicaid and CHIP until they've had a qualifying immigration status for five years. If an applicant was denied Medicaid or CHIP on the basis of their immigration status within the last five years, the Exchange will not revisit Medicaid or CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs. This is to prevent applicants from being sent back to their SMA when they are still ineligible due to their immigration status. |
| 12 - Medicaid transfer | 137 | Has [applicant] had their current immigration status since [five years ago]? | Radio buttons: - Yes - No |
Applicants who attest to having been denied Medicaid or CHIP due to immigration status in Item 136 | Required | Applicants are generally ineligible for Medicaid and CHIP until they've had a qualifying immigration status for five years. If an applicant attests that they have not had their status since five years ago, the Exchange will not revisit Medicaid or CHIP eligibility and instead only evaluate them for QHP and APTC/CSRs, unless the applicant selects that they have had a change in immigration status since their denial in Item 133. This is to prevent consumers from being sent back to their SMA when they are still ineligible due to their immigration status. |
| 12 - Medicaid transfer | 138 | Has [applicant] had a change in their immigration status since they were found not eligible for Medicaid or CHIP? | Radio buttons: - Yes - No |
Applicants who select "No" to having had their immigration status since five years ago in Item 137 | Required | Applicants are generally ineligible for Medicaid and CHIP until they've had a qualifying immigration status for five years. If an applicant selects that they've had a change in their status since they were last denied, they will be evaluated for Medicaid or CHIP coverage, along with eligibility for a QHP and APTC/CSRs, and their information will be sent to their SMA if otherwise eligible. |
| 13 - Income | 139 | Will [consumer] get income this month? | Radio buttons: - Yes - No |
All consumers on financial assistance applications | Required | The household's current month income, minus qualifying expenses, is used to determine eligibility for Medicaid and CHIP. |
| 13 - Income | 140 | Select a type of income [consumer] currently gets this month. | Dropdown, single-selection: - Job (like salary, wages, commissions, or tips) - Self-employment (like own business, consulting, or freelance work) - Farming or fishing - Unemployment - Social Security benefits (retirement and disability) - Retirement (like IRA and 401(k) withdrawals) - Pension benefits - Investment (including interest and dividend income) - Capital gains - Rental or royalty - Alimony received - Scholarship - Canceled debt - Cash support - Court awards - Gambling, prizes, or awards - Jury duty pay - Other income |
All consumers who attested to getting income this month in Item 139 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 141 | 1. Enter the employer name 2. Enter the amount [consumer] gets paid 3. How often is [consumer] paid? 4. Enter a phone number where we can reach [employer]. |
1. Open text field 2. Open text field 3. Radio buttons: - Hourly - Daily - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only |
All consumers who select "Job (like salary, wages, commissions, or tips)" in Item 140 | Required | Consumers who select income from a job must provide basic information about their employer. This helps the application ask questions about employer-sponsored coverage later in the application. |
| 13 - Income | 142 | Enter the hours per week [consumer] works. | Open text field | All consumers who select "Hourly" frequency in Item 141 | Required | Consumers who select an hourly pay frequency must include the hours per week they work so that their monthly income can be calculated. |
| 13 - Income | 143 | How many days a week does [consumer] work? | Open text field | All consumers who select "Daily" frequency in Item 141 | Required | Consumers who select a daily pay frequency must include the days per week they work so that their monthly income can be calculated. |
| 13 - Income | 144 | 1. Enter [consumer]'s net income (total income minus business expenses) for [current month current year]. 2. Describe the kind of work in a few words. |
1. Open text field 2. Open text field |
All consumers who select "Self-employment (like own business, consulting, or freelance work)" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 145 | 1. How much does [consumer] get from net farming or fishing income (the profit after subtracting costs)? 2. How often does [consumer] get this amount? |
1. Open text field 2. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only |
All members who select "Farming or fishing" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 146 | 1. Enter the amount [consumer] gets paid. 2. How often does [consumer] get this amount? If consumer selected "Unemployment" in Item 140: 3.Which state provides [consumer] with unemployment benefits? 4. Enter the date that unemployment benefits are set to expire. If consumer selected "Other income" in Item 140: 3. Describe the kind of income in a few words. |
1. Open text field 2. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only If consumer selected "Unemployment" in Item 140: 3. Open text field 4. Open text field: MM / DD / YYYY If consumer selected "Other income" in Item 140: 3. Open text field |
All consumers who select any of the following in Item 140: -"Unemployment" -"Retirement (like IRA and 401(k) withdrawals)" -"Pension benefits" -"Alimony received" -"Cancelled debt" -"Cash support" -"Court awards" -"Gambling, prizes, or awards" -"Jury duty pay" -"Other income" |
1. Required 2. Required If consumer selected "Unemployment" in Item 140: 3. Optional 4. Optional If consumer selected "Other income" in Item 140: 3. Optional |
The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 147 | 1. Enter the amount [Consumer] gets paid. 2. How often does [consumer] get this amount? |
1. Open text field 2. Radio buttons: -Monthly -Yearly -One time only |
All consumers who select "Social Security benefits (retirement and disability)" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 148 | 1. Enter the amount [consumer] gets paid. 2. How often does [consumer] get this amount? |
1. Open text field 2. Radio buttons: - Monthly - Quarterly - Yearly - One time only |
All consumers who select "Investment (including interest and dividend income)" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 149 | 1. How much does [consumer] expect to get from net capital gains? 2. How often does [consumer] get this amount? |
1. Open text field 2. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only |
All consumer who select "Capital gains" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 150 | 1. How much does [consumer] get from net rental or royalty income (after subtracting property expenses)? 2. How often does [consumer] get this amount? |
1. Open text field 2. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only |
All consumers who select "Rental or royalty" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Having the consumer select the income type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including income that is not countable. |
| 13 - Income | 151 | 1. Enter the amount [consumer] gets paid. 2. Enter the amount [consumer] used to pay for education expenses. 3. How often does [consumerget this amount? |
1. Open text field 2. Open text field 3. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly - One time only |
All consumers who select "Scholarship" in Item 140 | Required | The household's current month income is used to determine eligibility for Medicaid and CHIP. Scholarship amounts that are used for education expenses are not countable as income for Medicaid or CHIP eligibility. |
| 13 - Income | 152 | You told us [consumer] is American Indian or Alaska Native. How much of this income comes from a type of tribal income? | Open text field Checkbox: None of this income is tribal income |
All consumers who attest to being American Indian or Alaska Native in Item 83, and who select a type of current month income in Item 140 | Required | Qualifying tribal income is not countable as income for Medicaid or CHIP eligibility. |
| 13 - Income | 153 | Does [consumer] pay student loan interest, alimony, educator expenses, or contribute to an IRA in [coverage year]? | Radio buttons: - Yes - No |
All consumers on financial assistance applications | Required | The household's current month income, minus qualifying expenses, is used to determine eligibility for Medicaid and CHIP. |
| 13 - Income | 154 | Select [consumer]'s current expenses. | Radio buttons: - Student loan interest - Alimony payments. Only tell us about alimony if the divorce or separation was finalized before January 1, 2019. - One of these expenses: IRA contributions (if [consumer] doesn't have a retirement account through a job) Educator expenses (if [consumer] is a teacher and pays for supplies out-of-pocket) Penalty on early withdrawal of savings - None of these |
All consumers who select "Yes" to having one of these expenses in Item 153 | Required | The household's current month income, minus qualifying expenses, is used to determine eligibility for Medicaid and CHIP. Having the consumer select the expense type ensures that the application can trigger appropriate follow-up questions, and helps guard against consumers including expenses that are not countable. |
| 13 - Income | 155 | 1. Enter the amount [consumer] pays in [expense type]. 2. How often does [consumer] pay this amount? |
1. Open text field 2. Open text field 3. Radio buttons: - Weekly - Every 2 weeks - Twice a month - Monthly - Yearly |
All consumers who select an expense in Item 154 | Required | The household's current month income, minus qualifying expenses, is used to determine eligibility for Medicaid and CHIP. |
| 13 - Income | 156 | Describe this expense in a few words | Open text field | All consumers who select "One of these expenses: IRA contributions (if [consumer] doesn't have a retirement account through a job), Educator expenses (if [consumer] is a teacher and pays for supplies out-of-pocket), Penalty on early withdrawal of savings" in Item 154 |
Required | The household's current month income, minus qualifying expenses, is used to determine eligibility for Medicaid and CHIP. Having the user describe the expense helps guard against consumers including expenses that are not countable. |
| 13 - Income | 157 | We calculated this expected yearly income amount based on what you entered for [consumer]'s monthly income and expenses. Is this correct for [coverage year]? | Radio buttons: - Yes - No |
All consumers on financial assistance applications | Required | Expected yearly income is used to determine eligibility for APTC and CSR. Each consumer's expected yearly income is calculated based on their current month income and expenses. |
| 13 - Income | 158 | Is [consumer]'s income for [coverage year] hard to predict? | Radio buttons: - Yes - No |
All consumer who select "No" to whether the yearly income estimate is correct in Item 157 | Required | In certain states, consumers who have income that is hard to predict may qualify to have their yearly income used to determine their Medicaid and CHIP eligibility instead of their current month income. |
| 13 - Income | 159 | Make your best estimate of [consumer]'s expected yearly income for [coverage year]. | Open text field | All consumers who select "No" to whether the yearly income estimate is correct in Item 157 | Required | Expected yearly income is used to determine eligibility for APTC and CSRs. Consumers who disagree with the yearly income that is shown on the application (calculated based on their current monthly income) can provide their own estimate of their expected yearly income. |
| 13 - Income | 160 | The income you entered for [consumer] at [employer] is lower than our records show. Why do you think it'll be lower? | Radio buttons: - [consumer] stopped working at [employer] - [consumer]'s hours at [employer] were reduced - [consumer]'s wages or salary at [employer] were cut Another reason: Open text field |
Consumer whose job income is significantly lower than job income from trusted data sources | Required | Consumers for whom we are unable to verify income against trusted data sources or documentation on file have the opportunity to select a reason that their income has changed, and by doing so, avoid needing to submit additional information later. |
| 13 - Income | 161 | [consumer]’s household income in [coverage year] seems like it'll be lower than records for the past 2 years show. Why do you expect it to be lower? | Checkboxes, multi-selection: - [consumer]'s household members have changed - [consumer]'s income will be lower because of a job change like a new job, reduced hours, loss of employment, disability, retirement, sabbatical, or use of the Family Medical Leave Act (FMLA) - [consumer]'s income changes every year because of self-employment Another reason: Open text field |
Households whose attested annual income is significantly lower than income data from trusted data sources | Required | Consumers for whom we are unable to verify income against trusted data sources or documentation on file have the opportunity to attest to a reason that their income has changed, and by doing so, avoid needing to submit additional information later. |
| 13 - Income | 162 | Why is [consumer]'s income this month different than other months in [coverage year]? | Open text field | Certain consumers with variable monthly income and attested annual income that is significantly lower than trusted data sources indicates. | Required | Consumers for whom we are unable to verify income against data sources or documentation on file have the opportunity to select a reason that their income has changed, and by doing so, avoid needing to submit additional information later. |
| 14 - Current Coverage | 163 | Is [applicant] currently enrolled in health coverage? Select "Yes" only if they'll have their coverage on or after [today + 60 days]. |
Radio buttons: - Yes - No |
All applicants seeking financial assistance who are preliminarily eligible for Medicaid, CHIP, or APTC | Required | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 164 | What type of coverage does [applicant] have? | Checkboxes, multi-selection: - Marketplace coverage - Medicaid - CHIP - Medicare - TRICARE - Veterans Affairs (VA) health care program - COBRA - Retiree health benefits - Coverage through a job (or another person's job, like a spouse or parent): - Other full benefit coverage - Other limited benefit coverage |
All applicants who select "Yes" to being currently enrolled in health coverage in Item 163 | Required | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 165 | Tell us about [applicant]'s Medicare coverage. Medicare number: | Open text field | All applicants who select current Medicare coverage in Item 164 | Optional | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 166 | Tell us about [applicant]'s TRICARE coverage. 1. Policy number 2. Member ID |
1. Open text field 2. Open text field |
All applicants who select current TRICARE coverage in Item 164 | Optional | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 167 | Tell us about [applicant]'s VA health care program coverage. 1. Plan ID 2. Member number |
1. Open text field 2. Open text field |
All applicants who select current VA health care program coverage in Item 164 | Optional | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 168 | Through which employer does [applicant] have [coverage type]? | Checkboxes, multi-selection: Employers added in Item 141 Button: Add an employer |
All applicants who selected "COBRA," "Retiree health benefits," or "Coverage through a job" in Item 164 | Required | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 169 | Enter the employer name. | Open text field | All applicants who select "Add an employer" in Item 168 | Required | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 14 - Current Coverage | 170 | Tell us about [applicant]'s [coverage type]: 1. Name of health plan 2. Policy number 3. Member ID |
1. Open text field 2. Open text field 3. Open text field |
All applicants who select "Other full benefit coverage" or "Other limited benefit coverage" in Item 164 | Optional | Information about current coverage is used to determine eligibility for APTC, targeted low-income Medicaid, and CHIP. Additional plan information is optional to provide, and may be used for coordination of benefits if the applicant also has Medicaid coverage. |
| 15 - Medicaid and CHIP | 171 | Has [applicant] ever gotten health services from the Indian Health Service, or a tribal or urban Indian health program, or through a referral from one of these programs? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for Medicaid or CHIP, and who selected being American Indian or Alaska Native in Item 83 | Required | This information is collected to determine whether applicants qualify for an exemption from co-insurance, deductibles, and copayments in Medicaid and CHIP. Applicants who have ever received care through the Indian Health Service, Tribal Health Programs, or Urban Indian Health Programs are exempt from co-insurance, deductibles, and copayments in Medicaid and CHIP. |
| 15 - Medicaid and CHIP | 172 | Is [applicant] eligible to get health services from the Indian Health Service, or a tribal or urban Indian health program, or through a referral from one of these programs? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for Medicaid or CHIP, and who selected being American Indian or Alaska Native in Item 83 and who attested "No" to having received tribal health services in Item 171 | Required | This information is collected to determine whether applicants qualify for an exemption from premiums and enrollment fees in Medicaid and CHIP. Applicants who are eligible to receive services through the Indian Health Service, Tribal Health Programs, or Urban Indian Health Programs are exempt from any premiums and enrollment fees in Medicaid and CHIP. |
| 15 - Medicaid and CHIP | 173 | Would [applicant] like help paying for medical bills from the last 3 months? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for Medicaid | Optional | If the applicant is ultimately assessed eligible for Medicaid, this information will be passed on to the applicant's SMA so that the state may coordinate retroactive coverage, as applicable. |
| 15 - Medicaid and CHIP | 174 | Does [non-applicant child] currently have health coverage? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for adult group Medicaid, and who have a non-applicant child that they are a parent or caretaker to on their application | Required | In order to qualify for adult group Medicaid, any non-applicant children on the adult's application must have other health coverage. |
| 15 - Medicaid and CHIP | 175 | Does [child] have a parent living outside the home? | Radio buttons: - Yes - No |
All application filers who are preliminarily Medicaid eligible and not pregnant, and are applying on behalf of a child who is also preliminarily Medicaid eligible, and it is unknown whether the child lives with two parents | Required | Application filers who are applying on behalf of a child generally must agree to cooperate with child support agencies that collect medical support from absent parents. This question is used to establish whether there is an absent parent, so that a related agreement can be shown later in the application. |
| 15 - Medicaid and CHIP | 176 | Does [child] live with 2 parents? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for Medicaid under the parent/caretaker-relative group and who are applying in a state that maintains the requirement that children be deprived of parental support | Optional | This information is used to determine Medicaid eligibility in states that maintain a requirement that children live with fewer than two parents, or live with two parents who are unemployed or underemployed, in order for their parent or caretaker to qualify for Medicaid. |
| 15 - Medicaid and CHIP | 177 | How many hours per week do [child]'s parents work? 1. [parent 1]'s hours per week 2. [parent 2]'s hours per week |
1. Open text field 2. Open text field |
All applicants who are preliminarily eligible for Medicaid under the parent/caretaker-relative group and who are applying in a state that maintains the requirement that children be deprived of parental support, and who answered "Yes" to the child living with two parents in Item 176 | Required | This information is used to determine Medicaid eligibility in states that maintain a requirement that children live with fewer than two parents, or live with two parents who are unemployed or underemployed, in order for their parent or caretaker to qualify for Medicaid. |
| 15 - Medicaid and CHIP | 178 | Did [applicant] have coverage through a job that ended in the last [waiting period] months? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for CHIP, not pregnant, and who are applying in a state with a CHIP waiting period | Required | This information is used to figure out if a applicant must wait a period of time between when the applicant's job based coverage ends and when their CHIP coverage can start. |
| 15 - Medicaid and CHIP | 179 | Why did [applicant]'s coverage end? | Radio buttons: - The coverage wasn't affordable. - [applicant]'s parent is no longer offered coverage through their employer. - [applicant]'s parent had a change in employment status, so [applicant is no longer eligible for coverage through the employer. - [applicant] has special health care needs that weren't being met by coverage through the employer. - [applicant] lost coverage as a result of divorce or death of a parent. - Another reason |
All applicants who select "Yes" to having job-based coverage that ended within the CHIP waiting period in Item 178 | Optional | This information is used to figure out if the applicant may not have to wait to enroll in CHIP. |
| 15 - Medicaid and CHIP | 180 | Is [applicant] offered [state of application]’s state employee health benefit plan through a job or a family member’s job (like a parent)? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for CHIP and who are applying in a state that doesn't allow CHIP eligibility for applicants who are offered state health benefit plans | Required | This information is used to determine CHIP eligibility in states that don't allow CHIP eligibility for applicants who are offered a state employee health benefit plan. |
| 15 - Medicaid and CHIP | 181 | Is [applicant] enrolled in the [state of application] state employee health benefit plan through a job or family member's job (like a parent)? | Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for CHIP, who selected to being enrolled in a job-based plan in Item 164, and who are applying in a state that allows CHIP eligibility for applicants who are enrolled in a state health benefit plan | Required | This information is used to determine CHIP eligibility in states that allow CHIP eligibility for applicants who are enrolled in a state employee health benefit plan. |
| 16 - Health Reimbursement Arrangements (HRA) | 182 | Does [applicant] already have an individual coverage HRA? | Radio buttons: - Yes - No |
All applicants seeking financial assistance and are preliminarily APTC eligible | Required | If an applicant has already accepted an ICHRA offer from an employer, they are considered to be currently covered by the ICHRA, and are not eligible for APTC. |
| 16 - Health Reimbursement Arrangements (HRA) | 183 | Select the option that best describes [applicant]'s individual coverage HRA. | Radio buttons: -The HRA has already started, and [applicant] can request reimbursements today. -The HRA hasn't started yet, but [applicant] has told the employer they want to sign up and can no longer decline ("opt out" of) the offer. |
Applicant selected "yes" for Item 182 | Required | If an applicant has already accepted an ICHRA offer from an employer, they are considered to be currently covered by the ICHRA, and are not eligible for APTC. |
| 16 - Health Reimbursement Arrangements (HRA) | 184 | Will this HRA still be available 2 months from today (on [date 60 days from current date])? | Radio buttons: - Yes - No |
Applicant selected either option for Item 183 | Required | This question determines whether the applicant will be able to access their ICHRA offer in 60 days from the current date. This is collected so that the system can disregard ICHRA offers that will be inaccessible by 60 days from the current date. |
| 16 - Health Reimbursement Arrangements (HRA) | 185 | Does [applicant] have an individual coverage HRA offer they haven't accepted yet and that they can still decline ("opt out" of)? | Radio buttons: - Yes - No |
All applicants seeking financial assistance and are preliminarily APTC eligible | Required | An applicant who has an ICHRA offer that they have not accepted is eligible for APTC if that ICHRA is determined to be unaffordable. |
| 16 - Health Reimbursement Arrangements (HRA) | 186 | If [applicant] accepts the offer, will this HRA still be available 2 months from today (on [date 60 days from current date])? | Radio buttons: - Yes - No |
Applicant selected "yes" for Item 185 | Required | This question determines whether the applicant will be able to access their ICHRA offer in 60 days from the current date. This is collected so that the system can disregard ICHRA offers that will be inaccessible by 60 days from the current date. |
| 16 - Health Reimbursement Arrangements (HRA) | 187 | Which employers offer [applicant] an individual coverage HRA? | [Checkboxes, multi-selection] Where possible, prepopulate check box list of the employers provided in income section Add an employer |
All applicants seeking financial assistance and are preliminarily APTC eligible, and have also indicated they have an individual coverage HRA offer they haven't accepted yet and can still decline | Required | This question is needed for reporting to employers when an applicant has an ICHRA offer and receives APTC, and for determining whether the ICHRA offer comes from someone in the applicant's tax household. |
| 16 - Health Reimbursement Arrangements (HRA) | 188 | Enter the employer name. | [Open text field] Enter the employer name |
Consumer selected "Add an employer" for Item 187 | Required | This question is needed for reporting to employers when an applicant has an ICHRA offer and receives APTC, and for determining whether the ICHRA offer comes from someone in the applicant's tax household. |
| 16 - Health Reimbursement Arrangements (HRA) | 189 | Who works for this employer? | Radio buttons: - Display any tax household members - None of these people |
Consumer selected "Add an employer" for Item 187 | Required | This question determines who is the employee with the ICHRA offer to facilitate employer sampling and noticing. If the offer is not through someone in the applicant's tax household, the offer does not count as minimum essential coverage and does not disqualify the applicant for APTC. |
| 16 - Health Reimbursement Arrangements (HRA) | 190 | Tell us about the individual coverage Health Reimbursement Arrangement (HRA) offer from [employer] | What's the HRA's start date? [MM-DD-YYYY] What's the HRA's end date? [MM-DD-YYYY] |
Applicant indicated the ICHRA is offered by the applicant's own employer or the employer of a tax household member for Item 187 | Required | Start dates are collected so that the system can determine on a versioned application whether the applicant is selecting a new or an existing ICHRA offer. In some cases, existing offers will not have affordability recalculated because an affordability safe harbor applies. End dates are collected so that the system can disregard ICHRA offers that will end in the next 60 days. Start and end dates may be used to allow the applicant to select an ICHRA amount for the duration of the ICHRA, rather then another frequency (monthly, yearly, etc). |
| 16 - Health Reimbursement Arrangements (HRA) | 191 | Enter the dollar amount of reimbursement funds that will be available for [applicant] only. | Amount: [Open text field] | Applicant indicated the individual coverage HRA is offered by the applicant's own employer or the employer of a tax household member for Item 187 AND the consumer indicates that the individual coverage HRA will still be available 2 months from today for Item 190 | Required | The amount given for an ICHRA offer is used to calculate the offer's affordability. Only affordable offers prevent APTC eligibility. |
| 16 - Health Reimbursement Arrangements (HRA) | 192 | How often will this amount be available? | Radio buttons: -Weekly -Every 2 weeks -Twice a month -Monthly -Quarterly -Yearly -I entered a prorated amount for coverage for part of the year |
Applicant indicated the ICHRA is offered by the applicant's own employer or the employer of a tax household member for Item 187 AND the applicant indicates that the ICHRA will still be available 2 months from today for Item 190 | Required | The amount given for an ICHRA offer is used to calculate the offer's affordability. Only affordable offers prevent APTC eligibility. |
| 16 - Health Reimbursement Arrangements (HRA) | 193 | Tell us how to contact [employer (consumer's job)]. | Answer Fields 1. Phone number: [Open text field] (xxx)-xxx-xxxx 2. Contact email address: [Open text field] 3. Employer Identification Number (EIN): (optional): [Open text field] 4. First Name: [Open text field] 5. Middle Name: [Open text field] 6. Last Name: [Open text field] 7. Suffix: [drop-down, single selection]: Jr., Sr., II, III, IV, V 8a. Street address: [Open text field] 8b. Street address 2: [Open text field] 8c. City: [Open text field] 8d. State: [Drop-down, single-selection] Display all states 8e. ZIP code: [Open text field] |
Applicant indicated the ICHRA is offered by the applicant's own employer or the employer of a tax household member for Item 187 AND the applicant indicates that the ICHRA will still be available 2 months from today for Item 190 | 1. Required 2. Optional 3. Optional 4. Optional 5. Optional 6. Optional 7. Optional 8a. Optional 8b. Optional 8c. Optional 8d. Optional 8e. Optional |
Allows applicants offered an ICHRA to enter employer information not previously entered. |
| 17 - Employer Sponsored Coverage (ESC) | 194 | Will [applicant] be offered health coverage through their job, or through the job of another person, like a spouse or parent? Only select "Yes" if they'll have an offer of coverage as of [first day of next month], even if they haven't enrolled or the enrollment period for the employer coverage is over. |
Radio buttons: - Yes - No |
All applicants who are preliminarily eligible for APTC | Required | This question is used to determine if an applicant has access to ESC that needs to be evaluated. Consumers who are offered coverage from an employer that meets the minimum value standard and is considered affordable are not eligible for APTC. |
| 17 - Employer Sponsored Coverage (ESC) | 195 | Which employers offer [applicant] health coverage? | Checkboxes, multi-selection: -All employers listed by all applicants in the income section of the application -Add an employer |
All applicants who select that they are offered coverage through their job or the job of another person | Required | Collecting this information enables the Exchange to determine whether the offer of ESC comes from within the applicant's tax household. If an offer of ESC is not from the applicant's own employer or an employer of a tax household member, it will not impact an applicant's APTC eligibility unless they choose to enroll in it. |
| 17 - Employer Sponsored Coverage (ESC) | 196 | Tell us about [applicant's] other coverage offers: 1. Enter the employer name. 2. Who works for this employer? |
1. Open text field 2. Radio buttons: -Applicant -Other tax household members -None of these people |
All applicants who select "add an employer" in Item 195 | Required | Collecting this information enables the Exchange to determine whether the offer of ESC comes from within the applicant's tax household. If an offer of ESC is not from the applicant's own employer or an employer of a tax household member, it will not impact an applicant's APTC eligibility unless they choose to enroll in it. |
| 17 - Employer Sponsored Coverage (ESC) | 197 | Does [employer name] offer a health plan that meets the minimum value standard? Most job-based plans meet the minimum value standard. |
Radio buttons: - Yes - No |
All applicants who attest that they are offered coverage through their job or the job of another consumer, and that offer is from a consumer in their tax household | Required | The Exchange collects this information to determine if an offer of ESC affects an applicant's eligibility for APTC. If an offer of ESC does not meet the minimum value standard, it will not impact an applicant's APTC eligibility unless they choose to enroll in it. |
| 17 - Employer Sponsored Coverage (ESC) | 198 | How much would [applicant] pay for themselves for the lowest-cost health plan at [employer name]? | Open text field | All applicants who select that they are offered coverage through their job or the job of another consumer, and that offer is from another consumer in their tax household, and the employer offers a plan that meets the minimum value standard | Required | If an offer of ESC meets the minimum value standard, the Exchange asks this question to determine whether that offer of coverage is "affordable," per IRS rules. If the offer is considered affordable, the applicant will be ineligible for APTC. |
| 17 - Employer Sponsored Coverage (ESC) | 199 | How often would [applicant] pay this amount? | Radio buttons: -Weekly -Every 2 weeks -Twice a month -Monthly -Quarterly -Yearly |
All applicants who select that they are offered coverage through their job or the job of another consumer, and that offer is from another consumer in their tax household, and the employer offers a plan that meets the minimum value standard | Required | The Exchange uses the frequency of premiums to calculate whether an offer of ESC is considered affordable. If the offer is considered affordable, the applicant will be ineligible for APTC. |
| 17 - Employer Sponsored Coverage (ESC) | 200 | Does [employer name] offer a health plan to [tax household members] that meets the minimum value standard? Most job-based plans meet the minimum value standard. |
Radio buttons: - Yes - No |
All applicants who attest that they are offered coverage through the job of someone else in their tax household | Required | If the April 7, 2022 IRS "Affordability of Employer Coverage for Family Members of Employees" NPRM is finalized, the Exchange would collect family premium information, and information about whether an employer-sponsored family plan meets the minimum value standard and who on the application is eligible for that employer plan, to determine ESC affordability for members of employee’s tax household other than the employee themselves. |
| 17 - Employer Sponsored Coverage (ESC) | 201 | How much would the lowest-cost plan at [employer name] that covers [tax household members] cost? | Open text field | All applicants who attest that they are offered coverage through the job of someone else in their tax household, and the employer offers a plan to their household that meets the minimum value standard | Required | If the April 7, 2022 IRS "Affordability of Employer Coverage for Family Members of Employees" NPRM is finalized, the Exchange would collect family premium information, and information about whether an employer-sponsored family plan meets the minimum value standard and who on the application is eligible for that employer plan, to determine ESC affordability for members of employee’s tax household other than the employee themselves. |
| 17 - Employer Sponsored Coverage (ESC) | 202 | How often would [tax household members] pay this amount? | Radio buttons: -Weekly -Every 2 weeks -Twice a month -Monthly -Quarterly -Yearly |
All applicants who attest that they are offered coverage through the job of someone else in their tax household, and the employer offers a plan to their household that meets the minimum value standard | Required | If the April 7, 2022 IRS "Affordability of Employer Coverage for Family Members of Employees" NPRM is finalized, the Exchange would collect family premium information, and information about whether an employer-sponsored family plan meets the minimum value standard and who on the application is eligible for that employer plan, to determine ESC affordability for members of employee’s tax household other than the employee themselves. |
| 17 - Employer Sponsored Coverage (ESC) | 203 | Tell us how to contact [employer name]: 1. Phone number 2. Email address 3. Employer Identification Number (EIN) 4. First Name 5. Middle Name 6. Last Name 7. Suffix 8. Street address 9. Street address 2 10. City 11. State 12. ZIP code |
1. Open text field 2. Open text field 3. Open text field 4. Open text field 5. Open text field 6. Open text field 7. Dropdown, single selection: Jr., Sr., II, III, IV, V 8. Open text field 9. Open text field 10. Open text field 11. Dropdown, all U.S. states and territories 12. Open text field |
All applicants who select that they are offered coverage through their job or the job of another consumer, and that offer is from a consumer in their tax household | 1. Required 2. Optional 3. Optional 4. Optional 5. Optional 6. Optional 7. Optional 8. Optional 9. Optional 10. Optional 11. Optional 12. Optional |
If consumers elect to provide employer contact information, it may be used for employer sampling and noticing. |
| 18 - Membership in federally recognized tribes | 204 | Is [Name selected in item 83] a member of a federally recognized tribe? | Radio buttons: - Yes - No |
The applicant identified as being American Indian or Alaskan Native, did not select being currently incarcerated, and is preliminarily eligible for QHP or APTC. | Required | Members of a federally recognized tribe that are eligible for enrollment in a QHP through an Exchange are eligible for specific SEPs and CSRs available to tribal members. |
| 18 - Membership in federally recognized tribes | 205 | Where's [Name selected in Item 201] tribe located? | [Drop-down single selection] Display all states |
Applicant identified as being American Indian or Alaskan Native, did not select being currently incarcerated, is preliminarily eligible for QHP or APTC, and indicated that they were a member of a federally recognized tribe for Item 201 | Required | This question ensures that the applicant's tribe is on the list of federally recognized tribes. Members of a federally recognized tribe that are eligible for enrollment in a QHP through an Exchange are eligible for specific SEPs and CSRs available to tribal members. |
| 18 - Membership in federally recognized tribes | 206 | Which federally recognized tribe does [Name selected in Item 201] belong to? | [Open text field] List of all tribe names from selected state that narrows as applicant types | Applicant identified as being American Indian or Alaskan Native, did not select being currently incarcerated, is preliminarily eligible for QHP or APTC, and indicated that they were a member of a federally recognized tribe for Item 201 | Required | This question ensures that the applicant's tribe is on the list of federally recognized tribes. Members of a federally recognized tribe that are eligible for enrollment in a QHP through an Exchange are eligible for specific SEPs and CSRs available to tribal members. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 207 | Has [applicant] been offered an individual coverage HRA or provided a QSEHRA with a start date between [current date - 60 days] and [current date + 60 days]? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP eligible | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Marketplace. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 208 | Which HRA type(s) are available to [applicant]? | [Checkboxes, multi-selection] - Individual coverage HRA - Qualified Small Employer HRA (QSEHRA) |
Applicant AND is preliminarily QHP eligible AND answered "yes" for Item 204 | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Exchange. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 209 | What's the HRA's start date? | [Open text field]: MM-DD-YYYY | Applicant AND is preliminarily QHP eligible AND answered "yes" for Item 204 AND selected "ICHRA" or "QSEHRA" for Item 205 | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Exchange. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 210 | What date was the HRA notice sent? | [Open text field]: MM-DD-YYYY | Applicant AND is preliminarily QHP eligible AND answered "yes" for Item 204 AND selected "ICHRA" or "QSEHRA" for Item 205 | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Exchange. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 211 | Is [applicant] currently enrolled in an [individual coverage HRA / QSEHRA] through this employer? |
Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP eligible AND answered "yes" for Item 204 AND selected "ICHRA" or "QSEHRA" for Item 205 | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Exchange. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 212 | Will [applicant] stay enrolled in the current [individual coverage HRA / QSEHRA] until the new one begins on [attested start date]? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP eligible AND answered "yes" for Item 204 AND selected "ICHRA" or "QSEHRA" for Item 205 AND selected "yes" in Item 208 | Required | This information is used to determine whether employees and their dependents who are newly offered an ICHRA or provided a QSHERA may be eligible for a SEP in the Exchange. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 213 | Did [applicant] lose qualifying health coverage between [60 days prior to current date] - [current date]? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP or APTC eligible | Required | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The triggering event generally must be within the last 60 days, or for some SEPs, in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 214 | What was the last day of [applicant]’s coverage? | [Open text field]: MM-DD-YYYY | Applicant AND is preliminarily QHP or APTC eligible AND selected "yes" for Item 210 | Required | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The triggering event generally must be within the last 60 days, or for some SEPs, in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 215 | Enter the name of the plan. | [Open text field] | Applicant AND is preliminarily QHP or APTC eligible AND selected "yes" for Item 210 | Optional | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The triggering event generally must be within the last 60 days, or for some SEPs, in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 216 | Will [applicant] lose qualifying health coverage between [current date] - [60 days after current date]? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP or APTC eligible | Required | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The triggering event generally must be within the last 60 days, or for some SEPs, in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 217 | What's the last day of [applicant]’s coverage? | [Open text field]: MM-DD-YYYY | Applicant AND is preliminarily QHP or APTC eligible AND selected "yes" for Item 213 | Required | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The triggering event generally must be within the last 60 days, or for some SEPs, in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 218 | Enter the name of the plan. | [Open text field] | Applicant AND is preliminarily QHP or APTC eligible AND selected "yes" for Item 213 | Optional | These questions are necessary for SEP eligibility. They must be asked during OE as well as during the rest of the year. The life change generally must be within the last 60 days, or for some SEPs in the next 60 days. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 219 | Has [applicant] had any of these changes since [date 60 days from current date]? | [Checkboxes, multi-selection] - Got married - Gained a dependent (or became a dependent) due to an adoption, foster care placement, or court order - Moved - Was released from incarceration (detention or jail) - Gained eligible immigration status - None of these changes |
Applicant AND is preliminarily QHP or APTC eligible. Only applicants that attested to having eligible immigration status will see the answer option "Gained eligible immigration status" | Required | These questions are necessary to determine whether a qualified individual and/or their dependents may be eligible for a SEP in the Exchange due to certain life changes. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 220 | Which of these people got married since [date 60 days from current date]? | [Checkboxes] - [Applicant] & [spouse] - None of these people |
Applicant AND is preliminarily QHP or APTC eligible AND applicant checked "got married" for Item 216 | Required | For the applicant to be eligible for a SEP based on marriage, the applicant or their spouse must either be a member of a federally-recognized tribe, have had prior coverage within the last 60 days, or have moved from a foreign country. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 221 | When were [applicant] and [spouse] married? | [Open text field]: MM-DD-YYYY | Applicant AND is preliminarily QHP or APTC eligible AND applicant checked "got married" in Item 216 AND applicant selected "[applicant] and [spouse]" for Item 217 | Required | For the applicant to be eligible for a SEP based on marriage, the applicant or their spouse must either be a member of a federally-recognized tribe, have had prior coverage within the last 60 days, or have moved from a foreign country. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 222 | Did [applicant] or [spouse] have qualifying health coverage at any time in the 60 days before they got married? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP or APTC eligible AND applicant checked "got married" for Item 216 AND applicant selected "[applicant] and [spouse]" for Item 217 | Required | For the applicant to be eligible for a SEP based on marriage, the applicant or their spouse must either be a member of a federally-recognized tribe, have had prior coverage within the last 60 days, or have moved from a foreign country. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 223 | Did [applicant] or [spouse] live in a foreign county or a U.S. territory for at least one of the 60 days before marriage? | Radio buttons: - Yes - No |
Applicant selected "no" for Item 219 | Required | For the applicant to be eligible for a SEP based on marriage, the applicant or their spouse must either be a member of a federally-recognized tribe, have had prior coverage within the last 60 days, or have moved from a foreign country. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 224 | Who was adopted, got placed in foster care, or became a dependent through a child support order or other court order on or after [date 60 days from current date]? | [Checkboxes, multi-selection] Display all consumer names (regardless of age) |
Applicant AND is preliminarily QHP or APTC eligible AND selected "Gained a dependent due to an adoption, foster care placement, or court order" for Item 216. | Required | This information is necessary because if a QHP-eligible applicant has recently become or gained a dependent, then they qualify for a SEP. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 225 | When did [name selected in Item 221] become a dependent? | [Open text field]: MM-DD-YYYY | Applicant selected a name for Item 221 | Required | This information is necessary because if a QHP-eligible applicant has recently become or gained a dependent, then they qualify for a SEP. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 226 | Did [applicant] gain eligible immigration status since [date 60 days from current date]? | Radio buttons: - Yes - No |
Applicant AND is preliminarily QHP or APTC eligible AND selected "Gained eligible immigration status" for Item 216 | Required | This information is necessary because if a QHP-eligible applicant has gained lawful presence status in the past 60 days, then they qualify for a SEP. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 227 | When did [applicant] gain eligible immigration status? | [Open text field]: MM-DD-YYYY | Applicant selected "yes" for Item 223 | Required | This information is necessary because if a QHP-eligible applicant has gained lawful presence status in the past 60 days, then they qualify for a SEP. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 228 | Who changed their primary place of living on or after [date 60 days from current date]? | [Checkboxes] [Applicant] |
Applicant selected "Moved" for Item 216 | Required | This information is necessary because for an applicant to be eligible for a SEP based on moving, the applicant must have moved to a different ZIP code or county. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 229 | What's the ZIP code of [applicant]'s previous address? |
[Open text field]: Five or nine digit ZIP Code | Applicant was selected for question "Who changed their primary place of living on or after [date 60 days from current date]?" | Required | This information is necessary because for an applicant to be eligible for a SEP based on moving, the applicant must have moved to a different ZIP code or county. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 230 | Check this box if [applicant] moved from a foreign country or U.S. territory. You don’t need to enter a ZIP code above. | [Checkbox] | Applicant was selected for question "Who changed their primary place of living on or after [date 60 days from current date]?" | Optional | This information is necessary because for an applicant to be eligible for a SEP based on moving, the applicant must have moved to a different ZIP code or county, including moving to the U.S. from a foreign county or U.S. territory. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 231 | When did [applicant] move? | [Open text field]: MM-DD-YYYY | Applicant was selected for question "Who changed their primary place of living on or after [date 60 days from current date]?" | Required | This information is necessary because for an applicant to be eligible for a SEP based on moving, the applicant must have moved to a different ZIP code or county within the last 60 days or next 60 days to qualify for the Move SEP. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 232 | Did [applicant] have qualifying health coverage at any time in the 60 days before moving? | Radio buttons: - Yes - No |
Applicant was selected for question "Who changed their primary place of living on or after [date 60 days from current date]?" | Required | For the applicant to be eligible for a SEP based on moving, the applicant must either be a member of a federally-recognized tribe, have had prior coverage within the last 60 days, or have moved from a foreign country. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 233 | Who was released from incarceration? | [Checkboxes] [Applicant] |
Consumer selected "Was released from incarceration (detention or jail)" for Item 216 | Required | This information is necessary to determine if an applicant is eligible for an SEP due to being released from incarceration. |
| 19 - Life Changes/Special Enrollment Period (SEP) | 234 | When was [applicant] released from incarceration? | [Open text field]: MM-DD-YYYY | Applicant selected "Was released from incarceration (detention or jail)" for Item 216 | Required | The life change must be within the last 60 days to qualify for the SEP due to being released from incarceration. |
| 20 - Sign and Submit | 235 | Did [applicant] reconcile premium tax credits on their tax return for any past years? | [Checkbox] Yes, I reconciled premium tax credits for past years. |
Applicant is requesting coverage and is a tax filer AND at least one applicant is preliminary APTC eligible | Optional | Under IRS regulations, applicants who receive APTC must reconcile the advance payments to the actual amount of the PTC that they are eligible for based on their actual household income and family size. |
| 20 - Sign and Submit | 236 | If anyone on this application enrolls in Medicaid, I'm giving the Medicaid agency the right to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent. | [Checkbox] I agree to this statement. |
An applicant on the application is preliminarily Medicaid eligible. | Required | In order for applicants on the application to be eligible for Medicaid, the application filer must agree to this statement. |
| 20 - Sign and Submit | 237 | If a child on this application has a parent living outside of the home, 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 the agency and I may not have to cooperate. | [Checkbox] I agree to this statement. |
An applicant on the application is preliminarily Medicaid eligible, and there is a preliminarily Medicaid child on the application that has a parent living outside the home. | Required | In order for applicants on the application to be eligible for Medicaid, the application filer must agree to this statement. |
| 20 - Sign and Submit | 238 | 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, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time. | Radio buttons: - I Agree - I Disagree |
All applicants requesting financial assistance | Required | For the Exchange to be able to automatically verify an applicant's income against available tax data from the IRS during the annual re-enrollment process, the applicant must agree to allow the use of their tax data in future years. |
| 20 - Sign and Submit | 239 | How long would you like your eligibility for help paying for coverage to be renewed? | Radio buttons: - 1 year - 2 years - 3 years - 4 years - 5 years - Don't renew eligibility |
Applicant disagreed with attestation to reuse their income data for future financial assistance eligibility | Required | For the Exchange to be able to automatically verify an applicant's income against available tax data from the IRS during the annual re-enrollment process, the applicant must agree to allow the use of their tax data in future years. |
| 20 - Sign and Submit | 240 | I know I must tell the program I'll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household. | [Checkbox] I agree to this statement. |
All applicants | Required | Applicants must agree in order to be found eligible for any program. |
| 20 - Sign and Submit | 241 | If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or the Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. | Radio buttons: - I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation. - I don’t give the Marketplace permission to end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan. |
Applicant is preliminarily QHP eligible | Required | Applicants may agree to this statement if they would like to provide written consent to the Exchange to end coverage on their behalf if they are later found to have other qualifying coverage. An applicant's selection does not impact their eligibility results. |
| 20 - Sign and Submit | 242 | I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information. | [Checkbox] I agree to this statement. |
Application filer | Required | Application filer must agree in order to be found eligible for any program. |
| 20 - Sign and Submit | 243 | [Applicant], type your full name below to sign electronically. | [Open text field] | Application filer | Required | Application filer must electronically sign their application prior to submitting their application. |
| 21 - Eligibility Results and Enrollment | 244 | It looks like these people aren't eligible for Medicaid. They can still continue with a Medicaid application if we send their information to the [state Medicaid agency]. Do any of these people want us to send their information to the [state Medicaid agency] so they can check on Medicaid and The Children's Health Insurance Program (CHIP) eligibility, if applicable? | Checkboxes, multi-selection: - [Medicaid-ineligible applicant] - None of these people |
Applicants who are not assessed eligible for Medicaid in states where the Exchange assesses eligibility for Medicaid | Optional | The Exchange application must give applicants who are assessed ineligible for Medicaid the opportunity to request a full determination by the SMA. |
| 21 - Eligibility Results and Enrollment | 245 | Do any of these people want to request a determination for Medicaid as conducted by [state Medicaid agency] on the basis of disability, blindness, or reoccurring medical needs and bills? | Checkboxes, multi-selection: - [Medicaid-ineligible applicant] - None of these people |
Applicants who are not determined eligible for Medicaid in states where the Exchange determines eligibility for Medicaid | Optional | The Exchange application must give applicants who are determined ineligible for Medicaid the opportunity to request a determination by the SMA of whether they qualify for Medicaid on a basis other than income. |
| 21 - Eligibility Results and Enrollment | 246 | Would you like to register to vote? | Register to vote. [hyperlink] | All application filers | Optional | Under the National Voter Registration Act, mandated voter registration agencies, such as SBEs and Medicaid or CHIP Agencies, must include a pathway to voter registration. |
| 21 - Eligibility Results and Enrollment | 247 | How much of your [$XXX] monthly tax credit do you want to use to lower your premium? | Radio buttons: - ALL of the tax credit each month. Good choice if you're pretty sure your final [coverage year] income will be about the same as your estimate. - SOME of the tax credit each month. Good choice if it's likely your final [coverage year] income will be higher than your estimate. - NONE of the tax credit each month. Good choice if you don't want to risk having to pay money back on your federal taxes if anything changes. |
All application filers with APTC-eligible applicants on their applications | Required | Applicants must have the opportunity to select how much of the APTC they are eligible for they would like to apply towards their Exchange plan premiums every month. |
| 21 - Eligibility Results and Enrollment | 248 | Enter the tax credit amount you want to use each month. | Open text field | All application filers who select that they want to use some of their tax credit in Item 244 | Required | Applicants must have the opportunity to select how much of the APTC they are eligible for they would like to apply towards their Exchange plan premiums every month. |
| 21 - Eligibility Results and Enrollment | 249 | Within the past 6 months, has [applicant] used tobacco regularly? Select "yes" if [applicant] has used tobacco 4 or more times per week on average during the past 6 months. Don't include ceremonial uses. | Radio buttons: - Yes - No |
All applicants who are eligible to enroll in a QHP and who are 21 years of age or older | Required | Applicants with a history of tobacco use may be charged higher premiums than non-smokers. |
| 21 - Eligibility Results and Enrollment | 250 | When was the last time [applicant] used tobacco regularly? | Open text field: MM / DD / YYYY | All applicants who select "yes" to tobacco use in Item 245 | Required | Applicants with a history of tobacco use may be charged higher premiums than non-smokers. |
| 21 - Eligibility Results and Enrollment | 251 | Are you interested in a separate dental plan? You may want this if the health coverage you choose doesn't include dental coverage, or if you want different dental coverage. | Radio buttons: - Yes - No |
All applicants who select a plan that does not include adult dental coverage | Required | Applicants whose plans do not include dental coverage must have an option to enroll in a separate dental plan. |
| 21 - Eligibility Results and Enrollment | 252 | Select each person who should enroll in a dental plan. | Checkboxes, multi-selection: - [Applicants who select a plan that does not include adult dental coverage] - None |
All applicants who select "yes" to being interested in a separate dental plan in Item 248 | Required | Applicants whose plans do not include dental coverage must have an option to enroll in a separate dental plan. |
| 21 - Eligibility Results and Enrollment | 253 | I understand that I'm not eligible for a premium tax credit if I'm found eligible for other qualifying health coverage, like Medicaid, the Children's Health Insurance Program, or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don't, the person who files taxes in my household may need to pay back my premium tax credit. Agree and confirm |
Radio buttons: - I agree with the above statement - I disagree with the statement above. |
All applicants who are eligible for APTC | Required, must agree to continue | Applicants who will apply APTC towards their premiums must select that they understand their eligibility may change if they become eligible for other coverage, and that there may be a tax liability for failure to terminate coverage with APTC if they become eligible for other coverage. |
| 21 - Eligibility Results and Enrollment | 254 | These statements apply to: [tax filer] I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: - I must file a federal income tax return for the 2022 tax year. - If I'm married at the end of 2022, I must file a joint income tax return with my spouse. I also expect that: - No one else will be able to claim me as a dependent on their 2022 federal income tax return. - I'll claim as a dependent on my 2022 federal income tax return all individuals listed on this application as my dependent, who are enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit. If any of the above changes: - I understand that it may impact my ability to get the premium tax credit. - I also understand that when I file my 2022 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax |
Radio buttons: - I agree with the above statements - I disagree with the above statements |
All tax filers who are eligible for APTC | Required, must agree to continue | Tax filers to whom APTC will be paid must select that they understand the requirements for maintaining eligibility for the PTC, and must sign before applicants are able to enroll in a plan. |
| 21 - Eligibility Results and Enrollment | 255 | Tax filers signature (full name) | Open text field | All tax filers who are eligible for APTC | Required, must sign to continue | Tax filers to whom APTC will be paid must select that they understand the requirements for maintaining eligibility for the PTC, and must sign before applicants are able to enroll in a plan. |
| Acronym | Defined |
| AI/AN | American Indian/Alaska Native |
| APTC | Advance Payments of the Premium Tax Credit |
| CHIP | Children's Health Insurance Program |
| COBRA | Consolidated Omnibus Budget Reconciliation Act |
| CSR | Cost-Sharing Reduction |
| DHS | Department of Homeland Security |
| DOB | Date of Birth |
| EIN | Employer Identification Number |
| ESC | Employer-sponsored Coverage |
| FMLA | Family Medical Leave Act |
| FPL | Federal Poverty Level |
| HH | Household |
| HHS | Department of Health and Human Services |
| HRA | Health Reimbursement Arrangement |
| ICHRA | Individual Coverage Health Reimbursement Arrangement |
| IRS | Internal Revenue Service |
| MAGI | Modified Adjusted Gross Income |
| MEC | Minimum Essential Coverage |
| MVS | Minimum Value Standard |
| OE | Open Enrollment |
| OEP | Open Enrollment Period |
| ORR | Office of Refugee Resettlement |
| PCR | Parent/Caretaker Relative |
| PPACA | Patient Protection and Affordable Care Act |
| PTC | Premium tax credit |
| QHP | Qualified Health Plan |
| QSEHRA | Qualified Small Employer Health Reimbursement Arrangement |
| RIDP | Remote Identity Proofing |
| SBE | State-based Exchange |
| SEP | Special Enrollment Period |
| SEVIS | Student and Exchange Visitor Information System |
| SMA | State Medicaid/CHIP Agency |
| SSA | Social Security Administration |
| SSN | Social Security Number |
| VA | Department of Veteran's Affairs |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |