CMS-10440 Application for Health Coverage & Help Paying Costs

Data Collection to Support Eligibility Determinations for Insurance Affordability Programs and Enrollment through Health Benefits Exchanges, Medicaid and CHIP Agencies (CMS-10440)

CMS-10440 - Att C.-Application-with-costs-help-508

OMB: 0938-1191

⚠️ Notice: This form may be outdated.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

Document [pdf]

Download: pdf | pdf

Application for Health Coverage &
Help Paying Costs

Form Approved
OMB No. 0938-1191
Expires: XX/XX/XXXX

Apply faster online at HealthCare.gov
Use this application
to see what coverage
you qualify for

• Marketplace plans that offer comprehensive coverage to help you stay well.
• A tax credit that can immediately help lower your premiums for health coverage.
• Free or low-cost coverage through Medicaid or the Children’s Health Insurance

Program (CHIP).

• Certain income levels may qualify for free or low-cost programs.

Who can use this
application?

• Use this application to apply for anyone in your household.
• Apply even if you, your spouse, or your child already have health coverage.

You could be eligible for free or lower-cost coverage.

• If you’re single, you may be able to use a short form. Visit HealthCare.gov.
• Households that include eligible immigrants can apply. You can apply for

your child even if you aren’t eligible for coverage. Applying won’t affect your
immigration status or chances of becoming a permanent resident or citizen.

• If someone is helping you fill out this application, you may need to complete

Appendix C.

What you may
need to apply

• Social Security Numbers (SSNs) (or document numbers for any eligible

immigrants who need coverage).

• Employer and income information for everyone in your household (like from pay

stubs, W-2 forms, or wage and tax statements).

• Policy numbers for any current health insurance.
• Information about any job-related health insurance available to your household.

Why do we ask for
this information?

We ask about income and other information to let you know what coverage
you qualify for and if you can get any help paying for it. We’ll keep all the
information you provide private and secure, as required by law. To view the
Privacy Act Statement, visit HealthCare.gov or see instructions.

What happens
next?

Send your complete, signed application to the address on page 8. If you don’t
have all the information we ask for, sign and submit your application
anyway. We’ll follow up with you within 1–2 weeks, and you may get a call from
the Marketplace if we need more information. You’ll get an Eligibility Notice
in the mail after we process your application. If you don’t hear from us, contact
the Marketplace Call Center. Filling out this application doesn’t mean you have to
buy health coverage.

Get help with this
application

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

1-855-889-4325.

• In-person: There may be counselors in your area who can help. Visit

HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for more
information.

• En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.
• Other languages: If you need help in a language other than English, call

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

You have the right to get Marketplace information in an accessible format, like large print, Braille, or
audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit
CMS.gov/about-cms/agency-Information/aboutwebsite/cmsnondiscriminationnotice, or call the
Marketplace Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325.
This product was produced at U.S. taxpayer expense.
Health Insurance Marketplace® is a registered service mark of
the U.S. Department of Health & Human Services.

Page 1 of 9

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

Step 1: Tell us about yourself.
(We need one adult in the household to be the contact person for your application.)
1. First name

Middle name

Last name

Suffix

3. Home address 2

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

4. City

5. State

6. ZIP code

7. County

8. Mailing address (if different from home address)

10. City

9. Mailing address 2

11. State

14. Phone number

12. ZIP code

13. County

15. Second phone number

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

Yes

Email address:
17. Preferred language:

Written

Spoken

Step 2: Tell us about your household.
Who do you need to include on this application?

Complete the Step 2 pages for each person in your household, even if the person has health coverage already. The information
in this application helps us make sure everyone gets the best coverage they can. The amount of help or type of program you
qualify for is based on the number of people in your household and your household income. If you don’t include someone, even
if they already have health coverage, your eligibility results could be affected.
For adults who need coverage:
Include these people even if they aren’t applying for health coverage for themselves:
• Any spouse
• Any child under age 21 they live with, including stepchildren
• Any other person on the same federal income tax return (including any children over age 21 who are claimed on a parent’s

tax return). You don’t need to file taxes to get health coverage.

For children under age 21 who need coverage:
Include these people even if they aren’t applying for health coverage themselves:
• Any parent (or stepparent) they live with
• Any sibling they live with
• Any child they live with, including stepchildren
• Any spouse they live with
• Any other person on the same federal income tax return. You don’t need to file taxes to get health coverage.

Complete Step 2 for each person in your household.

Start with yourself, then add other adults and children. If you have more than 2 people in your household, you’ll need to make a
copy of the pages and attach them.
You don’t need to provide immigration status or SSNs for household members who don’t need health coverage. We’ll keep all the
information you provide private and secure, as required by law. We’ll use personal information only to check if you’re eligible for
health coverage.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Page 2 of 9

Step 2: PERSON 1 (Start with yourself.)

Complete Step 2 for yourself, your spouse/partner and dependents who live with you, and/or anyone on your same federal income tax return if you file one.
See page 1 for more information about who to include. If you don’t file a tax return, remember to still add the people in your household.
1. First name
2. Relationship to PERSON 1?

Middle name

Last name

3. Are you married?

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

SELF

Yes

Suffix
5. Sex
Female

Male

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

Yes

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

How are you related to the tax filer?

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

Yes

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

9. Do you need health coverage? Even if you have coverage, there might be a program with better coverage or lower costs.
YES. If yes, answer all the questions below. NO. If no, skip to the income questions on page 3. Leave the rest of this page blank.
10. Do you have a special heath care need or a physical or mental health condition that causes limitations in activities (like working,
attending school, dressing, or bathing), or live in a medical facility or nursing home? ........................................................................................................

Yes

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

Yes

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

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

Status type (optional)

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

Write your name as it appears on your immigration document.

Alien or I-94 number

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

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

Yes
Yes

No
No

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

Yes

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

Yes

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

Yes

18. Are you of Hispanic, Latino/a, or Spanish origin? ...........................................................................................................................................

Yes

List the names and relationships of any children under 19 that live with you in your household:

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

Optional: If yes:

Mexican

(Fill in all that
19. Race:
apply.)

Yes

Mexican American

Chicano/a

Puerto Rican

Cuban

Other

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

Korean

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Page 3 of 9

Step 2: PERSON 1 (Continue with yourself.)
Current job & income information
Employed: If you’re currently employed, tell us
about your income. Start with item 20.

Not employed:
Skip to item 30.

Self-employed:
Skip to item 29.

Current job 1:
20. Employer name

a. Employer address (optional)

b. City

c. State

22. Wages/tips (before taxes)

d. ZIP code

21. Employer phone number

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

23. Average hours worked each WEEK

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

a. Employer address (optional)

b. City

c. State

26. Wages/tips (before taxes)

$
28. In the past year, did you:

d. ZIP code

25. Employer phone number

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Change jobs

Stop working

Start working fewer hours

27. Average hours worked each WEEK

None of these

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

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

Alimony received (Note: Only for divorces finalized before 1/1/2019.)

$
How often?
Net farming/fishing

How often?

Pension

How often?

Social Security

Net rental/royalty

$
How often?
Retirement accounts

$
How often?
Other income, type:

How often?

31. Deductions: Fill in all that apply, and give the amount and how often you pay it. If you pay for certain things that can be deducted on a federal income tax
return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include child support that you pay, or a cost already considered in your answer to net self-employment (question 29b).
Alimony paid (Note: Only for divorces finalized before 1/1/2019.)

Other deductions, type:

How often?
Student loan interest

How often?

$
How often?
32. Complete this question if your income changes during the year, like if you only work at a job for part of the year or receive a benefit for certain
months. If you don’t expect changes to your monthly income, skip to the next person.
Your total income this year
Your total income next year (if you think it’ll be different)
$

Fill in if you think your income will be hard to predict.

Thanks! This is all we need to know about you.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Step 2: PERSON 2

Page 4 of 9

Note: If this person doesn’t need health coverage, just answer questions 1–10 on this
page. Make a copy of pages 4–5 if there are more than 2 people in your household.

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

Middle name

2. Relationship to PERSON 1? See instructions.

3. Is PERSON 2 married?
Yes

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

Suffix
5. Sex
Female

Male

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

6. Social Security Number (SSN)

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

Yes

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

Yes

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

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

Yes

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

10. Does PERSON 2 need health coverage? (Even if PERSON 2 has coverage, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below. NO. If no, skip to the income questions on page 5. Leave the rest of this page blank.
11. Does PERSON 2 have a special health care need or a physical or mental health condition that causes limitations in activities (like working,
attending school, dressing, or bathing), or live in a medical facility or nursing home? ........................................................................................................

Yes

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

Yes

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

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

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

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

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

Yes
Yes

No
No

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

Yes

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

Yes

17. Tell us the names and relationships of any children under 19 that live with PERSON 2 in their household: (These can be the same children listed on page 2.)
Was PERSON 2 in foster care at age 18 or older? .......................................................................................................................................................................
Answer these questions if PERSON 2 is 22 or younger:
18. Did PERSON 2 have insurance through a job and lose it within the past 3 months?......................................................................................................
a. If yes, end date:

Yes

b. Reason the insurance ended:

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

Yes

20. Are you of Hispanic, Latino/a, or Spanish origin? ...........................................................................................................................................
Optional: If yes: Mexican Mexican American Chicano/a Puerto Rican Cuban Other

Yes

(Fill in all that
21. Race:
apply.)

White Black or African American American Indian or Alaska Native Asian Indian Chinese Filipino Japanese Korean
Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Step 2: PERSON 2

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

Page 5 of 9

Current job & income information
Employed: If PERSON 2 is currently employed,
tell us about his/her income. Start with item 22.

Not employed:
Skip to item 32.

Self-employed:
Skip to item 31.

Current job 1:
22. Employer name

a. Employer address (optional)

b. City

c. State

24. Wages/tips (before taxes)

d. ZIP code

23. Employer phone number

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

25. Average hours worked each WEEK

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

a. Employer address (optional)

b. City

c. State

28. Wages/tips (before taxes)

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

d. ZIP code

27. Employer phone number

Hourly

Weekly

Every 2 weeks

Twice a month

Monthly

Yearly

Change jobs

Stop working

29. Average hours worked each WEEK

Start working fewer hours

None of these

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

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

Alimony received (Note: Only for divorces finalized before 1/1/2019.)

$
How often?
Net farming/fishing

How often?

Pension

How often?

Social Security

Net rental/royalty

$
How often?
Retirement accounts

$
How often?
Other income, type:

How often?

33. Deductions: Fill in all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays for certain things that can be deducted on a
federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include child support that PERSON 2 pays, or a cost already considered in the answer to net self-employment (question 31b).
Alimony paid (Note: Only for divorces finalized before 1/1/2019.)

Other deductions, type:

How often?
Student loan interest

How often?

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

Fill in if you think your income will be hard to predict.

Thanks! This is all we need to know about PERSON 2.
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Page 6 of 9

Step 3: American Indian or Alaska Native (AI/AN)
household member(s)
1. Are you or is anyone in your household American Indian or Alaska Native?
NO. If no, continue to Step 4.

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

Step 4: Your household’s health coverage
1. Was anyone on this application found not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in the
past 90 days? (Select yes only if someone was found not eligible for this coverage by your state, not by the Marketplace.)...............................................
Who?

Yes

Date:

Or, was anyone on this application found not eligible for Medicaid or CHIP due to their immigration status in the last 5 years? ............
Who?
Did anyone on this application apply for coverage during the Marketplace Open Enrollment Period or after a qualifying life event? ....
Who?

2. Is anyone listed on this application offered health coverage from a job (employer insurance)? Check yes even if the coverage is from someone else’s job, like
a parent or spouse, even if they don’t accept the coverage. Check no if the only coverage offered is COBRA or retiree insurance.
YES. Continue and then complete Appendix A. NO.
If yes, is this a state employee benefit plan?.....................................................................................................................................................................

Yes

Is anyone listed on the application offered an individual coverage Health Reimbursement Arrangement (HRA)
or a Qualified Small Employer HRA (QSEHRA)? ..................................................................................................................................................................

Yes

3. Is anyone enrolled in health coverage now?
YES. If yes, continue to question 4.

NO. If no, skip to Step 5.

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

PERSON 1:

Type of coverage:
Employer insurance (through your or another person’s job, like a parent or spouse)
Retiree insurance
COBRA
Medicaid
CHIP
Medicare
TRICARE
VA health care program
Peace Corps
Other
If it’s employer insurance: (You’ll also need to complete Appendix A.)
Name of health insurance company

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

Policy/ID number

Fill in if this is Marketplace health coverage.
Policy/ID number

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

Yes

Name of person enrolled in health coverage

PERSON 2:

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

Fill in if this is Marketplace health coverage.
Policy/ID number

Page 7 of 9

Step 5: Your agreement & signature
1. Do you agree to allow the Marketplace to use income data, including information from tax returns,

for the next 5 years? ..........................................................................................................................................................................................
Yes No
To make it easier to determine your eligibility for help paying for coverage in future years, you can agree to allow the Marketplace to use updated income data,
including information from tax returns. The Marketplace will send a notice and let you make any changes. You can opt out at any time.
If no, automatically update my information for the next:

5 years

4 years

3 years

2 years

1 year

Don’t use my tax data to renew my eligibility for help paying for health coverage (selecting this option may impact your ability to get help paying for
coverage at renewal.)
2. Is anyone applying for health insurance on this application incarcerated (detained or jailed)? ..................................................................

Yes

If yes, tell us the person’s name. The name of the incarcerated person is:
Fill in here if this person is facing
disposition of charges.
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare,
Medicaid, or 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.
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.
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 to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

• Does any child on this application have a parent living outside of the home? ........................................................................................ Yes No
• If yes, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to
collect medical support will harm me or my children, I can tell the Medicaid agency and I may not have to cooperate.

• I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my
knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false information.

• I know that I must tell the program I’ll be enrolled in if the information I listed in this application changes. I know I can visit HealthCare.gov or
call 1-800-318-2596 to report any changes. I know that a change in my information could affect my eligibility as well as eligibility for member(s)
of my household.
• I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender
identity, or disability. I can file a complaint of discrimination by visiting hhs.gov/ocr/office/file.

• I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and
for lawful purposes of the Marketplace and programs that help pay for coverage.

We need this information to check your eligibility for help paying for health coverage if you choose to apply. We’ll check your answers using
information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland
Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us confirmation.

What should I do if I think my Eligibility Notice is wrong?

If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Review your Eligibility Notice to find appeals instructions
specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here’s important
information to consider when requesting an appeal:
• You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual.
Or, you can request and participate in your appeal on your own.

• If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.
• The outcome of an appeal could change the eligibility of other members of your household.
To appeal your Marketplace eligibility results, visit HealthCare.gov/marketplace-appeals. Or, call the Marketplace Call Center at
1-800-318-2596. TTY users can call 1-855-889-4325. You can also mail an appeal request form or your own letter requesting an appeal to
Health Insurance Marketplace, Dept. of Health and Human Services, Attn: Appeals, 465 Industrial Blvd., London, KY 40750-0001. You can
appeal eligibility for purchasing health coverage through the Marketplace, enrollment periods, tax credits, cost-sharing reductions, Medicaid, and
CHIP, if you were denied these. If you qualify for tax credits or cost-sharing reductions, you can appeal the amount we determined you’re eligible
for. Depending on your state, you may be able to appeal through the Marketplace or you may have to request an appeal with the state Medicaid
or CHIP agency.
PERSON 1 should sign this application. If you’re an authorized representative, you may sign here as long as PERSON 1 signed Appendix C.
Signature

Date signed (mm/dd/yyyy)

If you’re signing this application outside of Open Enrollment (between November 1 and January 15), make sure you review Appendix D
(“Questions about life changes”).
NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a
language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users can call 1-855-889-4325.

Page 8 of 9

Step 6: Mail completed application
Mail your signed application to:

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

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

Get help in a language other than English
If you, or someone you’re helping, has questions about the Health Insurance Marketplace®, you have the right to get help and
information in your language at no cost to you. To talk to an interpreter, call 1-800-318-2596.
Here’s a listing of the available languages and the same message provided above in those languages:

Get help in a language other than English (Continued)

Page 9 of 9

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1191. The time required to complete this information collection is estimated to average
45 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection.
If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Form Approved
OMB No. 0938-1191
Expires: XX/XX/XXXX

Appendix A: Health Coverage from Jobs

You DON’T need to answer these questions unless someone in the household is eligible for health coverage from a job, even if
they don’t accept the coverage. You also don’t need to answer these questions if the only coverage someone is offered is COBRA
or retiree insurance. Attach a copy of this page for each job that offers coverage.

Tell us about the job that offers coverage.

Make a copy of this page and take it to the employer who offers coverage to help you answer these questions.
Employee information
1. Employee name (First, Middle, Last)

2. Employee Social Security Number (SSN)

Employer information
3. Employer/company name

4. Employer Identification Number (EIN)

5. Employer phone number

Now, enter the information of the person or department who manages employee benefits. We may contact this person
if we need more information:
6. Person or department we can contact about employee health coverage

7. Employer address (the Marketplace may send notices to this address) (optional)

8. City

9. State

11. Phone number (if different from above)

10. ZIP code

12. Email address (optional)

13. Is the employee offered health coverage by this employer? Only select “yes” if they’ll have an offer of coverage as of the beginning of next month, or as of
January 1 if applying during Open Enrollment.
NO (EMPLOYER: STOP and return this form to the employee.

YES (Continue)
Does the employer offer a health plan that covers this
employee’s spouse or dependent(s)?
YES. If yes, which people?

Spouse

Dependent(s)

EMPLOYEE: Return to your application for Marketplace
coverage.)

NO (Go to question 14.)

List the names of anyone else in the employee’s
household who’s eligible for coverage from this job.
Name

Name

continued on the next page

Tell us about the health coverage offered by this employer.
14. Does the employer offer a health plan that meets the minimum value standard*?
YES (Go to question 15.)

NO (STOP and return this form to employee.)

15. How much would the employee have to pay for the lowest cost plan offered to the employee only that meets the minimum value standard*? Don’t
include family plans. NOTE: If the employer offers wellness programs, enter the premium that the employee would pay if the employee got the maximum
discount for any tobacco cessation programs and didn’t get any other discounts based on wellness programs.
a. Employee would pay this premium: $
NOTE: Enter the lowest amount the employee could pay for health coverage.
b. Employee would pay this amount:

Weekly

Every 2 weeks

Twice a month

Once a month

Quarterly

Yearly

NOTE: If the premium changes, come back and update your application.
* A health plan meets the minimum value standard if pays at least 60% of the total cost of medical services for a standard population and offers substantial coverage of hospital and
doctor services. Most job-based plans meet the minimum value standard.

Form Approved
OMB No. 0938-1191
Expires: XX/XX/XXXX

Appendix B: American Indian or Alaska Native (AI/AN)
Household Member(s)

Complete this appendix if you or a household member are American Indian or Alaska Native and are applying for coverage.
Submit this with your “Application for Health Coverage & Help Paying Costs.”

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

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

AI/AN PERSON 1:

If yes, Tribe name:

Yes

State tribe is located in:

3. Has this person ever gotten a service from the Indian Health Service, a tribal health program,
or urban Indian health program, or through a referral from one of these programs? ...............................................................................................
If no, is this person eligible to get services from the Indian Health Service, tribal health programs,
or urban Indian health programs, or through a referral from one of these programs? .........................................................................................

Yes

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

How often?
Rental or royalty

Farming or fishing

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

AI/AN PERSON 2:

If yes, Tribe name:

Yes

State tribe is located in:

Yes

How often?
Rental or royalty

Farming or fishing

Form Approved
OMB No. 0938-1191
Expires: XX/XX/XXXX

Appendix C: Help with Completing this Application
For certified application counselors, navigators, agents, and brokers only

Complete this section if you’re a certified application counselor, navigator, agent, or broker filling out this application for somebody else.
1. Application start date (mm/dd/yyyy)

2. First name, Middle name, Last name, & Suffix

3. Organization name

4. ID number (if applicable)

5. Agents/Brokers only: NPN number

You can choose an authorized representative.

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

2. Address

4. City

3. Home address 2

5. State

6. ZIP code

7. Phone number

8. Organization name

9. ID number (if applicable)

By signing, you allow this person to sign your application, get official information about this application, and act for you on all future matters
related to this application.
10. Signature of PERSON 1 listed on this application

11. Date signed (mm/dd/yyyy)

Form Approved
OMB No. 0938-1191
Expires: XX/XX/XXXX

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

If anyone on this application experienced certain life changes—like losing health coverage, getting married, or having a baby—in the past
60 days (OR expects to in the next 60 days), fill out this page and include it with your completed, signed application. Certain life changes allow
your coverage through the Marketplace to start right away. We also recommend you answer these questions if you’re applying outside
Open Enrollment.
These questions are optional. If your life circumstances haven’t changed, you can leave the answers blank. You can enroll in Medicaid and the
Children’s Health Insurance Program (CHIP) any time of the year, even if you didn’t experience life changes. Members of federally recognized
tribes and Alaska Native shareholders can enroll in coverage through the Marketplace any time of the year.

Tell us about changes in your household.
1. Did anyone lose qualifying health coverage (such as Medicaid, CHIP, coverage from a job, or COBRA) in the last 60 days,
or expect to lose qualifying health coverage in the next 60 days?
Date coverage ended or will end (mm/dd/yyyy)

Name(s)

2. Did anyone get married in the last 60 days?
Date (mm/dd/yyyy)

Name(s)

a. Did any of these people have qualifying health coverage at any time in the last 60 days? ...........................................................................

Yes

If yes, enter their name(s) below:
Name(s)

3. Did anyone get released from incarceration (detention or jail) in the last 60 days?
Date (mm/dd/yyyy)

Name(s)

4. Did anyone gain eligible immigration status in the last 60 days?
Name(s)

Date (mm/dd/yyyy)

5. Did anyone gain a dependent (or become a dependent) due to an adoption, foster care placement, child support, or other court order
in the last 60 days?
Name(s)

Date (mm/dd/yyyy)

6. Did anyone move in the last 60 days?
Name(s)

a. What is the ZIP code of your previous address?

Date of move (mm/dd/yyyy)

Fill in here if you moved from a foreign country or U.S. territory

b. Did any of these people have qualifying health coverage at any time in the last 60 days? ...........................................................................
If yes, enter their name(s) below:
Name(s)

File Type	application/pdf
File Title	Application for Health Coverage and Help Paying Costs
File Modified	2023-03-27
File Created	2022-03-21