CMS-10440 Application for Health Coverage & Help Paying Costs

Application for Health Coverage & Help Paying Costs

Apply faster online at HealthCare.gov

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

Use this application to find out what coverage you qualify for

Who can use this application?

What you may need to apply

Why do we ask for this information?

What happens next?

• 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.

• 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.

• 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.

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. For the Privacy Act Statement, visit HealthCare.gov, or check the instructions.

Make a copy to keep, then send your complete, signed application to the address on page 10. 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.

1-855-889-4325.

• In-person: There may be assisters 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.

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 1 adult in the household to be the contact person for your application.)

Page 1 of 11

1. First name Middle name Last name Suffix
2. Home address (Leave blank if you don’t have one.)							3. Home address 2
4. City		5. State	6. ZIP code		7. County
8. Mailing address (if different from home address)							9. Mailing address 2
10. City		11. State	12. ZIP code		13. County
14. Phone number			15. Second phone number
16. Do you want to get information about this application by email? ......................................................................................................... Yes No 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.

Step 2: PERSON 1 (Start with yourself.)

Page 2 of 11

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. Go to 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 Middle name Last name Suffix

2. Relationship to PERSON 1?

SELF

3. Are you married? Yes No

4. Date of birth (mm/dd/yyyy) 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 find out who’s eligible for help paying for health coverage. For more information on getting an SSN, visit SSA.gov, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

6. 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.

1. Will you file jointly with a spouse ................................................................................................................................................................ Yes No

If yes, write name of spouse:

2. Will you claim any dependents on your tax return?........................................................................................................................................ Yes No

If yes, list name(s) of dependents:

3. Will you be claimed as a dependent on someone’s tax return?..................................................................................................................... Yes No

If yes, list the name of the tax filer: How are you related to the tax filer

6. Are you pregnant? ....................................................................................... Yes No a. If yes, how many babies are expected during this pregnancy?

7. 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.

6. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing,

dressing, daily chores, etc.), a special health care need, or live in a medical facility or nursing home? ............................................................................ Yes No

6. Are you a U.S. citizen or U.S. national? ................................................................................................................................................................................ Yes No

7. 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.

1. 

   
   

   Alien number: b. Certificate number: _{After you complete a and b,} skip to question 14.

6. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? YES. Enter document type and ID number. Go to instructions. Immigration document type Status type (optional) 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)

1. Have you lived in the U.S. since 1996? .................................................................................................................................................................................... Yes No

2. Are you, or your spouse or parent, a veteran or an active-duty member of the U.S. military? ...................................................................................... Yes No

6. Do you want help paying for medical bills from the last 3 months? ................................................................................................................................ Yes No

7. 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 No

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

6. Are you a full-time student?.................... Yes No 17. Were you in foster care at age 18 or older? ............................................................... Yes No

continued on the next page

Page 3 of 11

Step 2: PERSON 1 (Continue with yourself.)

Current job 1:

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

continued on the next page

Page 4 of 11

33. Other income you get this month: Fill in all that apply, and give the amount and how often you get it. Fill in here if none. Note: You don’t need to tell us about income from child support, veteran’s payments, or Supplemental Security Income (SSI).
Unemployment $ How often?		Alimony received (Note: Only for divorces finalized before 1/1/2019.) $ How often?
Pension $ How often?		Net farming/fishing $ How often?
Social Security $ How often?		Net rental/royalty $ How often?
Retirement accounts $ How often?		Other income, type: $ How often?
34. Deductions: Fill in all that apply, and give the amount and how often 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. Don’t include child support that you pay, or a cost already considered in your answer to net self-employment (question 32b).
Alimony paid (Note: Only for divorces finalized before 1/1/2019.) $ How often?		Other deductions, type: $ How often?
Student loan interest $ How often?
35. Complete this question if your income changes during the year, like if you only work at a job for part of the year or get 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.

Step 2: PERSON 2

Note: If this person doesn’t need health coverage, just answer questions 1–10 on this page. Make a copy of pages 5–7 if there are more than 2 people in your household.

Page 5 of 11

Complete this section 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. Go to page 1 for more information about who to include.

1. First name Middle name Last name Suffix

2. Relationship to PERSON 1? Go to instructions. 3. Is PERSON 2 married?

Yes No

4. Date of birth (mm/dd/yyyy) 5. Sex

Female Male

6. 

   and PERSON 2 has an SSN.

   _{Social Security Number (SSN)} We need this if you want health coverage for PERSON 2,

7. Does PERSON 2 live at the same address as PERSON 1?..................................................................................................................................... Yes No

If no, list address:

6. 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.

1. Will PERSON 2 file jointly with a spouse ...................................................................................................................................................... Yes No

If yes, write name of spouse:

2. Will PERSON 2 claim any dependents on his or her tax return? ...................................................................................................................... Yes No

If yes, list name(s) of dependents:

3. Will PERSON 2 be claimed as a dependent on someone’s tax return? ........................................................................................................... Yes No

If yes, list the name of the tax filer: How is PERSON 2 related to the tax filer

6. Is PERSON 2 pregnant? ............................................................................... Yes No a. If yes, how many babies are expected during this pregnancy?

7. 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 6. Leave the rest of this page blank.

6. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities

(like bathing, dressing, daily chores, etc.), a special health care need, or live in a medical facility or nursing home? ..................................................... Yes No

6. Is PERSON 2 a U.S. citizen or U.S. national? ......................................................................................................................................................................... Yes No

7. 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.

1. Alien number b. Certificate number _{After you complete a and b,} skip to question 15.

6. 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. Go to 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)

1. Has PERSON 2 lived in the U.S. since 1996? ............................................................................................................................................................................ Yes No

2. Is PERSON 2, or PERSON 2’s spouse or parent, a veteran or an active-duty member of the U.S. military? ................................................................... Yes No

6. Does PERSON 2 want help paying for medical bills from the last 3 months? .................................................................................................................. Yes No

7. 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 No

6. 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? ....................................................................................................................................................................... Yes No

Answer these questions if PERSON 2 is 22 or younger:

6. 

   
   

   Did PERSON 2 have insurance through a job and lose it within the past 3 months?...................................................................................................... Yes No

   1. If yes, end date: b. Reason the insurance ended:

7. Is PERSON 2 a full-time student? ........................................................................................................................................................................................... Yes No

continued on the next page

Page 6 of 11

Step 2: PERSON 2

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

Current job 1:

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

continued on the next page

Page 7 of 11

35. Other income PERSON 2 gets this month: Fill in all that apply, and give the amount and how often PERSON 2 gets it. Fill in here if none. Note: You don’t need to tell us about PERSON 2’s income from child support, veteran’s payments, or Supplemental Security Income (SSI).
Unemployment $ How often?		Alimony received (Note: Only for divorces finalized before 1/1/2019.) $ How often?
Pension $ How often?		Net farming/fishing $ How often?
Social Security $ How often?		Net rental/royalty $ How often?
Retirement accounts $ How often?		Other income, type: $ How often?
36. 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. Don’t include child support that PERSON 2 pays, or a cost already considered in the answer to net self-employment (question 34b).
Alimony paid (Note: Only for divorces finalized before 1/1/2019.) $ How often?		Other deductions, type: $ How often?
Student loan interest $ How often?
37. 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 gets a benefit for certain months. If PERSON 2 doesn’t expect changes to their monthly income, skip to the next person.
PERSON 2’s total income this year $	PERSON 2’s total income next year $ Fill in if they think their income will be hard to predict.

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

Step 3: American Indian or Alaska Native (AI/AN) household member(s)

Page 8 of 11

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? 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?				Yes Yes Yes	No No No
2. Is anyone listed on this application offered health coverage fr m a job? Check yes even if the coverage is from someone else’s job, like a parent or spouse, even if they don’t accept the coverage. Check no if the only coverage offered is COBRA YES. Continue and then complete Appendix A. NO. If yes, is this a state employee benefit plan ..................................................................................................................................................................... Yes No Is anyone listed on the application offered an individual cover ge Health Reimbursement Arrangement (HRA) or a Qualified Small Employer HRA (QSEHRA) .................................................................................................................................................................. Yes No
3. Is anyone enrolled in health coverage now? YES. If yes, continue to item 4. NO. If no, skip item 4.
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, 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.)
PERSON 1:	Name of person enrolled in health coverage
	Type of coverage: Employer 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.)		Policy/ID number
	Name of health insurance company
	If it’s another kind of coverage: Fill in if this is Marketplace health coverage.		Policy/ID number
	Name of health insurance company
	Is this a limited-benefit plan, like a school accident policy? ............................................................................................................................................			Yes	No

PERSON 2:	Name of person enrolled in health coverage
	Type of coverage: Employer 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	Policy/ID number
	If it’s another kind of coverage: Fill in if this is Marketplace health coverage.
	Name of health insurance company	Policy/ID number
	Is this a limited-benefit plan, like a school accident policy? ............................................................................................................................................ Yes No

Step 5: Your agreement & signature

Page 9 of 11

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 is eligible for Medicaid:

• I’m giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

• Does any child on this application have a parent living outside of the home? .................................................................................................... Yes No

• If yes, I know I’ll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.

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

• I know that I must tell the Health Insurance Marketplace^® within 30 days if anything changes (and is different than) what I wrote on thi application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affec 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/civil-rights/filing-a-complain .

• 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?

You’ll get an Eligibility Notice in the mail after we process your application. 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.

If you’re signing this application outside of Open Enrollment (November 1–January 15), make sure you review Appendix D (“Questions about life changes”).

Step 6: Mail completed application

Page 10 of 11

Mail your signed application to:

Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd.

London, KY 40750-0001

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 some of the available languages and the same message provided above in those languages:

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.

Get help in a language other than English (Continued)

Page 11 of 11

Appendix A: Health Coverage from Jobs

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

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. 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

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)
8. City		9. State	10. ZIP code
11. Phone number (if different from above)	12. Email address

continued on the next page

Tell us about the health coverage offered by this employer.

14. Do the plans offered by the employer meet 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.

    1. Employee would pay this premium: $

Note: Enter the lowest amount the employee could pay for health coverage.

2. Employee would pay this amount: Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly

16. If other household members are listed for question 13: How much would the employee pay for the lowest-cost plan that covers the employee and the household members listed in question 13? 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.

    1. Employee would pay this premium: $

    2. ^{Employee would pay this amount: Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly}

* A health plan meets the minimum value standard if pays at least 60% of the total cost of medical services for a standard population and offers substantial coverage of hospital and doctor services. Most job-based plans meet the minimum value standard.

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

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

AI/AN PERSON 2:

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.

AI/AN PERSON 1:

Note: If you have more people to include, make a copy of this page and attach.

Appendix C: Help with Completing this Application

For certified application counselors, navigators, agents, and brokers only

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

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, access your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person is called an “authorized representative.” If you ever need to change or remove your authorized representative, contact the Marketplace. If you’re a legally appointed representative for someone on this application, submit proof with the application.

1. Name of authorized representative (First name, Middle name, Last name)

2. Address

3. Home address 2

4. City

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 matter related to this application.

10. Signature of PERSON 1 listed on this application

11. Date signed (mm/dd/yyyy)

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.)

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

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 (November 1–January 15).

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 in the last 60 days, or expect to lose qualifying health coverage in the next 60 days?

   Name(s)

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

2. Did anyone get married in the last 60 days?

   Name(s)

   Date (mm/dd/yyyy)

   a. Did any of these people have qualifying health coverage at any time in the last 60 days? ........................................................................... Yes No If yes, enter their name(s) below: Name(s)

3. Did anyone get released from incarceration (detention or jail) in the last 60 days?

   Name(s)

   Date (mm/dd/yyyy)

4. Did anyone gain eligible immigration status in the last 60 days?

   Name(s)

   Date (mm/dd/yyyy)

5. Was anyone adopted, placed for adoption, or placed for foster care in the last 60 days?

   Name(s)

   Date (mm/dd/yyyy)

6. Did anyone become a dependent due to a child support or other court order in the last 60 days?

   Name(s)

   Date (mm/dd/yyyy)

7. 

   
   

   Did anyone move in the last 60 days?

Name(s)

Date of move (mm/dd/yyyy)

a. What is the ZIP code of your previous address? 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? ........................................................................... Yes No If yes, enter their name(s) below: Name(s)