CMS-10440 Application for Health Coverage (no cost help)

Application for Health Coverage

Apply faster online at HealthCare.gov

Form Approved OMB No. 0938-1191

Expires: 10/31/2025

Who can use this application?

What happens next?

Anyone who needs health coverage and isn’t looking for help with costs can use this application.

If someone is helping you fill out this application, you may ne d to complete Appendix C.

Make a copy to “keep, then send your complete, signed application to the address on page 4. If you don’t have all the information we ask for, sign and submit your application anyway.

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.

Filling out this application doesn’t mean you have to buy health coverage.

_{Get help with costs} You need to use a different application to get help with costs. You may qualify for:

• 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.

Visit HealthCare.gov or call the Marketplace Call Center to learn more.

Get help with this application

• Online: HealthCare.gov.

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

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.

Page 1 of 4

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

Step 1: Tell us about yourself (PERSON 1).

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

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. Home address 2

10. City 11. State

14. Daytime phone number

12. ZIP code 13. County

14. Evening phone number

14. Do you want to get information about this application by email? ....................................................................................................... Yes No Email address:

15. Preferred language: Written Spoken

14. Do you need health coverage for yourself?

YES. If yes, answer all the questions below. NO. If no, skip to Step 2 on page 2. (Leave the rest of this page blank.)

14. 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.

14. Sex

Female Male

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

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

15. Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.)

YES. If yes, complete a and b. NO. If no, continue to question 24.

a. Alien number: b. Certificate number: _{After you complete a and b,} skip to question 25.

14. 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

SEVIS ID or expiration date (optional)

Card number or passport number

Other (category code or country of issuance)

continued on the next page

Page 2 of 4

Step 2: Tell us about anyone who needs health coverage.

(If you have more people to include, make a copy of pages 2–3 and attach.)

PERSON 2

1. First name Middle name Last name Suffix

2. Relationship to PERSON 1

3. Social Security Number (SSN) 4. Date of birth (mm/dd/yyyy) 5. Sex

Female Male

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

If no, list address:

6. Is PERSON 2 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 9.

a. Alien number: b. Certificate number: _{After you complete a and b,} skip to question 10.

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)

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

continued on the next page

Page 3 of 4

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

American Indians and Alaska Natives can get services from the Indian Health Service, tribal health programs, or urban Indian health programs. They also may not have to pay cost sharing and may get special monthly enrollment periods. Answer these questions to make sure your household gets the most help possible.

1. Are you or is anyone in your household American Indian or Alaska Native? NO. If no, skip questions 2 and 3. YES. If yes, continue. If you have more people to include, make a copy of this page and attach.
2. Name (First name, Middle name, Last name)
3. Member of a federally recognized tribe? ............................................................................................................................................................................. Yes No
If yes, tribe name:		State tribe is located in:

Step 4: Your agreement & signature

Page 4 of 4

• 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 health coverage. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof.

What should I do if I think my Eligibility 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 5: Mail completed application.

Mail your signed application to:

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

London, KY 40750-0001

PRA Disclosure Statement: According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1191. The time required to complete this information collection is estimated to average 20 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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)