health insurance marketplace application-for-family (obamacare) from healthcare.gov

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 should call 1-855-889-4325.

Application for Health Coverage & Help Paying CostsTH

ING

S TO

KN

OW

Use this application to see what coverage you qualify for

• Affordableprivatehealthinsuranceplansthatoffercomprehensivecoveragetohelpyoustaywell

• Anewtaxcreditthatcanimmediatelyhelppayyourpremiumsfor healthcoverage

• Freeorlow-costinsurancefromMedicaidortheChildren’sHealthInsuranceProgram(CHIP)You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).

Who can use this application?

• Usethisapplicationtoapplyforanyoneinyourfamily.• Applyevenifyouoryourchildalreadyhashealthcoverage.Youcould

beeligibleforlower-costorfreecoverage.• Ifyou’resingle,youmaybeabletouseashortform.

VisitHealthCare.gov.• Familiesthatincludeimmigrantscanapply.Youcanapplyforyour

childevenifyouaren’teligibleforcoverage.Applyingwon’taffectyourimmigrationstatusorchancesofbecomingapermanentresident orcitizen.

• Ifsomeoneishelpingyoufilloutthisapplication,youmayneedtocompleteAppendixC.

Apply faster online

ApplyfasteronlineatHealthCare.gov.

What you may need to apply

• SocialSecuritynumbers(ordocumentnumbersforanyeligibleimmigrantswhoneedinsurance)

• Employerandincomeinformationforeveryoneinyourfamily(forexample,frompaystubs,W-2forms,orwageandtaxstatements)

• Policynumbersforanycurrenthealthinsurance• Informationaboutanyjob-relatedhealthinsuranceavailabletoyourfamily

Why do we ask for this information?

Weaskaboutincomeandotherinformationtoletyouknowwhatcoverageyouqualifyforandifyoucangetanyhelppayingforit.We’ll keep all the information you provide private and secure, as required by law. ToviewthePrivacyActStatement,gotoHealthCare.govorseeinstructions.

What happens next?

Sendyourcomplete,signedapplicationtotheaddressonpage7. If you don’t have all the information we ask for, sign and submit your application anyway.We’llfollowupwithyouwithin1–2weeks.You’llgetinstructionsonthenextstepstocompleteyourhealthcoverage.Ifyoudon’thearfromus,visitHealthCare.govorcall1-800-318-2596.Fillingoutthisapplicationdoesn’tmeanyouhavetobuyhealthcoverage.

Get help with this application

• Online: HealthCare.gov• Phone: CallourHelpCenterat1-800-318-2596.• In person: Theremaybecounselorsinyourareawhocanhelp.

VisitHealthCare.govorcall1-800-318-2596formoreinformation.• En Español:Llameanuestrocentrodeayudagratisal1-800-318-2596.

FormApprovedOMBNo.0938-1191

10/2013


Initial here: Page 1 of 7

STEP 1(Weneedoneadultinthefamilytobethecontactpersonforyourapplication.)

1.Firstname Middlename Lastname Suffix

2.Homeaddress(Leaveblankifyoudon’thaveone.) 3.Apartmentorsuitenumber

4.City 5.State 6.ZIPcode 7.County

8.Mailingaddress(ifdifferentfromhomeaddress) 9.Apartmentorsuitenumber

10.City 11.State 12.ZIPcode 13.County

14.Phonenumber

( ) – 15.Otherphonenumber

( ) –

16. Doyouwanttogetinformationaboutthisapplicationbyemail? Yes No

Emailaddress:17.Whatisyourpreferredspokenorwrittenlanguage(ifnotEnglish)?

STEP 2Who do you need to include on this application?Tellusaboutallthefamilymemberswholivewithyou.Ifyoufiletaxes,weneedtoknowabouteveryoneonyourtaxreturn.(Youdon’tneedtofiletaxestogethealthcoverage.)

DO Include: You DON’T have to include: • Yourself • Yourunmarriedpartnerwhodoesn’tneedhealthcoverage• Yourspouse • Yourunmarriedpartner’schildren• Yourchildrenunder21wholivewithyou • Yourparentswholivewithyou,butfiletheirowntaxreturn• Yourunmarriedpartnerwhoneedshealthcoverage (ifyou’reover21)

• Anyoneyouincludeonyourtaxreturn,evenifthey • Otheradultrelativeswhofiletheirowntaxreturndon’tlivewithyou

• Anyoneelseunder21whoyoutakecareofandlives withyou

Theamountofassistanceortypeofprogramyouqualifyfordependsonthenumberofpeopleinyourfamilyandtheirincomes.Thisinformationhelpsusmakesureeveryonegetsthebestcoveragetheycan.

Complete Step 2 for each person in your family. Startwithyourself,thenaddotheradultsandchildren.Ifyouhavemorethan2peopleinyourfamily,you’llneedtomakeacopyofthepagesandattachthem.Youdon’tneedtoprovideimmigrationstatusoraSocialSecurityNumber(SSN)forfamilymemberswhodon’tneedhealthcoverage.We’llkeepalltheinformationyouprovideprivateandsecureasrequiredbylaw.We’llusepersonalinformationonlytocheckifyou’reeligibleforhealthcoverage.

Tell us about yourself.

Tell us about your family.

Use blue or black ink to complete this application.



STEP 2: PERSON 1CompleteStep2foryourself,yourspouse/partnerandchildrenwholivewithyou,and/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.


2.Relationshiptoyou?

SELF3.Dateofbirth(mm/dd/yyyy)

/ /4.Sex

Male Female

5.SocialSecuritynumber(SSN) - -We need this if you want health coverage and have an SSN. Evenifyoudon’twanthealthcoverageforyourself,providingyourSSNcanbehelpfulsinceitcanspeeduptheapplicationprocess.WeuseSSNstocheckincomeandotherinformationtoseewho’seligibleforhelpwithhealthcoveragecosts.ForhelpgettinganSSN,call1-800-772-1213orvisitsocialsecurity.gov. TTYusersshouldcall1-800-325-0778.

6.Do you plan to file a federal income tax return NEXT YEAR?(You can still apply for health insurance even if you don’t file a federal income tax return.)

YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.

a. Willyoufilejointlywithaspouse? Yes NoIf yes,nameofspouse:

b. Willyouclaimanydependentsonyourtaxreturn? Yes NoIf yes,listname(s)ofdependents:

c. Willyoubeclaimedasadependentonsomeone’staxreturn? Yes NoIf yes,pleaselistthenameofthetaxfiler:

Howareyourelatedtothetaxfiler?

7. Areyoupregnant? Yes Noa.If yes,howmanybabiesareexpectedduringthispregnancy?

8.Do you need health coverage?(Even if you have insurance, there might be a program with better coverage or lower costs.)

YES. If yes,answerallthequestionsbelow.

NO. If no, SKIPtotheincomequestionsonpage3. Leavetherestofthispageblank.

9. Doyouhaveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,daily chores,etc.)orliveinamedicalfacilityornursinghome? Yes No

10. AreyouaU.S.citizenorU.S.national? Yes No11. If you aren’t a U.S. citizen or U.S. national,doyouhaveeligibleimmigrationstatus?(See instructions.)

Yes.FillinyourdocumenttypeandIDnumberbelow. No

a.Immigrationdocumenttype: b.DocumentIDnumber

c.HaveyoulivedintheU.S.since1996? d.Areyou,oryourspouseorparent,aveteranoranactive-duty Yes No memberoftheU.S.military? Yes No

12.Doyouwanthelppayingformedicalbillsfromthelast3months? Yes No

13.Doyoulivewithatleastonechildundertheageof19,andareyouthemainpersontakingcareofthischild? Yes No

14.Areyouafull-timestudent? Yes No 15.Wereyouinfostercareatage18orolder? Yes No

16.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other

17.Race (OPTIONAL—check all that apply.)

White BlackorAfrican American

AmericanIndianor AlaskaNative

AsianIndian Chinese

Filipino Japanese Korean

Vietnamese OtherAsian NativeHawaiian

GuamanianorChamorro Samoan OtherPacificIslander Other

(Start with yourself)

http://www.socialsecurity.gov



STEP 2: PERSON 1 (Continue with yourself)

Current job & income information Employed: Ifyou’recurrentlyemployed,tellusabout yourincome.Startwithquestion18.

Not employed: Skiptoquestion28. Self-employed: Skiptoquestion27.

CURRENT JOB 1:18.Employername

a.Employer address

b.City c.State d.ZIPcode 19.Employerphonenumber

( ) – 20.Wages/tips(beforetaxes)

$ Hourly Weekly Every2weeks

Twiceamonth Monthly Yearly

21.AveragehoursworkedeachWEEK

CURRENT JOB 2: (Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper.)22.Employername

a.Employeraddress






26.In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese

27.If self-employed, answer the following questions:

a.Typeofwork:

b. Howmuchnetincome(profitsoncebusinessexpensesarepaid)willyougetfrom thisself-employmentthismonth?(See instructions.) $

28.OTHER INCOME THIS MONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.Checkhereifnone. NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).

Unemployment $ Howoften? Alimonyreceived $ Howoften?

Pension $ Howoften? Net farming/fishing $ Howoften?

SocialSecurity $ Howoften? Netrental/royalty $ Howoften?

Retirement accounts

$ Howoften? Otherincome Type:

$ Howoften?

29.DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenyougetit.Ifyoupayforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question27b).

Alimonypaid $ Howoften? Otherdeductions Type:

$ Howoften?

Studentloan interest

$ Howoften?

30.YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your monthly income, skip to the next person. THANKS!

This is all we need to know about you.

Yourtotalincomethis year

$

Yourtotalincomenext year(ifyouthinkitwillbedifferent)

$



STEP 2: PERSON 2CompleteStep2foryourself,yourspouse/partnerandchildrenwholivewithyou,and/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.


2.Relationshiptoyou?(See instructions.) 3.Dateofbirth(mm/dd/yyyy) 4.Sex

Male Female/ /We need this if you want health coverage for PERSON 2

5.SocialSecuritynumber(SSN) - - and PERSON 2 has an SSN.

6.DoesPERSON2liveatthesameaddressasyou? Yes No

If no,listaddress:

7.Does PERSON 2 plan to file a federal income tax return NEXT YEAR?(You can still apply for health insurance even if PERSON 2 doesn’t file a federal income tax return.)

YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.

a. WillPERSON2filejointlywithaspouse? Yes NoIf yes,nameofspouse:

b. WillPERSON2claimanydependentsonhisorhertaxreturn? Yes NoIf yes,listname(s)ofdependents:

c. WillPERSON2beclaimedasadependentonsomeone’staxreturn? Yes NoIf yes,pleaselistthenameofthetaxfiler:

HowisPERSON2relatedtothetaxfiler?

8. IsPERSON2pregnant? Yes Noa.If yes,howmanybabiesareexpectedduringthispregnancy?

9.Does PERSON 2 need health coverage?(Even if PERSON 2 has insurance, there might be a program with better coverage or lower costs.)

YES. If yes,answerallthequestionsbelow. NO. If no, SKIPtotheincomequestionsonpage5. Leavetherestofthispageblank.

10. DoesPERSON2haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc.)orliveinamedicalfacilityornursinghome? Yes No

11. IsPERSON2aU.S.citizenorU.S.national? Yes No12. If PERSON 2 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?(See instructions.)

Yes.FillinPERSON2’sdocumenttypeandIDnumberbelow. No

a.Immigrationdocumenttype: b.DocumentIDnumber

c.HasPERSON2livedintheU.S.since1996? d.IsPERSON2,orPERSON2’sspouseorparent,aveteranoran Yes No active-dutymemberoftheU.S.military? Yes No

13.DoesPERSON2wanthelppayingfor 14.DoesPERSON2livewithatleastonechildundertheageof19, 15.WasPERSON2infostermedicalbillsfromthelast3months? andisPERSON2themainpersontakingcareofthischild? careatage18orolder?

Yes No Yes No Yes NoPlease answer the following questions if PERSON 2 is 22 or younger:

17.IsPERSON2afull-timestudent?16. DidPERSON2haveinsurancethroughajobandloseitwithinthepast3months? Yes No Yes No a.If yes,enddate: b.Reasontheinsuranceended:

18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other

19.Race (OPTIONAL—check all that apply.) White AmericanIndianor Filipino Vietnamese GuamanianorChamorro BlackorAfrican AlaskaNative Japanese OtherAsian SamoanAmerican AsianIndian Korean NativeHawaiian OtherPacificIslander

Chinese Other

Now, tell us about any income from PERSON 2 on the back.

If you have more than two people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.



STEP 2: PERSON 2Current job & income information

Employed: IfPERSON2iscurrentlyemployed,tellus abouthisorherincome.Startwithquestion20.

Not employed: Skiptoquestion30. Self-employed: Skiptoquestion29.

CURRENT JOB 1:20.Employername

a.Employer address






CURRENT JOB 2: (IfPERSON2hasmorejobs,attachanothersheetofpaper.)24.Employername

a.Employeraddress






28.In the past year, did PERSON 2: Changejobs Stopworking Startworkingfewerhours Noneofthese

29.If PERSON 2 is self-employed, answer the following questions:

a.Typeofwork:

b. Howmuchnetincome(profitsoncebusinessexpensesarepaid)willPERSON2 getfromthisself-employmentthismonth?(See instructions.) $

30.OTHER INCOME THIS MONTH: Checkallthatapply,andgivetheamountandhowoftenPERSON2getsit.Checkhereifnone. NOTE: Youdon’tneedtotellusaboutPERSON2’schildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).

Unemployment $ Howoften? Alimonyreceived $ Howoften?

Pension $ Howoften? Net farming/fishing $ Howoften?

SocialSecurity $ Howoften? Netrental/royalty $ Howoften?

Retirement accounts

$ Howoften? Otherincome Type:

$ Howoften?

31.DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenPERSON2getsit.IfPERSON2paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealthcoveragealittlelower.NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment(question29b).

Alimonypaid $ Howoften? Otherdeductions Type:

$ Howoften?

Studentloan interest

$ Howoften?

32.YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month. If you don’t expect changes to PERSON 2’s monthly income, skip to the next person. THANKS!

This is all we need to know about PERSON 2.

PERSON2’stotalincomethis year

$

PERSON2’stotalincomenext year(ifyouthinkitwillbedifferent)

$



1. Are you or is anyone in your family American Indian or Alaska Native?

NO. If no, skiptoStep4.

YES. If yes, gotoAppendixB.

Answerthesequestionsforanyonewhoneedshealthcoverage.

1. Is anyone enrolled in health coverage now from the following?

YES. If yes,checkthetypeofcoverageandwritetheperson(s)’name(s)nexttothecoveragetheyhave. NO.

Medicaid Employerinsurance

Nameofhealthinsurance:CHIPPolicynumber: Medicare

IsthisCOBRAcoverage? Yes No TRICARE(Don’tcheckifyouhaveDirectCareorLineofDuty) Isthisaretireehealthplan? Yes No

OtherNameofhealthinsurance: VAhealthcareprogramPolicynumber:

PeaceCorpsIsthisalimited-benefitplan(likeaschoolaccidentpolicy)?

Yes No

2. Is anyone listed on this application offered health coverage from a job?Checkyesevenifthecoverageisfromsomeoneelse’sjob,suchasaparentorspouse.

YES. If yes,you’llneedtocompleteandincludeAppendixA.Isthisastateemployeebenefitplan? Yes No

NO. If no, continue to Step 5.

STEP 4 Your family’s health coverage

American Indian or Alaska Native (AI/AN) family member(s)

STEP 5• I’msigningthisapplicationunderpenaltyofperjury,whichmeansI’veprovidedtrueanswerstoallthequestionsonthisform

tothebestofmyknowledge.IknowthatImaybesubjecttopenaltiesunderfederallawifIintentionallyprovidefalseoruntrueinformation.

• IknowthatImusttelltheHealthInsuranceMarketplaceifanythingchanges(andisdifferentthan)whatIwroteonthisapplication.IcanvisitHealthCare.govorcall1-800-318-2596toreportanychanges.Iunderstandthatachangeinmyinformationcouldaffecttheeligibilityformember(s)ofmyhousehold.

• Iknowthatunderfederallaw,discriminationisn’tpermittedonthebasisofrace,color,nationalorigin,sex,age,sexualorientation,genderidentity,ordisability.Icanfileacomplaintofdiscriminationbyvisitingwww.hhs.gov/ocr/office/file.

• Iknowthatmyinformationonthisformwillbeusedonlytodetermineeligibilityforhealthcoverageandwillbekeptprivateasrequiredbylaw.

• Isanyoneapplyingforhealthinsuranceonthisapplicationincarcerated(detainedorjailed)? Yes No If yes,writethenameofthepersonincarceratedhere: Checkhereifthispersonispendingdispositionofcharges.

Weneedthisinformationtocheckyoureligibilityforhelppayingforhealthcoverageifyouchoosetoapply.We’llcheckyouranswersusinginformationinourelectronicdatabasesanddatabasesfromtheInternalRevenueService(IRS),SocialSecurity,theDepartmentofHomelandSecurity,and/oraconsumerreportingagency.Iftheinformationdoesn’tmatch,wemayaskyoutosendusproof.

Read & sign below on the next page

STEP 3

http://www.hhs.gov/ocr/office/file



Mailyoursignedapplicationto:

Health Insurance Marketplace Dept. of Health and Human Services465 Industrial Blvd. London, KY 40750-0001

Ifyouwanttoregistertovote,youcancompleteavoterregistrationformatusa.gov.

STEP 6 Mail completed application.

Renewal of coverage in future yearsTomakeiteasiertodeterminemyeligibilityforhelppayingforhealthcoverageinfutureyears,IagreetoallowtheMarketplacetouseincomedata,includinginformationfromtaxreturns.TheMarketplacewillsendmeanoticeandletmemakeanychanges,andIcanoptoutatanytime.

Yes,renewmyeligibilityautomaticallyforthenext 5years(themaximumnumberofyearsallowed),orforashorternumberofyears: 4years 3years 2years 1year Don’tuseinformationfromtaxreturnstorenewmycoverage.

If anyone on this application is eligible for Medicaid• I’mgivingtotheMedicaidagencyourrightstopursueandgetanymoneyfromotherhealthinsurance,legalsettlements,or

otherthirdparties.I’malsogivingtotheMedicaidagencyrightstopursueandgetmedicalsupportfromaspouseorparent.• Doesanychildonthisapplicationhaveaparentlivingoutsideofthehome? Yes No• Ifyes,IknowI’llbeaskedtocooperatewiththeagencythatcollectsmedicalsupportfromanabsentparent.IfIthinkthat

cooperatingtocollectmedicalsupportwillharmmeormychildren,IcantellMedicaidandImaynothavetocooperate.

What should I do if I think my eligibility results are wrong? Ifyoudon’tagreewithwhatyouqualifyfor,inmanycases,youcanaskforanappeal.Pleasereviewyoureligibilitynoticetofindappealsinstructionsspecifictoeachpersoninyourhousehold,includinghowmanydaysyouhavetorequestanappeal.Belowisimportantinformationtoconsiderwhenrequestinganappeal:

• Youcanhavesomeonerequestorparticipateinyourappealifyouwantto.Thatpersoncanbeafriend,relative,lawyer,orotherindividual.Or,youcanrequestandparticipateinyourappealonyourown.

• Ifyourequestanappeal,youmaybeabletokeepyoureligibilityforcoveragewhileyourappealispending.• Theoutcomeofanappealcouldchangetheeligibilityofothermembersofyourhousehold.

ToappealyourMarketplaceeligibilityresults,logintoyourMarketplaceaccountatHealthCare.gov/marketplace/individual orcall1-800-318-2596.TTYusersshouldcall1-855-889-4325.YoucanalsomailanappealrequestformoryourownletterrequestinganappealtoHealth Insurance Marketplace,Dept.ofHealthandHumanServices,465IndustrialBlvd.,London,KY40750-0001.YoucanappealeligibilityforpurchasinghealthcoveragethroughtheMarketplace,enrollmentperiods,taxcredits,cost-sharingreductions,Medicaid,andCHIP,ifyouweredeniedthese.Ifyouqualifyfortaxcreditsorcost-sharingreductions,youcanappealtheamountwedeterminedyouareeligiblefor.Dependingonyourstate,youmaybeabletoappealthroughtheMarketplaceoryoumayhavetorequestanappealwiththestateMedicaidorCHIPagency.

Sign this application. ThepersonwhofilledoutStep1shouldsignthisapplication.Ifyou’reanauthorizedrepresentative,youmaysignhereaslongasyou’veprovidedtheinformationrequiredinAppendixC.

Signature Date(mm/dd/yyyy)

/ /

(Continued)

PRA Disclosure Statement AccordingtothePaperworkReductionActof1995,nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysavalidOMBcontrolnumber.ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1191.Thetimerequiredtocompletethisinformationcollectionisestimatedtoaverage45minutesperresponse,includingthetimetoreviewinstructions,searchexistingdataresources,gatherthedataneeded,andcompleteandreview theinformationcollection.Ifyouhavecommentsconcerningtheaccuracyofthetimeestimate(s)orsuggestionsforimprovingthisform,pleasewriteto: CMS,7500SecurityBoulevard,Attn:PRAReportsClearanceOfficer,MailStopC4-26-05,Baltimore,Maryland21244-1850.

STEP 5

http://www.HealthCare.gov/marketplace/individual


Health Coverage from JobsYouDON’Tneedtoanswerthesequestionsunlesssomeoneinthehouseholdiseligibleforhealthcoveragefromajob.Attachacopyofthispageforeachjobthatofferscoverage.

Tell us about the job that offers coverage. TaketheEmployerCoverageToolonthenextpagetotheemployerwhoofferscoveragetohelpyouanswerthesequestions.Youonlyneedtoincludethispagewhenyousendinyourapplication,nottheEmployerCoverageTool.

Employee information1.Employeename(First,Middle,Last) 2.EmployeeSocialSecuritynumber

- -Employer information3.Employername 4.EmployerIdentificationNumber(EIN)

-5.Employeraddress 6.Employerphonenumber

( ) – 7.City 8.State 9.ZIPcode

10.Whocanwecontactaboutemployeehealthcoverageatthisjob?

11.Phonenumber(ifdifferentfromabove)

( ) – 12.Emailaddress

Tell us about the health plan offered by this employer.

14.Doestheemployerofferahealthplanthatmeetstheminimumvaluestandard*? Yes No15. Forthelowest-costplanthatmeetstheminimumvaluestandard*offeredonly to the employee(don’tincludefamilyplans):

Iftheemployerhaswellnessprograms,providethepremiumthattheemployeewouldpayifhe/shereceivedthemaximumdiscountforanytobaccocessationprograms,anddidnotreceiveanyotherdiscountsbasedonwellnessprograms.

a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan? $ b.Howoften? Weekly Every2weeks Twiceamonth OnceamonthQuarterly Yearly

16.Whatchangewilltheemployermakeforthenewplanyear(ifknown)? Employerwon’tofferhealthcoverage

Employerwillstartofferinghealthcoveragetoemployeesorchangethepremiumforthelowest-costplanavailableonlytotheemployeethatmeetstheminimumvaluestandard.*(Premiumshouldreflectthediscountforwellnessprograms.Seequestion15.)

a.Howmuchwilltheemployeehavetopayinpremiumsforthatplan? $ b.Howoften? Weekly Every2weeks Twiceamonth OnceamonthQuarterly Yearly

c.Dateofchange(mm/dd/yyyy): / / *Anemployer-sponsoredhealthplanmeetsthe“minimumvaluestandard”iftheplan’sshareofthetotalallowedbenefitcostscoveredbytheplanisnolessthan60percentofsuchcosts(Section36B(c)(2)(C)(ii)oftheInternalRevenueCodeof1986).

13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?

Yes(Continue)

13a.If you’re in a waiting or probationary period, when can you enroll in coverage? (mm/dd/yyyy)

/ /

Listthenamesofanyoneelsewhoiseligibleforcoveragefromthisjob.

Name: Name: Name:

No (StophereandgotoStep5intheapplication)

APPENDIX A FormApprovedOMBNo.0938-1191


EMPLOYEE informationTheemployeeneedstofilloutthissection.

1.Employeename(First,Middle,Last) 2.EmployeeSocialSecurityNumber

- -EMPLOYER informationAsktheemployerforthisinformation.

3.Employername 4.EmployerIdentificationNumber(EIN)

-5.Employeraddress(theMarketplacewillsendnoticestothisaddress) 6.Employerphonenumber

( ) – 7.City 8.State 9.ZIPcode

10.Whocanwecontactaboutemployeehealthcoverageatthisjob?

11.Phonenumber(ifdifferentfromabove)

( ) – 12.Emailaddress

13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?

Yes(Gotoquestion13a.)13a.Iftheemployeeisnoteligibletoday,includingasaresultofawaitingorprobationaryperiod,whenistheemployeeeligiblefor

coverage? (mm/dd/yyyy)(Gotonextquestion) No(STOPandreturnthisformtoemployee)

Tellusaboutthehealth planofferedbythisemployer.Doestheemployerofferahealthplanthatcoversanemployee’sspouseordependent? Yes.Whichpeople? Spouse Dependent(s) No

(Gotoquestion14)14.Doestheemployerofferahealthplanthatmeetstheminimumvaluestandard*?

Yes(Gotoquestion15) No(STOPandreturnthisformtoemployee)15. Forthelowest-costplanthatmeetstheminimumvaluestandard*offeredonly to the employee(don’tincludefamilyplans):Ifthe

employerhaswellnessprograms,providethepremiumthattheemployeewouldpayifhe/shereceivedthemaximumdiscountforanytobaccocessationprograms,anddidn’treceiveanyotherdiscountsbasedonwellnessprograms.

a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan?$ b.Howoften? Weekly Every2weeks Twiceamonth Onceamonth Quarterly Yearly(Gotonextquestion)Iftheplanyearwillendsoonandyouknowthatthehealthplansofferedwillchange,gotoquestion16.Ifyoudon’tknow,STOPandreturnthisformtoemployee.16.Whatchangewilltheemployermakeforthenewplanyear?

Employerwon’tofferhealthcoverage Employerwillstartofferinghealthcoveragetoemployeesorchangethepremiumforthelowest-costplanthatmeetstheminimumvaluestandard*andisavailabletotheemployeeonly.(Premiumshouldreflectthediscountforwellnessprograms.Seequestion15.)

a.Howmuchwilltheemployeehavetopayinpremiumsforthatplan? $ b.Howoften? Weekly Every2weeks Twiceamonth Onceamonth Quarterly Yearly

c.Dateofchange(mm/dd/yyyy): / / *Anemployer-sponsoredhealthplanmeetsthe“minimumvaluestandard”iftheplan’sshareofthetotalallowedbenefitcostscoveredbytheplanisnolessthan60percentofsuchcosts(Section36B(c)(2)(C)(ii)oftheInternalRevenueCodeof1986).

EMPLOYER COVERAGE TOOLUsethistooltohelpanswerquestionsinyourMarketplaceapplication,AppendixA.Thatpartoftheapplicationasksaboutanyemployerhealthcoveragethatyou’reeligiblefor(evenifit’sfromanotherperson’sjob,likeaparentoraspouse).TheinformationinthenumberedboxesbelowmatchtheboxesinAppendixA.Forexample,youcanusetheanswertoquestion14onthispagetoanswerquestion14onAppendixA. Write your name and Social Security number in boxes 1 and 2 and ask the employer to fill out the rest of the form. Complete one tool for each employer that offers health coverage that you’re eligible for.

FormApprovedOMBNo.0938-1191


American Indian or Alaska Native Family Member (AI/AN)CompletethisappendixifyouorafamilymemberareAmericanIndianorAlaskaNative.SubmitthiswithyourApplicationforHealthCoverage&HelpPayingCosts.

Tell us about your American Indian or Alaska Native family member(s).AmericanIndiansandAlaskaNativescangetservicesfromtheIndianHealthServices,tribalhealthprograms,orurbanIndianhealthprograms.Theyalsomaynothavetopaycostsharingandmaygetspecialmonthlyenrollmentperiods.Answerthefollowingquestionstomakesureyourfamilygetsthemosthelppossible.

NOTE:Ifyouhavemorepeopletoinclude,makeacopyofthispageandattach.

AI/AN PERSON 1 AI/AN PERSON 2

1. Name (Firstname,Middlename,Lastname)

FirstMiddle FirstMiddle

Last Last

2. Memberofafederallyrecognizedtribe? YesIf yes,tribename

No

YesIf yes,tribename

No

3. HasthispersonevergottenaservicefromtheIndianHealthService,atribalhealthprogram,orurbanIndianhealthprogram,orthroughareferralfromoneoftheseprograms?

Yes

NoIf no,isthispersoneligibletogetservicesfromtheIndianHealthService,tribalhealthprograms,orurbanIndianhealthprograms,orthroughareferralfromoneoftheseprograms?

Yes No

Yes

NoIf no,isthispersoneligibletogetservicesfromtheIndianHealthService,tribalhealthprograms,orurbanIndianhealthprograms,orthroughareferralfromoneoftheseprograms?

Yes No

4. CertainmoneyreceivedmaynotbecountedforMedicaidortheChildren’sHealthInsuranceProgram(CHIP).Listanyincome(amountandhowoften)reportedonyourapplicationthatincludesmoneyfromthesesources:• Percapitapaymentsfromatribethat

comefromnaturalresources,usagerights,leases,orroyalties

• Paymentsfromnaturalresources,farming,ranching,fishing,leases,orroyaltiesfromlanddesignatedasIndiantrustlandbytheDepartmentofInterior(includingreservationsandformerreservations)

• Moneyfromsellingthingsthathaveculturalsignificance

$

Howoften?

$

Howoften?

APPENDIX B FormApprovedOMBNo.0938-1191


Assistance with completing this applicationYou can choose an authorized representative.Youcangiveatrustedpersonpermissiontotalkaboutthisapplicationwithus,seeyourinformation,andactforyouonmattersrelatedtothisapplication,includinggettinginformationaboutyourapplicationandsigningyourapplicationonyourbehalf.Thispersoniscalledan“authorizedrepresentative.”Ifyoueverneedtochangeyourauthorizedrepresentative,contacttheMarketplace.Ifyou’realegallyappointedrepresentativeforsomeoneonthisapplication,submitproofwiththeapplication.

1.Nameofauthorizedrepresentative(Firstname,Middlename,Lastname)

2.Address 3.Apartmentorsuitenumber

4.City 5.State 6.ZIPcode

7.Phonenumber

( ) – 8.Organizationname

9.IDnumber(ifapplicable)

Bysigning,youallowthispersontosignyourapplication,getofficialinformationaboutthisapplication,andactforyouonallfuturemattersrelatedtothisapplication.10.Yoursignature 11.Date(mm/dd/yyyy)

/ /

For certified application counselors, navigators, agents, and brokers only. Completethissectionifyou’reacertifiedapplicationcounselor,navigator,agent,orbrokerfillingoutthisapplicationfor somebodyelse.

1.Applicationstartdate(mm/dd/yyyy)

/ /2.Firstname,Middlename,Lastname,&Suffix

3.Organizationname

4.IDnumber(ifapplicable) 5.Agents/Brokersonly:NPNnumber

APPENDIX C FormApprovedOMBNo.0938-1191

EagleEyePro

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Joseph Micah Shope InsureAcare (FFM username) 1 6 3 4 4 3 5 9

EagleEyePro

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EagleEyePro

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EagleEyePro

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EagleEyePro

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EagleEyePro

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health insurance marketplace application-for-family (obamacare) from healthcare.gov

Healthcare