Fillable Application for Exemption (Maryland Health Benefit Exchange)

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Application for Exemption (Maryland Health Benefit Exchange)

On average this form takes 42 minutes to complete

The Application for Exemption (Maryland Health Benefit Exchange) form is 8 pages long and contains:

  • 1 signature
  • 6 check-boxes
  • 160 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Maryland Health Benefit Exchange

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1
Application for Exemption
Section 1: Contact Information
The person who files a federal income tax return in your household should be the contact person for this
application and is known as Person 1. If you’re applying for an exemption for a child, an adult who claims
the child on his or her federal income tax return should complete and sign the application even if the adult
doesn’t need the exemption.
First Name: _______________________________ Middle Name: ______________
Last Name: _______________________________ Suffix: ____________________
Home Address: ____________________________ Apt or Suite #: ______________
City, County, State, Zip: ________________________________________________
Mailing Address (if different): ____________________________________________
Phone Number 1: _____________________ Phone Number 2: _________________
Email Address: _______________________________________________________
Preferred spoken language? _____________________________________________
Preferred written language? _____________________________________________
Section 2: Household Information
Who to include on this application:
• The adul
t who files the federal income tax return for this household – list this person, who will be
known as Person 1, on the first line of the table.
• A spouse who is filing taxes jointly with you.
• Anyone Person 1 claims as a dependent on the federal income tax return.
2
You should apply for this exemption based on how you file taxes, with the following exception: If you’re 21
or older and included as a dependent on someone else’s tax return, submit your own exemption
application.
Who NOT to include in this application:
• A spouse who files taxes separately. Spouses who file separately must fill out a separate
exemption application for themselves and include every person they claim on their tax return.
• Anyone who lives with you but isn’t (or won’t be) listed on your tax return for the year(s) you want
this exemption.
For each person included on your federal income tax return, select the relationship to Person 1 (either
spouse or dependent).
Include the SSN for anyone who has an SSN, however an SSN is not necessary to qualify for the
exemption. We use SSNs to match exemptions with the right tax returns and to correctly match to your
coverage application. For help getting an SSN, visit socialsecurity.gov or call 800-772-1213 or TTY: 800-
325-0778.
Relationship
to Person 1
First Name MI Last Name Date of
birth
SSN Gender Want
exemption?
Yes/No
Self
3
Section 3: Hardship Information
If you are applying for catastrophic coverage for the upcoming year and are seeking an exemption based
on the affordability of marketplace or employer-based coverage rather than one of the hardships listed
below, skip this section and go to Section 4.
Select the type of hardship(s) you’re applying for below and indicate the household member who
experienced this hardship. If everyone experienced the same hardship, say All. Each person needs only
one exemption for any given time period. You may apply for more than one hardship if the hardship events
were at different times during the year. Note the date the hardship started, when it will end, or if it’s ongoing.
Type of
Hardship
Name of
person with
this hardship
or say “All”
Tax Year
Needed
Date Started
(m/d/year)
Date ended
(m/d/year)
Check if
ongoing
Homeless
Eviction/Forecl
osure
Shut-off notice
Domestic
violence
Death of family
member
Disaster
Bankruptcy
Medical
expenses
4
Increase in
expenses to
care for family
member
Medical
support for
child
Eligibility
appeals
decision
Other hardship
Section 4: Income Information
Complete Section 4 if you are seeking an affordability exemption to enroll in catastrophic coverage for the
upcoming year.
Provide the income you or any other member of your tax household expect to make from a job, self-
employment, unemployment, retirement, pensions, rental property, fishing/farming, Social Security, or
alimony. (For alimony awarded prior to 1/1/19, the receiving spouse must claim alimony as income if the
paying spouse expects to take the alimony payments as a tax deduction.)
First Name MI Last Name Total estimated yearly
income
Include with this application proof of yearly income for each type of income listed for each person on this
application. The table below lists possible documents for each type of income, but you may submit other
documents not on the list if they show the income amount you listed on your application. If you expect
your income to go up or down during the year, you can provide additional documents such as a letter
stating when contract work will end, or a self-employment ledger that includes expected income.
5
A
re you or any other individuals on this application offered health coverage from a job? (Select yes if that
coverage is from someone else’s job, such as a parent or spouse. Select yes if you are offered coverage
from a job even if you have not signed up for it.)
Yes
No
I
f yes, provide the name of each person offered health coverage from a job and provide the cost of the
premium for that person and any other family members eligible for coverage from that employer. Do not
include any premium amount that is paid by the employer.
First Name MI Last Name Cost of premium
6
Is
everyone on this application seeking an exemption based on the affordability of coverage offered
through a job?
Yes
No
If anyone on this application is seeking an exemption based on the affordability of cov
erage offered
through the marketplace, you must complete an application on the marketplace to determine the monthly
premium of the lowest cost metal level plan you can buy and your eligibility for any premium tax credit. If
you need help completing an application, please contact the Maryland Health Connection Call Center for
assistance at (855) 642-8572.
7
Section 5: Authorized Representative
You can choose an Authorized Representative to talk about this application with us, see your information,
act for you on matters related to this application, and sign this application on your behalf. If you ever need
to change or remove your Authorized Representative, contact Maryland Health Connection. If you are a
legally appointed representative, include a copy of court documents as evidence of your appointment with
this application.
Authorized Representative Name
First Name: ___________________________________________ MI: ________________
Last Name: ____________________________________________ Suffix: _____________
Address: _________________________________________________________________
Phone number: ____________________________________________________________
Organization (if applicable): ___________________________________________________
For Certified Application Counselors, Navigators, or Brokers only
Name: ___________________________________________________________________
Address: _________________________________________________________________
Organization name: _________________________________________________________
ID Number of NPN if Broker: __________________________________________________
9
Section 6: Terms of Acceptance
I understand 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 or state law if I intentionally provide false or untrue information.
I understand that under federal law, discrimination isn’t permitted on the basis of race, color,
national origin, gender, age, sexual orientation or identity, or disability. I can file a complaint of
discrimination by visiting: https://www.marylandhealthconnection.gov/policies-
accessibility/nondiscrimination-accessibility-requirements-notice/
The person known as Person 1 should sign this application. The person who signs must be an adult over
the age of 18 who files a federal income tax return for the household. If you are an Authorized
Representative, you may sign as long as Section 6 is complete.
_________________________________________________
Person 1 or Authorized Representative signature
_____________________________
Date
Section 7: Submission
Mail your signed application and copies of supporting documents (do not send originals) to:
Maryland Health Connection
PO Box 857
Lanham, MD 20703
If we need more information, we will contact you via phone or mail. Once we have processed your
application, you will receive a decision via mail. If you do not hear from us within 15 days, please call us
at (855) 642-8572 (Deaf and hard of hearing use Relay service).
If we are unable to process your application because there is missing information, we will close your case
without a decision after 90 days.
If you think we made the wrong decision on your application, you may appeal within 90 days of the
decision. For more information about the case review and appeals process, please visit
www.marylandhealthconnection.gov/appeals/.
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Application for Exemption (Maryland Health Benefit Exchange)

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Completed 28 January 2021

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