Fillable individual-short-form Application for Health Coverage & Help Paying Costs (Short Form)

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individual-short-form Application for Health Coverage & Help Paying Costs (Short Form)

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Country of origin: US
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Application for Health Coverage & Help Paying Costs
(Short Form)
Apply faster online at HealthCare.gov
Use this application
to see what coverage
you qualify for
• Aordable private health insurance plans that oer comprehensive coverage to
help you stay well.
• A tax credit that can immediately help pay your premiums for health coverage.
• Free or low-cost coverage from Medicaid or the Children’s Health Insurance
Program (CHIP).
Who can use this
application?
Single adults who:
• Aren’t oered health coverage from their employer
• Don’t have any dependents and can’t be claimed as a dependent on someone
else’s tax return
NOTE: If any of the following apply, you need to ll out a dierent form to make
sure you get the most benets possible:
• You’re married or have dependent children.
• You were in the foster care system, and you’re under age 26.
• You have items that can be deducted from your income. If your only deduction
is student loan interest, you can use this form.
• You’re American Indian or Alaska Native.
What you may
need to apply
• Your Social Security number (or document number if you’re an eligible
immigrant)
• Employer and income information (for example, from paystubs, W-2 forms, or
wage and tax statements)
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, go to HealthCare.gov.
What happens
next?
Send your complete, signed application to the address on page 3. 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 receive a
call from the Marketplace if we need more information. You’ll get an eligibility
determination letter in the mail after your application is processed. 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 should
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 the information in this product in an alternate format.
You also have the right to file a complaint if you feel you’ve been discriminated
against. Visit
www.cms.gov/about-cms/agency-Information/aboutwebsite/
cmsnondiscriminationnotice.html
, or call the Marketplace Call Center at
1-800-318-2596 for more information. TTY users should call 1-855-889-4325.
10/2018
Form Approved
OMB No. 0938-1213
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 15 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.
(You must be 18 or older to submit this application. If you have an Authorized Representative, that person may submit the application for you
as long as you sign Appendix C.)
1. First name Middle name Last name Suffix
Home address (Leave blank if you don’t have one.)
3. Apartment or suite number
2.
4. City 5. State 6. ZIP code 7. County, parish, or township
8. Mailing address (if different from home address) 9. Apartment or suite number
10. City 11. State 12. ZIP code 13. County, parish, or township
15. 14. Daytime phone number Evening phone number
16. Do you want to get information about this application by email?
.......................................................................................................
Yes
No
Email address:
17. What’s your preferred spoken language? What’s your preferred written language?
18. Date of birth (mm/dd/yyyy) 19. Sex
Male
Female
20. Social Security Number (SSN)
We need a Social Security number (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. If you need help getting an SSN, visit socialsecurity.gov, or call
Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778.
STEP 1: Tell us about yourself.
Please print in capital letters using black or dark blue ink only.
Fill in the circles (
) like this
.
21. Are you a U.S. citizen or U.S. national? ...............................................................................................................................................................................
Yes
No
22. 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 23.
a. Alien number:
b. Certicate number:
After you complete a and b,
SKIP to question 24.
23. 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.
See 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)
24. Are you pregnant? .....................................................................................
Yes
No
a. If yes, how many babies are expected during this pregnancy?
25. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily
chores, etc.) or live in a medical facility or nursing home? ......................................................................................................................................................
Yes
No
Optional:
(Fill in all that
apply.)
26. If Hispanic/Latino, ethnicity:
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other
27. Race:
White
Black or African American
American Indian or Alaska Native
Filipino
Japanese
Korean
Asian Indian
Chinese
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 should call 1-855-889-4325.
Page 1 of 4
STEP 2: Current job & income information
Employed: If you’re currently employed, tell us
about your income. Start with question 1..
Not employed:
Skip to question 11.
Self-employed:
Skip to question 10.
Current job 1:
1. Employer name
a. Employer address
b. City c. State d. ZIP code 2. Employer phone number
3. Wages/tips (before taxes)
$
Hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
4. Average hours worked each WEEK
Current job 2:
(If you have additional jobs and need more space, attach another sheet of paper.)
5. Employer name
a. Employer address
b. City c. State d. ZIP code 6. Employer phone number
7. Wages/tips (before taxes)
$
Hourly
Weekly
Every 2 weeks
Twice a month
Monthly
Yearly
8. Average hours worked each WEEK
9. In the past year, did you:
Change jobs
Stop working
Start working fewer hours
None of these
10. 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.
$
11. 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
$
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?
12. Do you pay student loan interest (not the amount of the loan) that can be deducted on a federal income tax return?
YES. If yes, how much
$
How often?
NO.
13. 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 Step 3.
Your total income this year
$
Your total income next year (if you think it will be different)
$
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.
Page 2 of 4
STEP 3: Your health coverage
Are you enrolled in health coverage now from the following? ..............................................................................................................................
Yes
No
(If you have access to health coverage through a job, complete the Family Application and ll out Appendix A.)
If yes, check which coverage you have.
Medicaid
CHIP
Medicare
TRICARE
VA health care program
Peace Corps
Other:
Name of health insurance company
Fill in if this is Marketplace Health Coverage.
Policy/ID number
For every year that you got a premium tax credit, did you le a tax return and reconcile any premium tax credit you used?
YES, premium tax credits were reconciled. Fill in the circle only if ALL of these apply to you:
• You used advance payments of premium tax credits (APTC) in one or more past years to help lower your costs for Marketplace coverage.
• You led a federal income tax return for each of these years.
• The tax ler(s) submitted IRS Form 8962 (healthcare.gov/help/reconciling-your-tax-credit/) with the tax return.
Were you found not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in the past 90 days?
(Select yes only if you were not found not eligible for this coverage by your state, not by the Marketplace) ........................................................................
Yes
No
Date:
Or, were you found not eligible for Medicaid or CHIP due to your immigration status in the last 4 years? ...................................................
Yes
No
Did you apply for coverage during the Marketplace Open Enrollment Period? ..................................................................................................
Yes
No
Page 3 of 4
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.
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
If you want to register to vote, you can complete a
voter registration form at www.eac.gov.
Page 4 of 4
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.
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. The Marketplace will check to make sure you’re still
eligible, and may have to ask you to prove that your income still qualies. You can opt out at any time.
If no, automatically update my information for the next:
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.)
If I’m eligible for Medicaid: I’m giving to the Medicaid agency my 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.
• 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 dierent than) what I wrote on this
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 aect
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 le a complaint of discrimination by visiting www.hhs.gov/ocr/oce/le.
• 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 proof.
What should I do if I think my eligibility results are wrong?
If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to nd appeals
instructions specic 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 should 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, 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 who lled out Step 1 should sign this application. If you’re an authorized representative, you may sign here as long as you’ve provided
the information required in Appendix C.
Signature
Date signed (mm/dd/yyyy)
If you’re signing this application outside of Open Enrollment (between November 1 and December 15), make sure you review Appendix D
(“Questions about life changes”).
STEP 4: Your agreement & signature
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.
1. Name of authorized representative (First name, Middle name, Last name)
2. Address 3. Apartment or suite number
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 ocial 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)
Appendix C
Assistance with completing this application
For certified application counselors, navigators, agents, and brokers only
Complete this section if you’re a certied application counselor, navigator, agent, or broker lling 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.
Form Approved
OMB No. 0938-1191
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.
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 in the past 60 days, ll out the following questions. Certain life changes allow
your coverage through the Marketplace to start right away. We also recommend you answer these questions if you’re applying after the annual
Open Enrollment Period ends and before the next annual Open Enrollment Period starts.
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?
Names
Check here if coverage ended because not paying premiums.
Date coverage ended or will end (mm/dd/yyyy)
2. Did anyone get married in the last 60 days?
Names
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:
Names
3. Did anyone get released from incarceration (detention or jail) in the last 60 days?
Names
Date (mm/dd/yyyy)
4. Did anyone gain eligible immigration status in the last 60 days?
Names
Date (mm/dd/yyyy)
5. Was anyone adopted, placed for adoption, or placed for foster care in the last 60 days?
Names
Date (mm/dd/yyyy)
6. Did anyone become a dependent due to a child support or other court order in the last 60 days?
Names
Date (mm/dd/yyyy)
7. Did anyone change their primary place of living in the last 60 days?
Names
Date of move (mm/dd/yyyy)
What is the zip code of your previous address?
Fill in here if you moved from a foreign country or U.S. Territory
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:
Names
Appendix D
Form Approved
OMB No. 0938-1191
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individual-short-form Application for Health Coverage & Help Paying Costs (Short Form)

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Completed 5 October 2019

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