Application for Health Coverage & Help Paying Costs

Transcription

1 Application for Health Coverage & Help Paying Costs Use this application to see what coverage you qualify for 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). THINGS TO KNOW Who can use this application? Apply faster online HealthCare.gov HealthCare.gov What you may need to apply Why do we ask for this information? What happens next? We ll keep all the information you provide private and secure, as required by law. HealthCare.gov If you don t have all the information we ask for, sign and submit your application anyway. HealthCare.gov Get help with this Online: HealthCare.gov application Phone: In person: HealthCare.gov En Español:

2 Initial here: Use blue or black ink to complete this application. Page 1 of 7 STEP 1 Tell us about yourself. STEP 2 Tell us about your family. Who do you need to include on this application? DO Include: You DON T have to include: Complete Step 2 for each person in your family.

3 STEP 2: PERSON 1 (Start with yourself) Initial here: Page 2 of 7 SELF YES. If yes, NO. If no, If yes, If yes, If yes, If yes, We need this if you want health coverage and have an SSN. socialsecurity.gov. 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.) Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.) YES. If yes NO. If no, If you aren t a U.S. citizen or U.S. national, (See instructions.) If Hispanic/Latino, ethnicity (OPTIONAL check all that apply.) Race (OPTIONAL check all that apply.)

4 STEP 2: PERSON 1 Current job & income information (Continue with yourself) Employed: CURRENT JOB 1: Not employed: Self employed: Initial here: Page 3 of 7 CURRENT JOB 2: In the past year, did you: If self employed, answer the following questions: (See instructions.) OTHER INCOME THIS MONTH: NOTE: DEDUCTIONS: NOTE: 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. this year next THANKS! This is all we need to know about you.

5 STEP 2: PERSON 2 If you have more than two people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete. Initial here: Page 4 of 7 (See instructions.) If no, YES. If yes, If yes, We need this if you want health coverage for PERSON 2 and PERSON 2 has an SSN. 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.) If yes, If yes, If yes, NO. If no, 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 NO. If no, If PERSON 2 isn t a U.S. citizen or U.S. national, (See instructions.) Please answer the following questions if PERSON 2 is 22 or younger: If yes If Hispanic/Latino, ethnicity (OPTIONAL check all that apply.) Race (OPTIONAL check all that apply.) Now, tell us about any income from PERSON 2 on the back.

6 STEP 2: PERSON 2 Current job & income information Employed: CURRENT JOB 1: Not employed: Self employed: Initial here: Page 5 of 7 CURRENT JOB 2: In the past year, did PERSON 2: If PERSON 2 is self employed, answer the following questions: (See instructions.) OTHER INCOME THIS MONTH: NOTE: DEDUCTIONS: NOTE: 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. this year next THANKS! This is all we need to know about PERSON 2.

7 STEP 3 Initial here: Page 6 of 7 American Indian or Alaska Native (AI/AN) family member(s) Are you or is anyone in your family American Indian or Alaska Native? NO. If no, YES. If yes, STEP 4 Your family s health coverage Is anyone enrolled in health coverage now from the following? YES. If yes NO. Is anyone listed on this application offered health coverage from a job? YES. If yes, NO. If no, continue to Step 5. STEP 5 Read & sign this application. HealthCare.gov

8 STEP 5 (Continued) Initial here: Page 7 of 7 Renewal of coverage in future years If anyone on this application is eligible for Medicaid What should I do if I think my eligibility results are wrong? HealthCare.gov/marketplace/individual Health Insurance Marketplace Sign this application. STEP 6 Mail completed application. Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd. London, KY usa.gov PRA Disclosure Statement

9 APPENDIX A Health Coverage from Jobs DON T Tell us about the job that offers coverage. Employee information Employer information Yes If you re in a waiting or probationary period, when can you enroll in coverage? No only to the employee

10 EMPLOYER COVERAGE TOOL EMPLOYEE information employee EMPLOYER information employer Yes No health plan employer only to the employee

11 APPENDIX B American Indian or Alaska Native Family Member (AI/AN) Tell us about your American Indian or Alaska Native family member(s). NOTE: AI/AN PERSON 1 AI/AN PERSON 2 If yes If yes If no If no

12 APPENDIX C Assistance with completing this application You can choose an authorized representative. Garth Hassel Garth Hassel g h a s s e l