Application for for Health Coverage & Help Paying Costs

Transcription

1 Application for for Health Coverage & Help Paying Costs Use Use this this application to to see see what coverage choices qualify for e e coverage to to help stay well. A new tax credit that can immediately help pay r premiums for for coverage. Free or or low-cost insurance from Medicaid or the Children s Health Insurance Program (CHIP). Who can use this application? Use this application to apply for anyone in r family. Apply even if if or r child already has coverage. You could be be eligible for lower-cost or free coverage. If If re single, may be able to use a short form. Visit Visit HealthCare.gov. Families that include immigrants can apply. You can apply for for r r child child even even if if aren t eligible for coverage. Applying won t immigration status status or or chances of becoming a permanent resident resident or or citizen. citizen. d d to to complete Appendix C. complete Appendix C. THINGS TO KNOW THINGS TO KNOW Apply Apply faster faster online online What may What may need to apply need to apply Apply faster online at. Apply faster online at. Social Security numbers (or document numbers for any legal immigrants Social who need Security insurance). numbers (or document numbers for any legal immigrants who need insurance). Employer and income information for everyone in r family (for Employer example, and from income pay stubs, information W-2 forms, for or everyone wage and in tax r statements). family (for example, from pay stubs, W-2 forms, or wage and tax statements). Policy numbers for any current insurance. Policy numbers for any current insurance. Information any job-related insurance available to r family. Information any job-related insurance available to r family. Why do we ask for Why this do information? we ask for this information? We ask income and other information to let know what coverage We ask qualify for income and if and can other get information any help paying to let for it. know We ll keep what all coverage the information qualify and provide if can private get any and help secure, paying as for required it. We ll by keep law. all the information provide private and secure, as required by law. What happens next? us (See Step 7 What happens next? on Page 9). If don t have all the information we ask for, sign us (See and Step send 7 on r Page application 9). If anyway. don t have We ll all follow the information up with we within ask for, 2 weeks. sign and You ll send get r instructions application the anyway. next steps We ll to follow complete up with r within coverage. 2 weeks. If You ll don t get instructions hear from us, on call the next or steps to complete (after r pick coverage. a language, If press don t hear 2). Filling from out us, this call application or doesn t mean (after have to pick buy a language, coverage. press 2). Filling out this application doesn t mean have to buy coverage. Get help with this Get application help with this application Online: Online: Phone: Call us at or Phone: Call After us at pick a or language, press 2. In person: After pick a language, press 2. or call (after pick a language, press 1). In person: or call (after pick a language, press 1). Page 1 of 13 Page 1 of 13

2 STEP 1 Tell Tell us us rself (We (We need need one one adult adult in in the the family family to to be be the the contact contact person person for for r application.) 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix 2. Home 2. Home address address (Leave (Leave blank blank if if don t don t have have one.) Apartment or or suite suite number 4. City 4. City State 6. ZIP code County 8. Do 8. Do live live in in Texas? 9. Do plan to stay in Texas? Mailing address (if (if different from home address) 11. Apartment or or suite number City City 13. State 14. ZIP code 15. County Phone Phone number number ( ( ) ) Do Do want want to to get get information information this this application application by by ? ? address: address: 17. phone number 19. Preferred spoken or written language (if not English) 19. Preferred spoken or written language (if not English) STEP 2 Tell Tell us us r r family family Who do need to include on this application? Who do need to include on this application? : We need to know everyone on r tax return. : We need to know everyone on r tax return. taxes to get coverage). taxes to get coverage). DO Include: You DON T have to include: DO Include: You DON T have to include: Yourself Your unmarried partner who doesn t need Yourself Your spouse Your coverage unmarried partner who doesn t need Your Your spouse children under 21 who live with coverage Your unmarried partner s children Your Anyone children under include 21 on who r live tax with return, even if they Your unmarried partner s children Anyone don t live with include on r tax return, even if they tax return (if re over 21) don t Anyone live with else under 21 who take care of and lives tax return (if re over 21) Anyone with else under 21 who take care of and lives with The amount of assistance or type of program qualify for depends on the number of people in r family and The their amount incomes. of assistance This information type helps of program us make sure qualify everyone for depends gets the on best the coverage number they of people can. in r family and their Complete incomes. Step This 2 information each person helps in us r make family. sure everyone Start with gets rself, the best then coverage add other they adults can. and children. If Complete have more Step than 2 for two each people person in r in family, r family. ll need Start to with make rself, a copy of then add pages other and adults attach and them. children. You don t If have need more to provide than two immigration people in status r family, or a Social ll Security need to number make a (SSN) copy for of the family pages members and attach who don t them. need You don t need coverage. to provide We ll immigration keep all the information status a Social provide Security private number and (SSN) secure for as family required members by law. who We ll don t use personal need coverage. information We ll only keep to all check the if information re eligible for provide private coverage. and secure as required by law. We ll use personal information only to check if re eligible for coverage. Page 2 of 13 Page 2 of 13

3 STEP STEP 2: 2: PERSON 1 (Start with rself) Complete Complete Step Step 2 for 2 for rself, rself, r r spouse/partner spouse/partner and and children children who who live live with with and/or and/or anyone anyone on on r r same same federal federal income income tax tax return return if if with with.. 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix Relationship to to?? SELF 3. Date 3. Date of of birth birth (mm/dd/yyyy) Sex Male Female 5. Social 5. Social Security number (SSN) (SSN) We We need need this this if if want coverage and have an SSN. Providing r SSN can be helpful if don t want coverage too too since since it can it can speed up up the the application process. We use SSNs to to check income and other information to see who s eligible for help with coverage costs. If someone If wants help getting an an SSN, call or visit socialsecurity.gov. TTY users should call Do 6. Do plan plan to to file file a federal a income tax tax return NEXT YEAR? (You (You can can still still apply apply for for insurance even if if don t file a federal income tax return.) YES. YES. If yes, If yes, please please answer questions a c. a c. NO. If no, skip to question c. a. a. If yes, If yes, name name of of spouse: spouse: b. Will b. Will claim claim any any dependents dependents on on r r tax tax return? return? If yes, If yes, list list name(s) name(s) of of dependents: dependents: c. Will c. Will be be claimed claimed as as a dependent a dependent on on someone s someone s tax tax return? return? If yes, If yes, 7. Are pregnant? a. If yes, how many babies are expected during this pregnancy? 7. Are pregnant? a. If yes, how many babies are expected during this pregnancy? b. If yes, due date (mm/dd/yyyy) b. If yes, due date (mm/dd/yyyy) 8. Do need coverage? 8. Do (Even need if have insurance, coverage? there might be a program with better coverage or lower costs.) (Even if have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 4. YES. If yes, answer all the questions below. NO. Leave If the no, rest SKIP of to this the page income blank. questions on page 4. Leave the rest of this page blank. 9. Do have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily 9. Do have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? chores, etc.) or live in a medical facility or nursing home? 10. Are a U.S. citizen or U.S. national? 10. Are a U.S. citizen or U.S. national? 11. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? 11. If If yes, aren t answer a U.S. these citizen questions: or U.S. a. national, Immigration do document have eligible type immigration status? If yes, answer these questions: a. b. Immigration Document ID document number type b. c. Document Have lived ID number in the U.S. since 1996? c. Have lived in the U.S. since 1996? 12. Are, or r spouse or parent, an active-duty member of the U.S. military? 12. Are, or r spouse or parent, an active-duty member of the U.S. military? 13. Are, or r spouse or parent, a veteran of the U.S. military? 13. Are, or r spouse or parent, a veteran of the U.S. military? 14. Do want help paying for medical bills from the past 3 months? 14. Do want help paying for medical bills from the past 3 months? 15. Do live with at least one child under the age of 19, and are the main person taking care of this child? 15. Do live with at least one child under the age of 19, and are 17. Were the main in foster person care taking at age care 18 or of this older? child? 16. Are a full-time student? 17. Were If yes, in which in foster state? care at age 18 or older? 16. Are a full-time student? 18. Were in an approved Unaccompanied Refugee Minor s Resettlement If yes, in which Program state? age 18 or older? 18. Were If yes, in in which an approved state? Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? Please If yes, answer in which the state? following questions if PERSON 1 is age 22 or nger: Please 19. Did answer PERSON the 1 following have insurance questions through if PERSON a job and 1 lose is age it within 22 or the nger: past 3 months? a. If yes, end date: b. Reason the insurance ended: 19. Did PERSON 1 have insurance through a job and lose it within the past 3 months? a. If yes, end date: b. Reason the insurance ended: business closing. Change in parent s marital status. business Parent s closing. COBRA coverage ended. Private Change in parent s coverage marital ended. status. Parent s COBRA coverage ended. state ended. Private coverage ended. state ended. Page 3 of 13 Page 3 of 13

4 STEP 2: 2: PERSON 1 Current Job & Income Information Employed If re If currently employed, tell tell us us r r income. Start with with question 22.. CURRENT JOB JOB 1: 1: Employer name name and and address 23. Employer phone number ( )) Wages/tips Wages/tips (before (before taxes) taxes) Hourly Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Average Average hours hours worked worked each each WEEK WEEK CURRENT JOB 2: (If have more jobs and need more space, attach another sheet of paper.) CURRENT JOB 2: (If have more jobs and need more space, attach another sheet of paper.) 26. Employer name and address 27. Employer phone number 26. Employer name and address 27. Employer phone number ( )) 28. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice month Monthly Yearly 28. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly 29. Average hours worked each WEEK 29. Average hours worked each WEEK (Continue with rself) If Hispanic/Latino, If Hispanic/Latino, ethnicity ethnicity (OPTIONAL check (OPTIONAL check all all that that apply.) apply.) Mexican Mexican Mexican Mexican American American Chicano/a Chicano/a Puerto Puerto Rican Rican Cuban Race Race (OPTIONAL check all all that that apply.) apply.) White White Black Black or or African African American American Indian or or Alaska Native Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Asian Native Hawaiian Self-employed Skip to question In the past year, did : Change jobs Stop working Start working fewer hours ne of these 30. In the past year, did : Change jobs Stop working Start working fewer hours ne of these 31. If self-employed, answer the following questions: 31. If self-employed, answer the following questions: a. Type of work b. much net income (profits once business expenses are a. Type of work b. paid) much will net get income from this (profits self-employment once business this expenses month? are paid) will get from this self-employment this month? 32. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. 32. NOTE: OTHER You INCOME don t need to THIS tell us MONTH: child Check support, all that veteran s apply, payment, and give the or Supplemental amount and how Security often Income get (SSI). it. NOTE: You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). ne ne Unemployment Net farming/fishing Unemployment Pensions Net farming/fishing rental/royalty Pensions Social Security Net rental/royalty income Social Retirement Security accounts Type: income Retirement Alimony received accounts Type: Alimony received 33. DEDUCTIONS: Check all that apply, and give the amount and how often pay it. 33. If DEDUCTIONS: pay for certain Check things all that that can apply, be deducted and give on the a federal amount income and how tax often return, telling pay it. us them could make the cost of coverage If a little pay lower. for certain things that can be deducted on a federal income tax return, telling us them could make the cost of coverage a little NOTE: lower. You shouldn t include a cost that already considered in r answer to net self-employment (question 31b). NOTE: Alimony You shouldn t paid include a cost that already considered in r answer to deductions, net self-employment such as educator (question expenses, 31b). savings Alimony Student paid loan interest Student loan interest accounts, deductions, moving expenses, such as tuition, educator and expenses, fees savings accounts, moving expenses, tuition, and Type: fees 34. YEARLY INCOME: Complete only if r income changes from month to month. Type: 34. If YEARLY don t INCOME: expect changes Complete to r only monthly if r income, skip changes to the from next month person. to month. If Your don t total income expect this changes year to r monthly income, skip to the next Your person. total income next Your total income this year Your total income next THANKS! This is all we need to know. THANKS! This is all we need to know. Guamanian or or Chamorro Samoan t employed Skip to to question Page 4 of 13 Page 4 of 13

5 STEP 2: 2: PERSON 2 Complete Complete Step Step 2 for 2 for rself, rself, r r spouse/partner, spouse/partner, and and children children who who live live with with and/or anyone on on r r same same federal federal income income tax tax return return if if with with.. 1. First 1. First name, name, middle middle name, name, last last name, name, && suffix suffix Relationship to to?? 3. Date 3. Date of of birth birth (mm/dd/yyyy) 4. Sex Male Female 5. Social 5. Social Security number (SSN) We need this if want coverage and have an an SSN. 6. Does 6. Does PERSON 2 live 2 live at at the the same address as as? If no, If no, list list address: 7. Does 7. Does PERSON 2 plan 2 plan to to file file a a federal income tax return NEXT YEAR? (You (You can can still still apply apply for for insurance even if if don t file a federal income tax return.) YES. YES. If If yes, yes, please answer questions a c. NO. If no, skip to question c. a. a. If yes, If yes, name name of of spouse: b. Will b. Will PERSON PERSON 2 claim 2 claim any any dependents on on his his or or her her tax tax return? If yes, If yes, list list name(s) name(s) of of dependents: c. Will c. Will PERSON PERSON 2 be 2 be claimed claimed as as a a dependent dependent on on someone s someone s tax tax return? return? If yes, If yes, 8. Is PERSON 2 pregnant? 8. Is PERSON 2 pregnant? a. If yes, how many babies are expected during this pregnancy? a. If yes, how many babies are expected during this pregnancy? b. If yes, due date (mm/dd/yyyy) b. If yes, due date (mm/dd/yyyy) 9. Does PERSON 2 need coverage? 9. Does PERSON 2 need coverage? (Even if they have insurance, there might be a program with better coverage or lower costs.) (Even if they have insurance, there might be a program with better coverage or lower costs.) YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 6. YES. If yes, answer all the questions below. NO. If no, SKIP to the income questions on page 6. Leave the rest of this page blank. Leave the rest of this page blank. 10. Does PERSON 2 have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily 10. Does PERSON 2 have a physical, mental, or emotional condition that causes limitations in activities (like bathing, dressing, daily chores, etc) or live in a medical facility or nursing home? chores, etc) or live in a medical facility or nursing home? 11. Is PERSON 2 a U.S. citizen or U.S. national? 11. Is PERSON 2 a U.S. citizen or U.S. national? 12. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? 12. If aren t a U.S. citizen or U.S. national, do have eligible immigration status? If yes, please answer these questions: a. Immigration document type: If yes, please answer these questions: a. b. Immigration Document ID document number: type: b. c. Document Have lived ID number: in the U.S. since 1996? c. Have lived in the U.S. since 1996? 13. Are, or r spouse or parent, an active-duty member of the U.S. military? 13. Are, or r spouse or parent, an active-duty member of the U.S. military? 14. Are, or r spouse or parent, a veteran of the U.S. military? Are Does, PERSON or r 2 spouse want help or parent, paying a for veteran 16. of the Does U.S. PERSON military? 2 live with at least one child under 17. Was PERSON 2 in foster care at age 15. Does medical PERSON bills 2 from want the help past paying 3 months? for 16. Does the age PERSON of 19, 2 and live are with they at least the main one person child under Was or PERSON older? 2 in foster care at age medical bills from the past 3 months? the taking age care of 19, of and this are child? they the main person 18 or older? taking care of this child? If yes, in which state? 18. Was PERSON 2 in an approved Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? If yes, in which state? 18. Was If yes, PERSON in which 2 in state? an approved Unaccompanied Refugee Minor s Resettlement Program at age 18 or older? Please If yes, answer in which questions state? 19 and 20 if PERSON 2 is age 22 or nger: Please 19. Did answer PERSON questions 2 have insurance 19 and 20 through if PERSON a job 2 and is age lose 22 it within or nger: the past 3 months? 19. Did a. PERSON If yes, end 2 have date: insurance through a job and b. lose Reason it within the insurance the past 3 ended: months? a. If yes, end date: b. Reason the insurance ended: business closing. Change in parent s marital status. business Parent s COBRA closing. coverage ended. Private Change in parent s coverage marital ended. status. Parent s COBRA coverage ended. Private coverage ended. state ended. 20. Is PERSON 2 a full-time student? state ended Is PERSON If Hispanic/Latino, 2 a full-time ethnicity student? (OPTIONAL check all that apply.) 21. If Mexican Hispanic/Latino, Mexican ethnicity American (OPTIONAL check Chicano/a all Puerto that Rican apply.) Cuban 22. Mexican Race (OPTIONAL check Mexican American all that Chicano/a apply.) Puerto Rican Cuban 22. Race White (OPTIONAL check all American that apply.) Indian or Alaska Filipino Vietnamese Guamanian or Chamorro Black or African Native Japanese Asian Samoan White American American Asian Indian Indian or Alaska Filipino Vietnamese Guamanian or Chamorro Korean Native Hawaiian Black or African Native Chinese Japanese Asian Samoan American Asian Indian Korean Native Hawaiian NEED HELP WITH YOUR Chinese APPLICATION? We can help at no cost to. Call us at or Page 5 of 13 Page 5 of 13

6 STEP 2: 2: PERSON 2 Current Job Job & Income Information Employed Employed Self-employed If re If re currently employed, tell tell us us Skip to question 32. r r income. Start Start with with question t t employed Skip to to question CURRENT JOB JOB 1: 1: Employer name and and address 24. Employer phone number (( )) Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly Average hours hours worked each WEEK CURRENT JOB JOB 2: 2: (If (If have have more more jobs jobs and and need more space, attach another sheet of paper.) Employer Employer name name and and address address Employer phone phone number number (( )) Wages/tips Wages/tips (before (before taxes) taxes) Hourly Hourly Weekly Weekly Every Every 2 weeks weeks Twice Twice a month month Monthly Monthly Yearly Yearly 30. Average hours worked each WEEK 30. Average hours worked each WEEK 31. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours ne of these 31. In the past year, did PERSON 2: Change jobs Stop working Start working fewer hours ne of these 32. If self-employed, answer the following questions: 32. If self-employed, answer the following questions: a. Type of work b. much net income (profits once business expenses are a. Type of work b. paid) much will net get income from this (profits self-employment once business this expenses month? are paid) will get from this self-employment this month? 33. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. 33. OTHER INCOME THIS MONTH: Check all that apply, and give the amount and how often get it. NOTE: You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). NOTE: ne You don t need to tell us child support, veteran s payment, or Supplemental Security Income (SSI). ne Unemployment Net farming/fishing Unemployment Pensions Net Net rental/royalty farming/fishing Pensions Social Security Net rental/royalty income Social Retirement Security accounts Type: income Retirement Alimony received accounts Type: Alimony received 34. DEDUCTIONS: Check all that apply, and give the amount and how often pay it. 34. If DEDUCTIONS: PERSON 2 pays for Check certain all things that apply, that can and be give deducted the amount on a federal and how income often tax return, pay it. telling us them could make the cost of If PERSON coverage 2 a pays little for lower. certain things that can be deducted on a federal income tax return, telling us them could make the cost of coverage NOTE: You a little shouldn t lower. include a cost that already considered in r answer to net self-employment (question 32b). NOTE: Alimony You shouldn t paid include a cost that already considered in r answer to deductions, net self-employment such as educator (question expenses, 32b). savings Alimony Student paid loan interest accounts, deductions, moving expenses, such as tuition, educator and expenses, fees savings Student loan interest accounts, moving expenses, tuition, and fees 35. YEARLY INCOME: Complete only if PERSON 2 s income changes from month to month. 35. If YEARLY don t expect INCOME: changes Complete to PERSON only 2 s if monthly PERSON income, 2 s income skip to changes the next from section. month to month. If PERSON don t 2 s expect total income changes this to PERSON year 2 s monthly income, skip to the next PERSON section. 2 s total income next year PERSON 2 s total income this year PERSON 2 s total income next year THANKS! This is all we need to know PERSON 2. THANKS! This is all we need to know PERSON 2. If have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete. If have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete. Page 6 of 13 Page 6 of 13

7 STEP 3 Things Things Everyone Pays for or Owns 1. VEHICLES: 1. VEHICLES: We We need need to to know know all all vehicles vehicles everyone, everyone, including including tax tax dependents, dependents, pays pays for for or or owns, owns, such such as as a: a: car car truck truck boat boat motorcycle motorcycle other other Does Does anyone anyone pay pay for for or or own own a vehicle? a vehicle? If yes, If yes, give give the the facts: facts: Vehicle Vehicle 1: 1: Name Name of of owner: owner: Make Make / model: / model: Year: Year: Name Name of of co-owner: Money still still owed owed on on vehicle: Is the Is the vehicle used used for for a a person with a a disability? Vehicle 2: 2: Name Name of of owner: Make Make / model: / Year: Year: Name Name of of co-owner: Money Money still still owed owed on on vehicle: Is the Is the vehicle vehicle used used for for a a person person with with a a disability? Vehicle Vehicle 3: 3: Name Name of of owner: owner: Make Make / model: / model: Year: Year: Name of co-owner: Name of co-owner: Money still owed on vehicle: Money still owed on vehicle: Is the vehicle used for a person with a disability? Is the vehicle used for a person with a disability? If need to list more than 3 vehicles, add more pages with the same facts. If need to list more than 3 vehicles, add more pages with the same facts. 2. ITEMS EVERYONE PAYS FOR OR OWNS: We need to know items everyone, including tax dependents, pays 2. ITEMS EVERYONE PAYS FOR OR OWNS: We need to know items everyone, including tax dependents, pays for or owns, such as: cash bank accounts homes or other property insurance policies stocks for or owns, such as: cash bank accounts homes or other property insurance policies stocks Does anyone pay for or own these types of items? Does anyone pay for or own these types of items? If yes, give the facts: If yes, give the facts: Item 1: Item 1: Item: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names Name on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): Item 2: Item Item: 2: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): Item 3: Item Item: 3: Item: Account number: Account Value: number: Value: Names on account or deeds (include co-owners): Names Name on and account address or of deeds bank (include or business co-owners): (to contact the item): Name and address of bank or business (to contact the item): If need to list more than 3 items, add more pages with the same facts. If need to list more than 3 items, add more pages with the same facts. Page 7 of 13 Page 7 of 13

8 STEP Are Are or or is is anyone in in r family American Indian or Alaska Native? If, If, skip skip to to Step Step If If yes, yes, go go to to Appendix B. B. STEP 5 American Indian or Alaska Native (AI/AN) family member(s) Your Family s Health Coverage Answer these questions for for anyone who needs coverage. 1. Is 1. anyone Is enrolled in in coverage now from the following? YES. YES. If yes, If yes, check the the type type of of coverage and write the person(s ) name(s) next to the coverage they have. NO. Medicaid Employer insurance Which Which state? state? Name of insurance: Date Date coverage ends ends (if (if not not ending, write write t t ending ) Policy number: Coverage start date: CHIP CHIP Coverage end date: Which state? pay each month to cover r child(ren) on this Which state? Amount pay each month to cover r child(ren) on this Date coverage ends (if not ending, write t ending ) insurance? Date coverage ends (if not ending, write t ending ) insurance? Who Who pays pays the the premium? premium? Is this COBRA coverage? Medicare Is this COBRA coverage? Medicare Is this retiree plan? TRICARE (Don t check if have direct care or Line of Duty) Is this a retiree plan? TRICARE (Don t check if have direct care or Line of Duty) Name of insurance: Name of insurance: VA care programs Policy number: VA care programs Policy number: Peace Corps Peace Corps 2. Check yes even if the coverage is from someone else s job, 2. such as a parent or spouse. Check yes even if the coverage is from someone else s job, such as a parent or spouse. YES. If yes, ll need to complete and include Appendix A. Is this a state employee benefit plan? YES. If yes, ll need to complete and include Appendix A. Is this a state employee benefit plan? NO. If no, continue to Step 6. NO. If no, continue to Step 6. These questions will not be used to decide if r family can g These 1. Is questions a child in r will home not be in the used Children to decide with Special if r Health family Care can Needs g program? 1. Is a If child yes, who? in r home in the Children with Special Health Care Needs program? If 2. yes, who? 2. If yes, who? If yes, who? Signing up to vote Signing up to vote Applying to register or declining to register to vote will not s agency. Applying to register or declining to register to vote will not s agency. If are not registered to vote where live now, would like to apply to register to vote here today? If IF YOU are DO not NOT registered CHECK EITHER to vote BOX, where YOU WILL live BE now, CONSIDERED would TO HAVE like to DECIDED apply to NOT register TO REGISTER to vote TO here VOTE today? AT THIS TIME. IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED lication form, we TO will HAVE help. DECIDED The decision NOT whether TO REGISTER to seek oto VOTE AT THIS TIME. application form in private. If believe that someone has interfered with r right to register or to decline to register to vote, or r right to choose r own political lication form, we will help. The decision whether to seek o th the Elections Division, Secretary of State, PO Box 12060, Austin, TX Phone: application form in private. If believe that someone has interfered with r right to register or to decline to register to vote, or r right to choose r own political th the Elections Division, Secretary of State, PO Box 12060, Austin, TX Phone: Agency Use Only: Voter Registration Status Agency Already Use Only: registered Voter Registration Client declined StatusAgency transmitted Client to mail Mailed to client Already registered Client declined Agency transmitted Client to mail Mailed to client Agency staff signature: Agency staff signature: Page 8 of 13 Page 8 of 13

9 STEP 6 Read Read & sign this application I m I m signing signing this this application application under under penalty penalty of of perjury perjury which which means I ve provided true true answers answers to to all all the the questions questions on on this this form form to to the the best best of of my my knowledge. knowledge. I I know know that that I I may may be be subject to to penalties under federal law law if if I I provide provide false false or or untrue untrue information. information. what what I wrote I wrote on on this this application. To To report changes, I I can go to or call or or I I I know I know that that under federal law, law, discrimination isn t permitted on the basis of race, color, national origin, sex, age, sexual.. is is incarcerated. (name of of person) We We need need this this information to to check r eligibility for help paying for coverage if choose to apply. We ll check r answers using using information in in our our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the the Department of of Homeland Security, and/or a consumer reporting agency. If the information doesn t match, we we may ask ask to to send send us us proof. proof. Renewal of of coverage in in future years To To make make it easier it easier to to determine my my eligibility for for help paying for coverage in future years, I I agree to to allow the the agency to to use use income income data, data, including including information from from tax tax returns. The agency will send me a notice, let let me me make any any changes, and and I can I can opt opt out out at at any any time. time.,, renew renew my my eligibility eligibility automatically automatically for for the the next next 5 years 5 years (the (the maximum maximum number number of of years years allowed), allowed), or or for for a shorter shorter number number of of years: years: 4 years 3 years 2 years 1 year Don t use information from tax returns to renew my coverage. 4 years 3 years 2 years 1 year Don t use information from tax returns to renew my coverage. If anyone on this application is eligible for Medicaid If anyone on this application is eligible for Medicaid I am giving to HHSC the rights to pursue and get any money from other insurance, legal settlements, or other third I am giving to HHSC the rights to pursue and get any money from other insurance, legal settlements, or other third parties. I am also giving to HHSC rights to pursue and get medical support. parties. I am also giving to HHSC rights to pursue and get medical support. I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, can tell HHSC and I may not have to cooperate. cooperating to collect medical support will harm me or my children, I can tell HHSC and I may not have to cooperate. Does any child on this application have a parent living outside of the home? Does any child on this application have a parent living outside of the home? If yes, tell us the parent living outside of the home: If yes, tell us the parent living outside of the home: First and last name Birth date (mm/dd/yyyy) First and last name Birth date (mm/dd/yyyy) Social Security number Phone Social Security number Phone Mailing address Employer Mailing address Employer City, State, ZIP City, State, ZIP My right to appeal My right to appeal If I think HHSC has made a mistake, I can appeal its decision. To appeal means to tell someone at HHSC that I think the action is If I think HHSC has made a mistake, I can appeal its decision. To appeal means to tell someone at HHSC that I think or the action is (after pick a language, press 2). I know that I can be represented in the process by someone other or than myself. My eligibility (after and pick other a important language, information press 2). I know will be that explained I can be to represented me. in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application Sign this application as long as have provided the information required in Appendix C. as Signature long as have provided the information required in Appendix C. Date (mm/dd/yyyy) Signature Date (mm/dd/yyyy) STEP 7 STEP 7 Fax: Mail: HHSC Fax: If r form is 2-sided, fax both sides. Mail: HHSC PO Box If r form is 2-sided, fax both sides. PO Midland, Box Texas Midland, Texas Page 9 of 13 Page 9 of 13

10 APPENDIX A Health Coverage from Jobs You You DON T DON T need need to to answer answer these these questions questions unless unless someone in the household is is eligible eligible for for coverage coverage from from a a job. job. Attach Attach a a copy copy of of this this page page for for each each job job that that offers coverage. Tell Tell us us the the job job that that offers coverage. Take Take the the Employer Coverage Tool on on the next page to the employer who offers coverage to to help help answer these these questions. You You only only need need to to include this page when send in r application, not the Employer Coverage Tool. Tool. EMPLOYEE Information Employee name (First, Middle, Last) Employee Social Security number EMPLOYER Information Employer name Employer Identification Number (EIN) (EIN) Employer address Employer phone number City City State ZIP ZIP code code Who Who can can we we contact contact employee employee coverage coverage at at this this job? job? 11. Phone number (if different from above) 11. Phone number (if different from above) 12. address 12. address 13. A 13. A (Continue) (Continue) 13a. If re in a waiting or probationary period, when can enroll in coverage? 13a. If re in a waiting or probationary period, when can enroll in coverage? List the names of anyone else who is eligible for coverage from this job. List the names of anyone else who is eligible for coverage from this job. (mm/dd/yyyy) (mm/dd/yyyy) Name: Name: Name: Name: Name: Name: (Stop here and go to Step 5 in the application) (Stop here and go to Step 5 in the application) Tell us the plan offered by this employer. Tell us the plan offered by this employer. 15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don t include family plans): 15. For If the employer lowest-cost has plan wellness that meets programs, the minimum provide the value premium standard* that the offered employee only to would the employee pay if he/ she (don t received include the family maximum plans): discount for any tobacco If cessation the employer programs, has wellness and did programs, not receive provide any other the discounts premium based that the on employee wellness programs. would pay if he/ she received the maximum discount for any tobacco cessation a. programs, much would and the did employee not receive have any to other pay in discounts premiums based for this on plan? wellness programs. a. b. much would Weekly the employee Every have 2 weeks to pay in premiums Twice a month for this plan? Once a month Quarterly Yearly b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly 16. What change will the employer make for the new plan year (if known)? 16. What Employer change will won t the offer employer coverage make for the new plan year (if known)? Employer won t will start offer offering coverage coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) Employer will start offering coverage to employees or change the premium for the lowest-cost plan available only to the a. employee much that will meets the employee the minimum have to value pay in standard.* premiums (Premium for that plan? should reflect the discount for wellness programs. See question 15.) a. b. much will the Weekly employee Every have 2 to weeks pay in premiums Twice a for month that plan? Once a month Quarterly Yearly b. Date of change (mm/dd/yyyy): Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy): * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Page 10 of 13 Page 10 of 13

11 EMPLOYER COVERAGE TOOL Use Use this this tool tool to to help help answer answer questions questions in in Appendix Appendix A any any employer employer coverage coverage that that re re eligible eligible for for (even (even if if it s it s from from another another person s person s job, job, like like a parent a parent or or spouse). spouse). The The information information in in the the numbered boxes below match the the boxes boxes on on Appendix Appendix A. A. For For example, example, the the answer answer to to question question on on this this page page should should match match question on on Appendix A. Write Write r r name name and and Social Social Security Security number in in boxes 1 and and 2 and ask the employer to fill out the rest of of the the form. form. Complete one one tool tool for for each each employer employer that that offers offers coverage. EMPLOYEE Information The The employee needs to to fill fill out this section. 1. Employee 1. name name (First, (First, Middle, Last) Last) 2. Social Security Number EMPLOYER Information Ask Ask the the employer for for this information. 3. Employer 3. name name 4. Employer Identification Number (EIN) Employer 5. Employer address address (HHSC (HHSC will will send send notices to to this this address) 6. Employer phone number 7. City 7. City State ZIP ZIP code code Who Who can can we we contact contact employee employee coverage coverage at at this this job? job? 11. Phone number (if different from above) 11. Phone number (if different from above) 12. address 12. address 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? 13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months? (Continue) (Continue) 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? 13a. If the employee is not eligible today, including as a result of a waiting or probationary period, when is the employee eligible for coverage? (mm/dd/yyyy) (Continue) (mm/dd/yyyy) (Continue) (STOP and return this form to employee) (STOP and return this form to employee) Tell us the plan Tell us the plan. Which people? Spouse Dependent(s). Which people? (Go to question 14) Spouse Dependent(s) (Go to question 14) employer. employer. (Go to question 15) (STOP and return form to employee) 15. (Go to question 15) (STOP and return form to employee) only to the employee (don t include family plans): If the employer has wellness 15. programs, provide the premium that the employee would pay if he/ she received only to the maximum employee discount (don t include for any family tobacco plans): cessation If the programs, employer and has didn t wellness programs, receive any provide other the discounts premium based that on the wellness employee programs. would pay if he/ she received the maximum discount for any tobacco cessation programs, and didn t receive a. any other much discounts would the based employee on wellness have to programs. pay in premiums for this plan? a. b. much would Weekly the employee Every have 2 weeks to pay in premiums Twice a month for this plan? Once a month Quarterly Yearly b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly If the plan year will end soon and know that the plans offered will change, go to question 16. If don t know, STOP and return form to employee. If the 16. plan What year change will end will the soon employer and make know for that the the new plan year? plans offered will change, go to question 16. If don t know, STOP and return form to employee. 16. What Employer change will won t the offer employer make coverage for the new plan year? Employer Employer won t will offer start offering coverage coverage to employees or change the premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs. See question 15.) Employer will start offering coverage to employees or change the premium for the lowest-cost plan available only to the a. employee much that will meets the employee the minimum have value to pay standard.* in premiums (Premium for that should plan? reflect the discount for wellness programs. See question 15.) a. b. much will the Weekly employee Every have to 2 weeks pay in premiums Twice a for month that plan? Once a month Quarterly Yearly Date of change (mm/dd/yyyy): b. Weekly Every 2 weeks Twice a month Once a month Quarterly Yearly Date of change (mm/dd/yyyy): * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) * An employer-sponsored plan meets the minimum value standard if the plan s share of the total allowed benefit costs covered by the plan is no less than 60 percent of such costs (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986) Page 11 of 13 Page 11 of 13

12 APPENDIX B American Indian or or Alaska Native Family Member (AI/AN) Complete Complete this this appendix appendix if if or or a a family family member member are are American Indian or Alaska Native. Submit this this with with r r application. application. Tell Tell us us r r American Indian or or Alaska Native family member(s). American Indians Indians and and Alaska Alaska Natives can can get get services from the Indian Health Services, tribal programs, or or urban Indian programs. They They also also may may not not have to to pay cost sharing and may get special monthly enrollment periods. Answer the the following questions to to make sure sure r family gets the most help possible. NOTE: If If have have more people to to include, make a copy of this page and attach. 1. Name 1. Name (First (First name, Middle name, Last Last name) AI/AN PERSON 1 AI/AN PERSON 22 First Middle First Middle Last Last 2. Member 2. Member of of a federally a recognized tribe? tribe? If If yes, tribe name If If yes, tribe name 3. Has this person ever gotten a service from the 3. Has this person ever gotten a service from the Indian Health Service, a tribal program, Indian Health Service, a tribal program, or urban Indian program, or through a or urban Indian program, or through a referral from one of these programs? referral from one of these programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health Service, services from the Indian Health Service, tribal programs, or urban Indian tribal programs, programs, or through or urban referral Indian from one programs, of these or programs? through a referral from one of these programs? If no, is this person eligible to get If no, is this person eligible to get services from the Indian Health Service, services from the Indian Health Service, tribal programs, or urban Indian tribal programs, programs, or through or urban a referral Indian from one programs, of these programs? or through a referral from one of these programs? 4. Certain money received may not be counted 4. Certain for Medicaid money or received the Children s may not Health be counted Insurance for Program Medicaid (CHIP). or the List Children s any income Health (amount Insurance and Program how often) (CHIP). reported List any on income r application (amount and that how includes often) money reported from on these r application sources: that includes Per money capita payments from these from sources: a tribe that Per come capita from payments natural from resources, a tribe usage that rights, come leases, from or natural royaltiesresources, usage rights, leases, Payments or royalties from natural resources, farming, Payments from natural resources, farming, land designated as Indian trust land by land the designated Department as of Indian Interior trust (including land by the reservations Department and of former Interior reservations) (including reservations Money from and selling former things reservations) that have Money from selling things that have Page 12 of 13 Page 12 of 13

13 APPENDIX C Assistance with Completing this Application You You can can choose an an authorized representative. You You can can give give a trusted a person permission to to talk talk this application with us, see r information, and act act for for on on matters matters related to to this this application, including getting information r application and signing r application on on r r behalf. This This person is is called an an authorized representative. If ever need to change r authorized representative, contact HHSC. If If re a a legally appointed representative for someone on this application, submit proof proof with with the the application. 1. Name 1. Name of of authorized representative (First name, middle name, last name) 2. Address Apartment or suite number 4. City 4. City State 6. ZIP code 7. Phone 7. Phone number number ( ( ) ) 8. Organization 8. Organization name name Organization Organization ID ID number number (if (if applicable) applicable) By signing, allow this person to sign r application, get official information this application, By signing, allow this person to sign r application, get official information this application, and act for on all future matters with this agency. and act for on all future matters with this agency. 10. Your signature 11. Date (mm/dd/yyyy) 10. Your signature 11. Date (mm/dd/yyyy) For certified application counselors, navigators, agents, and brokers only. For certified application counselors, navigators, agents, and brokers only. Complete this section if re a certified application counselor, navigator, agent, or broker filling out this application Complete for somebody this section else. if re a certified application counselor, navigator, agent, or broker filling out this application for somebody else. 1. Application start date (mm/dd/yyyy) 1. Application start date (mm/dd/yyyy) 2. First name, middle name, last name, & suffix 2. First name, middle name, last name, & suffix 3. Organization name 4. Organization ID number (if applicable) 3. Organization name 4. Organization ID number (if applicable) Page 13 of 13 Page 13 of 13