HTML Preview Marketplace Application For Family page number 1.
Application for Health Coverage & Help Paying Costs
Apply faster online at HealthCare.gov
Use this application
to see what coverage
you qualify for
• Aordable private health insurance plans that oer comprehensive coverage to
help you stay well.
• A new 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).
You may qualify for a free or low-cost program, even if you earn as much as
$98,400 a year (for a family of 4).
Who can use this
application?
• Use this application to apply for anyone in your family.
• Apply even if you or your child already has health coverage. You could
be eligible for lower-cost or free coverage.
• If you’re single, you may be able to use a short form. Visit HealthCare.gov.
• Families that include immigrants can apply. You can apply for your child even if
you aren’t eligible for coverage. Applying won’t aect your immigration status
or chances of becoming a permanent resident or citizen.
• If someone is helping you ll out this application, you may need to complete
Appendix C.
What you may
need to apply
• Social Security Numbers (or document numbers for any eligible immigrants
who need coverage).
• Employer and income information for everyone in your family (for example,
from pay stubs, W-2 forms, or wage and tax statements).
• Policy numbers for any current health insurance.
• Information about any job-related health insurance available to your family.
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, visit HealthCare.gov or see instructions.
What happens
next?
Send your complete, signed application to the address on page 7. 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. If you don’t
hear from us, contact the Marketplace Call Center. 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.
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 45 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.
09/2017
Form Approved
OMB No. 0938-1213