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Application for Health Coverage & Help Paying Costs (Family)

Application for Health Coverage & Help Paying Costs (Family)

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Published by marketplaceapm
Newly released shortened draft application for health insurance and financial assistance for families under the Affordable Care Act.
Newly released shortened draft application for health insurance and financial assistance for families under the Affordable Care Act.

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Published by: marketplaceapm on Apr 30, 2013
Copyright:Attribution Non-commercial

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01/22/2014

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NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.
Application for Health Coverage & Help Paying Costs
   w   o   k   n   o   t   h   i   n   g   s   t
 
Use this applicationto see whatcoverage choicesyou qualify for 
Affordable private health insurance plans that offer comprehensivecoverage to help you stay ellA ne tax credit that can immediately help pay your premiums forhealth coverageFree or lo-cost insurance from Medicaid or the Children’s ealthnsurance Program (CP)
You may qualify for a free or low-cost program even if you earn asmuch as $94,000 a year (for a family of 4).
Who can use thisapplication?
Use this application to apply for anyone in your family.Apply even if you or your child already has health coverage. Youcould be eligible for loer-cost or free coverage.f 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 yourchild even if you aren’t eligible for coverage. Applying on’t affectyour immigration status or chances of becoming a permanentresident or citizen.f someone is helping you ll out this application, you may need tocomplete Appendix C.
Apply fasteronline
Apply faster online at
HealthCare.gov
.
What you mayneed to apply
ocial ecurity umbers (or document numbers for any legalimmigrants ho need insurance)Employer and income information for everyone in your family (forexample, from paystubs, w-2 forms, or age and tax statements)Policy numbers for any current health insurancenformation about any job-related health insurance available to yourfamily 
Why do we ask forthis information?
we ask about income and other information to let you kno hatcoverage you qualify for and if you can get any help paying for it.
We’llkeep all the information you provide private and secure, as requiredby law.
 end your complete, signed application to the address on page 7.
If you don’t have all the information we ask for, sign and submityour application anyway.
we’ll follo-up ith you ithin 1–2 eeks.You’ll get instructions on the next steps to complete your healthcoverage. f you don’t hear from us, visit
HealthCare.gov
or call
1-800-XXX-XXXX
. Filling out this application doesn’t mean you haveto buy health coverage.
What happensnext?Get help with thisapplication
Online:HealthCare.gov
Phone:
Call our elp Center at
1-800-XXX-XXXX.
In person:
here may be counselors in your area ho can help.Visit our ebsite or call
1-800-XXX-XXXX
for more information.
En Español:
Llame a nuestro centro de ayuda gratis al
1-800-XXX-XXXX.
 
 
Page 1 of 7
NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.
STEP 1
Tell us about yourself.
(we need one adult in the family to be the contact person for your application.)
1. First name, Middle name, Last name, & uffix2. ome address (Leave blanif you dont have one.)3. Apartment or suite number4. City5. tate6. ZP code7. County8. Mailing address (if different from home address)9. Apartment or suite number10. City11. tate12. ZP code13. County14. Phone number15. ther phone number
( ) ( )
16.
 
Do you ant to get information about this application by email? Yes oEmail address:17. Preferred spoen or ritten language (if not English)
STEP 2
Tell us about your family.
Who do you need to include on this application?
ell us about all the family members ho live ith you. f you le taxes, e need to no about everyone on your taxreturn. (You don’t need to le taxes to get health coverage).
DO Include:
• YourselfYour spouseYour children under 21 ho live ith youYour unmarried partner ho needs health coverageAnyone you include on your tax return, even if theydon’t live ith youAnyone else under 21 ho you tae care of and livesith you
You DON’T have to include:
Your unmarried partner ho doesn’t need healthcoverageYour unmarried partner’s childrenYour parents ho live ith you, but le their on taxreturn (if you’re over 21)ther adult relatives ho le their on tax returnhe amount of assistance or type of program you qualify for depends on the number of people in your family and theirincomes. his information helps us mae sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family.
tart ith yourself, then add other adults and children. f you havemore than 2 people in your family, you’ll need to mae a copy of the pages and attach them. You don’t need to provideimmigration status or a ocial ecurity umber () for family members ho don’t need health coverage. we’ll eep allthe information you provide private and secure as required by la. we’ll use personal information only to chec if you’reeligible for health coverage.
 
Page 2 of 7
NEED HELP WITH YOUR APPLICATION?
 
Visit
HealthCare.gov
or call us at
1-800-XXX-XXXX
. Para obtener una copia de esteformulario en Español, llame
1-800-XXX-XXXX
. If you need help in a language other than English, call
1-800-XXX-XXXX
and tell thecustomer service representative the language you need. We’ll get you help at no cost to you. TTY users should call
1-800-XXX-XXXX
.
STEP 2: PERSON 1
Complete tep 2 for yourself, your spouse/partner and children ho live ith you and/or anyone on your same federal income taxreturn if you le one. ee page 1 for more information about ho to include. f you don’t le a tax return, remember to still add familymembers ho live ith you.1. First name, Middle name, Last name, & uffix 2. Relationship to you?
SELF
3. Date of birth (mm/dd/yyyy)4. ex Male Female5. ocial ecurity number ()
 
- -
We need this if you want health coverage and have an SSN.
Providing your  can be helpful if you don’t ant health coverage toosince it can speed up the application process. we use s to chec income and other information to see ho’s eligible for help ithhealth coverage costs. f someone ants help getting an , call 1-800-772-1213 or visit
socialsecurity.gov.
Y users should call1-800-325-0778.6.
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.)
 
YES.If yes,
please anser questions a–c.
NO.If no,
sip to question c.a.
 
will you le jointly ith a spouse? Yes o
If yes,
name of spouse:b.
 
will you claim any dependents on your tax return? Yes o
If yes,
list name(s) of dependents:c.
 
will you be claimed as a dependent on someone’s tax return? Yes o
If yes,
please list the name of the tax ler:o are you related to the tax ler?7.
 
Are you pregnant? Yes o a.
If yes,
ho many babies are expected during this pregnacy?8.
Do you need health coverage?
(Even if you have insurance, there might be a program with better coverage or lower costs.)
 
YES.If yes
, anser all the questions belo.
NO.
 
If no,
kP to the income questions on page 3.Leave the rest of this page blan. 9.Do you have a physical, mental, or emotional health condition that causes limitations in activities (lie bathing, dressing, dailychores, etc) or live in a medical facility or nursing home? Yes o10.
 
Are you a U.. citizen or U.. national? Yes o11.
If you aren’t a U.S. citizen or U.S. national,
do you have eligible immigration status?Yes. Fill in your document type and D number belo.a. mmigration document type b. Document D numberc. ave you lived in the U.. since 1996? Yes o d. Are you, or your spouse or parent a veteran or an active-dutymember of the U.. military? Yes o12. Do you ant help paying for medical bills from the last 3 months? Yes o13. Do you live ith at least one child under the age of 19, and are you the main person taing care of this child? Yes o14. Are you a full-time student? Yes o15. were you in foster care at age 18 or older? Yes o16.
If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.)
 Mexican Mexican American Chicano/a Puerto Rican Cuban ther17.
Race (OPTIONAL—check all that apply.)
 
white
 
American ndian or Filipino
 
Vietnamese
 
uamanian or Chamorro
 
Blac or AfricanAlasa ative
 
Japanese
 
ther Asian
 
amoanAmerican
 
Asian ndian
 
korean
 
ative aaiian
 
ther Pacic slander
 
Chinese
 
ther
(Start with yourself)

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