Professional Documents
Culture Documents
Use this application to • Affordable private health insurance plans that offer comprehensive
coverage to help you stay well
see what coverage • A new tax credit that can immediately help pay your premiums for health
choices you qualify coverage
for • Free or low-cost insurance from Medicaid, Healthy Michigan Plan, or MIChild
(Children’s Health Insurance Program).
Who can use this • Use this application to apply for anyone in your family.
• Apply even if you or your child already has health coverage. You could be
application? eligible for lower-cost or free coverage.
• Families that include immigrants can apply. You can apply for your child
even if you aren’t eligible for coverage. Applying won’t affect your
immigration status or chances of becoming a permanent resident or citizen.
• If someone is helping you fill out this application, you may need to complete
Appendix C.
What you may need to • Social Security Numbers (or document numbers for any legal need to apply
immigrants who need insurance)
apply • Employer and income information for everyone in your family (for example,
from paystubs, 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 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
this information? information you provide private and secure, as required by law.
What happens next? Send your complete, signed application to the address on page 9. 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. You’ll get instructions on the
next steps to complete your health coverage. If you don’t hear from us call our
application help line at 855-276-4627 or 800-642-3195. Filling out this application
doesn’t mean you have to buy health coverage.
2. Home Address (Leave blank if you don’t have one.) 3. Apartment or Suite Number
8. Mailing Address (if different from home address) 9. Apartment or Suite Number
16. Do you want to get information about this application by email? Yes No
Email address:
17. Preferred spoken or written language (if not English)
The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This
information helps us make sure everyone gets the best coverage they can.
Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than
2 people in your family, you’ll need to make a copy of the pages and attach them. You don’t need to provide immigration status or a
Social Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information you provide private
and secure as required by law. We’ll use personal information only to check if you’re eligible for health coverage.
To be eligible for coverage, parents requesting health care coverage for themselves must provide proof that the children have
creditable coverage, even if not applying for the children. Credible coverage is health insurance coverage under any of the following: a
group health plan; individual health insurance; student health insurance; Medicare; Medicaid; CHAMPUS and TRICARE; The Federal
Employees Health Benefits Program; Indian Health Service; The Peace Corps; Public Health Plan (any plan established or maintained
by a State, the U.S. government, or a foreign country); Children’s Health Insurance Program (CHIP); or, a state health insurance high
risk pool.
1. First name, Middle name, Last name, & Suffix 2. Relationship to you?
SELF
3. Date of birth (mm/dd/yyyy) 4. Gender: 5. Are you married? Yes No
Male Female If YES, Spouse name:
6. Do you live with at least one or more child(ren) under the age of 19, and are you the main person taking care of this child? Yes No
If Yes, provide child(ren) names and relationship to you:
7. Are you a full-time student? Yes No
8. Did you consume water from the Flint Water System and live, work or receive childcare or education at an address that was served by the Flint Water
System from April 2014 through present day? Yes No If yes, complete Appendix D.
9. Are you under 21? Yes No If YES, provide parent names
Mother's Name: Father's Name:
11. 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 answer questions a–c. NO. If no, skip to question c.
c. Have you lived in the U.S. since 1996? Yes No d. Are you, or your spouse or parent a veteran or an active-duty
member of the U.S. military? Yes No
e. U.S. entry date
17. Do you want help paying for medical bills from the last 3 months? Yes No Which month(s)
18. If Hispanic/Latino, ethnicity (OPTIONAL - check all that apply.)
Mexican Mexican American Chicano/a Puerto Rican Cuban Other
19. Race (OPTIONAL - check all that apply.)
White American Indian or Filipino Other Asian Samoan
Black or African Alaska Native Japanese Native Hawaiian Other Pacific Islander
American Asian Indian Korean Guamanian or Other
Chinese Vietnamese Chamorro
CURRENT JOB 1 :
20. Employer name and address 21. Employer phone number
22. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
23. Average hours worked each WEEK
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
24. Employer name and address 25. Employer phone number
26. Average # of hours expected to work per Week Pay Period Rate of pay $ Hourly Weekly Other
27. How often paid: Weekly Every 2 weeks Twice a month Monthly Other
28. In the past year, did you: Change jobs Stop working Start working fewer hours None of these
28a. Is your income in the previous three months consistent with the current month’s income? Yes No
29. If self-employed, answer the following questions: b. How much net income (profits once business expenses are paid) will you get
a. Type of work from this self-employment this month?
$
30. OTHER INCOME THIS MONTH: Check all that apply, give the amount and how often you get it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None
Unemployment $ How often? Net farming/fishing $ How often?
Pensions $ How often? Net rental/royalty $ How often?
Social Security $ How often? Other income $ How often?
Retirement accounts $ How often? Type:
31. DEDUCTIONS: Check all that apply, give the amount and how often you get it.
If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 29b).
YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes to your
32.
monthly income, skip to the next person.
Your total income this year Your total income next year (if you think it will be different)
$ $
1. First name, Middle name, Last name, & Suffix 2. Relationship to you?
11. Social Security Number (SSN) - - We need this if you want health care coverage and have a SSN.
14. Is PERSON 2 pregnant now/last three months? Yes No If yes, how many babies are expected this pregnancy?
Due Date/end date?
16. Does PERSON 2 have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc),
live in a medical facility or nursing home, or are they medically frail? Yes No
17. Is PERSON 2 a U.S. citizen or U.S. national Yes No
18. If PERSON 2 isn't a U.S. citizen or U.S. national, do they have eligible immigration status?
Yes. Fill in their document type and ID Number below.
a. Document type b. Document ID number
c. Has PERSON 2 lived in the U.S. since 1996? Yes No d. Is PERSON 2, or their spouse or parent a veteran or an active-duty
member in the U.S. military? Yes No
e. U.S. entry date
19. Does PERSON 2 want help paying for medical bills from the last 3 months? Yes No Which month(s)
CURRENT JOB 1:
22. Employer name and address 23. Employer phone number
24. Wages/tips (before taxes) Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
$
25. Average hours worked each WEEK
CURRENT JOB 2: (If you have more jobs and need more space, attach another sheet of paper.)
26. Employer name and address 27. Employer phone number
28. Average # of hours expected to work per Week Pay Period Rate of pay $ Hourly Weekly Other
29. How often paid: Weekly Every 2 weeks Twice a month Monthly Other
30. In the past year, did you: Change jobs Stop working Start working fewer hours None of these
30a. Is your income in the previous three months consistent with the current month’s income? Yes No
31. If self-employed, answer the following questions: b. How much net income (profits once business expenses are paid) will
a. Type of work you get from this self-employment this month?
$
32. OTHER INCOME THIS MONTH: Check all that apply, give the amount and how often you get it.
NOTE: You don’t need to tell us about child support, veteran’s payment, or Supplemental Security Income (SSI).
None
Unemployment $ How often? Net farming/fishing $ How often?
Pensions $ How often? Net rental/royalty $ How often?
Social Security $ How often? Other income $ How often?
Retirement accounts $ How often? Type:
Alimony/Support rec’d $ How often? Court Order Date
33. DEDUCTIONS: Check all that apply, and give the amount and how often you get it.
If you pay for certain things that can be deducted on a federal income tax return, telling us about them could make the cost of health coverage a little
lower.
NOTE: You shouldn’t include a cost that you already considered in your answer to net self-employment (question 31b).
34. YEARLY INCOME: Complete only if PERSON 2's income changes from month to month.
NOTE: If you do not expect changes to PERSON 2 move on to STEP 3.
PERSON 2's total income this year PERSON 2's total income next year (if you think it will be different)
$ $
THANKS! This is all we need to know about PERSON 2.
If you have more than two people to include, make a copy of Step 2: Person 2 (pages 5 and 6) and complete.
Answer these questions for anyone who needs health coverage. Answer the questions for child(ren) even if not applying for the child(ren),
2. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or
spouse.
YES. If yes, you'll need to complete and include Appendix A. Is this a state employee benefit plan? Yes No
NO. If no, continue to Step 5.
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
Administration, 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.
Renewal of coverage in future years
To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow the Marketplace
and the State of Michigan to use income data, including information from tax returns. The Marketplace and the State of Michigan
will send me a notice, let me make any changes, and I can opt out at any time.
Yes, renew my eligibility automatically for the next
5 years (the maximum number of years allowed), or for a shorter number of years:
4 years 3 years 2 years 1 year Don’t use information from tax returns to renew my coverage.
NOTE: If you do not check either box, we will assume you have decided not to register to vote at this time. Checking ‘yes’ does not
register you to vote. If you check ‘yes’ a voter registration application will be forwarded to you. You may also register online at
www.michigan.gov/sos
Coordination of health care programs and providers (MA)
The State’s medical assistance program relies on a large number of managed care health programs, mental health and substance
abuse programs, and private providers to deliver quality care to individuals like you. To make sure you receive a high level of care and
that your benefits are coordinated, providers in the program may share information about your care (or your child or ward) with other
providers in the program when such information and consultation is clinically needed.
Information about you, your child or ward (MA)
Necessary information may be shared between health plans and programs in which you participate. Health plans, programs and
providers that deliver health care to you may share necessary information in order to manage and coordinate health care and benefits.
This information may include, when applicable, information relative to HIV, AIDS, AIDS-related complex (ARC) or other communicable
diseases, information about behavioral or mental health services, and referral or treatment for alcohol and drug abuse as permitted by
42 CFR Part 2.
Sign this application. The person who filled out Step 1 should sign this application. If you’re an authorized representative you may
sign here, as long as you have provided the information required in Appendix C.
Computer Cross-Checking. I understand that, as part of determining my eligibility for Healthcare Coverage, information I give on this
application will be verified by computer cross-checking with other public and private agencies.
Authority: The Patient Protection and Affordable Care Act (Publication L111-148) and the Health Care and Education Reconciliation Act
(Publication L111-152)
Completion: This form is required to enroll in health coverage.
EMPLOYEE Information
1. Employee name (First, Middle, Last) 2. Employee Social Security Number
EMPLOYER Information
3. Employer name 4. Employer Identification Number (EIN)
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
13. Are you currently eligible for coverage offered by this employer, or will you become eligible in the next 3 months?
Yes (Continue)
13a. If you're in a waiting or probationary period, when can you enroll in coverage?
(mm/dd/yyyy)
List the names of anyone else who is eligible for coverage from this job.
Name: Name: Name:
No (Stop here and go to Step 5 in the application)
14. Does the employer offer a health plan that meets the minimum value standard*? Yes No
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer
has wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation
programs, and did not receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Hourly Weekly Every 2 weeks Twice a month Monthly Yearly
16. What change will the employer make for the new plan year (if known)?
Employer won't offer health coverage
Employer will start offering health care 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.)
a. How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
Date of change (mm/dd/yyyy)
* An employer-sponsored health 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)
EMPLOYEE Information
The employee needs to fill out this section.
1. Employee name (First, Middle, Last) 2. Social Security Number
EMPLOYER Information
Ask the employer for this information.
3. Employer name 4. Employer Identification Number (EIN)
5. Employer address (the Marketplace will send notices to this address) 6. Employer phone number
10. Who can we contact about employee health coverage at this job?
11. Phone number (if different from above) 12. Email address
13. Is the employee currently eligible for coverage offered by this employer, or will the employee be eligible in the next 3 months?
Yes (Continue)
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)
If you're in a waiting or probationary period, when can you enroll in coverage?
No (STOP and return this form to employee)
14. Does the employer offer a health plan that meets the minimum value standard*?
Yes (Go to question 15) No (STOP and return form to employee)
15. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (don’t include family plans): If the employer has
wellness programs, provide the premium that the employee would pay if he/she received the maximum discount for any tobacco cessation
programs, and didn’t receive any other discounts based on wellness programs.
a. How much would the employee have to pay in premiums for this plan? $
b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
If the plan year will end soon and you know that the health plans offered will change, go to question 16. If you don’t know, STOP and return form
to employee.
16. What change will the employer make for the new plan year (if known)?
Employer won't offer health coverage
Employer will start offering health care 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.)
a . How much will the employee have to pay in premiums for that plan? $
b. How often? Weekly Every 2 weeks Twice a month Quarterly Yearly
Date of change (mm/dd/yyyy)
* An employer-sponsored health 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)
NOTE: If you have more people to include, make a copy of this page and attach.
No No
3. Has this person ever gotten a service from the Yes Yes
Indian Health Service, a tribal health program,
or urban Indian health program, or through a
referral from one of these programs? No No
If no, is this person eligible to get services If no, is this person eligible to get services from
from the Indian Health Service, tribal health the Indian Health Service, tribal health
programs, or urban Indian health programs, programs, or urban Indian health programs, or
or through a referral from one of these through a referral from one of these programs?
programs?
Yes No
Yes No
NEED HELP WITH YOUR APPLICATION? Visit www.michigan.gov/mibridges or call us at 855-276-4627. Para obtener una copia de este
formulario en Español, llame 855-276-4627. If you need help in a language other than English, call 855-276-4627 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 866-501-5656.
7. Phone number
By signing, you allow this person to sign your application, get official information about this application, and act for you on all
future matters with this department.
10. Your signature 11. Date (mm/dd/yyyy)
NEED HELP WITH YOUR APPLICATION? Visit www.michigan.gov/mibridges or call us at 855-276-4627. Para obtener una copia
de este formulario en Español, llame 855-276-4627. If you need help in a language other than English, call 855-276-4627 and tell the customer
service representative the language you need. We’ll get you help at no cost to you. TTY users should call 866-501-5656.
Answer the questions below for anyone who is currently under age 21, pregnant, or pregnant within the last 2 months. Please list
anyone who consumed water from the Flint water system and lived, worked, or received childcare or education at an address that
was served by the Flint water system at any time from April 2014 through the present.
1. Between April 2014 and present day, did any applicant live at an address that was served by the Flint water system? Please
include all addresses and indicate all applicants who lived at each address.
Address served by the Flint water Names of applicants who lived at the address Dates applicants lived at the
system address (From/To)
2. Between April 2014 and present day, did any applicant work at an address that was served by the Flint water system? Please include
all addresses and indicate all applicants who worked at each address.
Address served by the Flint water Names of applicants who worked at the address Dates applicants worked at the
system address (From/To)
3. Between April 2014 and present day, did any applicant attend school or receive childcare at an address that was served by the Flint
water system? Please include all addresses and indicate all applicants who attended school or received childcare at each address.
Address served by the Flint water Names of applicants who attended school/childcare at the Dates applicants attended
system address school/childcare at the address
(From/To)
You may be asked to provide verification or proof that you consumed water and lived, worked or received regular services (attend
childcare or school) at an address that was served by the Flint water system from April 2014 through present day. Any knowingly false
information or statements provided may be reviewed by the Office of Inspector General.
NEED HELP WITH YOUR APPLICATION? Visit www.michigan.gov/mibridges or call us at 855-276-4627. Para obtener una copia de
este formulario en Español, llame 855-276-4627. If you need help in a language other than English, call 855-276-4627 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 866-501-5656.
• Provides free aids and services to people with disabilities to communicate with us, such as:
o Qualified sign language interpreters
o Written information in other formats (large print, audio, accessible electronic formats, other formats); and
• Provides free language services to people whose primary language is not English, such as:
o Qualified interpreters
o Information written in other languages
If you need these services, contact the Section 1557 Coordinator. The contact information is found below.
If you believe that MDHHS has not provided services, or discriminated in another way, you can file a grievance with the Section
1557 Coordinator. You can file a grievance in person or by mail, fax, or email. If you need help filing a grievance, the Section 1557
Coordinator is available to help you.
If your grievance or complaint is about your If your grievance or complaint is about your application for or current food
Medicaid application, benefits or services assistance benefits, you can file a discrimination complaint with the U.S.
you can file a civil rights complaint with the Department of Agriculture (USDA) Program by:
U.S. Department of Health and Human
Services at https://bit.ly/2pBS4YG, or by Completing a Complaint Form, (AD-3027) found online at:
mail or phone at: https://bit.ly/2g9zzpU or at any USDA office, or write a letter addressed to
USDA at the address below. In your letter, provide all of the information
U.S. Department of Health and Human requested in the form.
Services
200 Independence Avenue, SW To request a copy of the complaint form, call 866-632-9992.
Room 509F, HHH Building Send your completed form or letter to USDA by mail:
Washington, D.C. 20201 U.S. Department of Agriculture
800-368-1019, 800-537-7697 (TDD) Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Complaint forms are available at Washington, D.C. 20250-9410
https://bit.ly/2IKsHMS.
Fax: 202-690-7442; or Email: program.intake@usda.gov