Health Insurance Application – Fill Out and Use This PDF

You have the right to get Marketplace information in an accessible format, like large print, Braille, or audio. You also have the right to file a complaint if you feel you’ve been discriminated against. Visit CMS.gov/about-cms/agency-Information/aboutwebsite/cmsnondiscriminationnotice, or call the Marketplace Call Center at 1-800-318-2596 for more information. TTY users can call 1-855-889-4325.

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Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.

Step 1: Tell us about yourself.

(We need one adult in the household to be the contact person for your application.)

Step 2: Tell us about your household.

Who do you need to include on this application?

Complete the Step 2 pages for each person in your household, even if the person has health coverage already. The information in this application helps us make sure everyone gets the best coverage they can. The amount of help or type of program you qualify for is based on the number of people in your household and your household income. If you don’t include someone, even if they already have health coverage, your eligibility results could be affected.

For adults who need coverage:

Include these people even if they aren’t applying for health coverage for themselves:

•Any spouse

•Any child under age 21 they live with, including stepchildren

•Any other person on the same federal income tax return (including any children over age 21 who are claimed on a parent’s tax return). You don’t need to file taxes to get health coverage.

For children under age 21 who need coverage:

Include these people even if they aren’t applying for health coverage themselves:

•Any parent (or stepparent) they live with

•Any sibling they live with

•Any child they live with, including stepchildren

•Any spouse they live with

•Any other person on the same federal income tax return. You don’t need to file taxes to get health coverage.

Complete Step 2 for each person in your household.

Start with yourself, then add other adults and children. If you have more than 2 people in your household, you’ll need to make a copy of the pages and attach them.

You don’t need to provide immigration status or SSNs for household 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.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

Complete Step 2 for yourself, your spouse/partner and dependents who live with you, and/or anyone on your same federal income tax return if you file one. See page 1 for more information about who to include. If you don’t file a tax return, remember to still add the people in your household.

6.Social Security Number (SSN) 

We need an SSN if you want health coverage and have an SSN or can get one. We use SSNs to check income and other information to see who’s eligible for help paying for health coverage. For more information on getting an SSN, visit socialsecurity.gov, or call Social Security at 1-800-772-1213. TTY users can call 1-800-325-0778.

7.Do you plan to file a federal income tax return NEXT YEAR? You can still apply for coverage even if you don’t file a federal income tax return.

YES. If yes, answer items a through c.     NO. If no, skip to item c.

9.Do you need health coverage? Even if you have coverage, 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 3. Leave the rest of this page blank. 

12.Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.) YES. If yes, complete a and b.     NO. If no, continue to question 13.

13. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?  YES. Enter document type and ID number. See instructions.

List the names and relationships of any children under 19 that live with you in your household:

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

Current job & income information

Current job 1:

20. Employer name

a. Employer address (optional)

Current job 2: (If you have additional jobs and need more space, attach another sheet of paper.) 24. Employer name

a. Employer address (optional)

29.If self-employed, answer a and b:

a. Type of work:

b. How much net income (profits once business expenses are paid) will you get from this $ self-employment this month? See instructions.

30.Other income you get this month: Fill in all that apply, and give the amount and how often you get it. Fill in here if none. NOTE: You don’t need to tell us about income from child support, veteran’s payments, or Supplemental Security Income (SSI).

31.Deductions: Fill in all that apply, and give the amount and how often you pay 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 child support that you pay, or a cost already considered in your answer to net self-employment (question 29b).

32.Complete this question if your income changes during the year, like if you only work at a job for part of the year or receive a benefit for certain

months. If you don’t expect changes to your monthly income, skip to the next person. 

this yearYour total income next year (if you think it’ll be different)Your total income

Thanks! This is all we need to know about you.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

Complete this page for your spouse/partner and children who live with you, and/or anyone on your same federal income tax return if you file one. If you don’t file a tax return, remember to still add household members who live with you. See page 1 for more information about who to include.

8.Does PERSON 2 plan to file a federal income tax return NEXT YEAR? (You can still apply for coverage even if PERSON 2 doesn’t file a federal income tax return.) YES. If yes, answer items a through c.     NO. If no, skip to item c.

10.Does PERSON 2 need health coverage? (Even if PERSON 2 has coverage, 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 5. Leave the rest of this page blank. 

13.Is PERSON 2 a naturalized or derived citizen? (This usually means they were born outside the U.S.) YES. If yes, complete a and b.      NO. If no, continue to question 14.

14. If PERSON 2 isn’t a U.S. citizen or U.S. national, do they have eligible immigration status?  YES. Enter document type and ID number. See instructions.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

Current job & income information

Current job 1:

22. Employer name

a. Employer address (optional)

Current job 2: (If PERSON 2 has more jobs, attach another sheet of paper.) 26. Employer name

a. Employer address (optional)

30.In the past year, did PERSON 2:  Change jobs  Stop working  Start working fewer hours  None of these

31.If PERSON 2 is self-employed, complete a and b:

32.Other income PERSON 2 gets this month: Fill in all that apply, and give the amount and how often PERSON 2 gets it. Fill in here if none. NOTE: You don’t need to tell us about PERSON 2’s income from child support, veteran’s payments, or Supplemental Security Income (SSI).

33.Deductions: Fill in all that apply, and give the amount and how often PERSON 2 gets it. If PERSON 2 pays 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 child support that PERSON 2 pays, or a cost already considered in the answer to net self-employment (question 31b).

34.Complete only if PERSON 2’s income changes during the year, like if PERSON 2 only works at a job for part of the year or receives a

benefit for certain months. If you don’t expect changes to PERSON 2’s monthly income, skip to the next person. 

this year PERSON 2’s total income next yearPERSON 2’s total income

Thanks! This is all we need to know about PERSON 2.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

1.Are you or is anyone in your household American Indian or Alaska Native?

NO. If no, continue to Step 4. YES. If yes, continue to Step 4, plus complete Appendix B and include with application.

Step 4: Your household’s health coverage

1.Was anyone on this application found not eligible for Medicaid or the Children’s Health Insurance Program (CHIP) in the

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, like a parent or spouse, even if they don’t accept the coverage. Check no if the only coverage offered is COBRA.

3.Is anyone enrolled in health coverage now?

4.Information about current health coverage. (Make a copy of this page if more than 2 people have health coverage now.)

Write the type of coverage, like employer insurance, COBRA, Medicaid, CHIP, Medicare, TRICARE, VA health care program, Peace Corps, or other. (Don’t tell us about TRICARE if you have Direct Care or Line of Duty.)

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

1.Do you agree to allow the Marketplace to use income data, including information from tax returns,

for the next 5 years? ..........................................................................................................................................................................................Yes  No

To make it easier to determine your eligibility for help paying for coverage in future years, you can agree to allow the Marketplace to use updated income data, including information from tax returns. The Marketplace will send a notice and let you make any changes. The Marketplace will check to make sure you’re still eligible, and may have to ask you to confirm that your income still qualifies. You can opt out at any time.

If no, automatically update my information for the next:5 years  4 years  3 years  2 years  1 year

Don’t use my tax data to renew my eligibility for help paying for health coverage (selecting this option may impact your ability to get help paying for coverage at renewal.)

Fill in here if this person is facing disposition of charges.

If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or CHIP), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.

I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation.

I don’t give the Marketplace permission to end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan.

If anyone on this application is eligible for Medicaid:

•I’m giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I’m also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.

•If yes, I know I’ll 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, I can tell Medicaid and I may not have to cooperate.

•I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.

•I know that I must tell the Health Insurance Marketplace® within 30 days if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.

•I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting hhs.gov/ocr/office/file.

•I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for lawful purposes of the Marketplace and programs that help pay for coverage.

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, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us confirmation.

What should I do if I think my Eligibility Notice is wrong?

If you don’t agree with what you qualify for, in many cases, you can ask for an appeal. Review your Eligibility Notice to find appeals instructions specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here’s important information to consider when requesting an appeal:

•You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual. Or, you can request and participate in your appeal on your own.

•If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.

•The outcome of an appeal could change the eligibility of other members of your household.

To appeal your Marketplace eligibility results, visit HealthCare.gov/marketplace-appeals. Or, call the Marketplace Call Center at

1-800-318-2596. TTY users can call 1-855-889-4325. You can also mail an appeal request form or your own letter requesting an appeal to Health Insurance Marketplace, Dept. of Health and Human Services, Attn: Appeals, 465 Industrial Blvd., London, KY 40750-0001. You can appeal eligibility for purchasing health coverage through the Marketplace, enrollment periods, tax credits, cost-sharing reductions, Medicaid, and CHIP, if you were denied these. If you qualify for tax credits or cost-sharing reductions, you can appeal the amount we determined you’re eligible for. Depending on your state, you may be able to appeal through the Marketplace or you may have to request an appeal with the state Medicaid or CHIP agency.

PERSON 1 should sign this application. If you’re an authorized representative, you may sign here as long as PERSON 1 signed Appendix C.

If you’re signing this application outside of Open Enrollment (between November 1 and January 15), make sure you review Appendix D (“Questions about life changes”).

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.

Get help in a language other than English

If you, or someone you’re helping, has questions about the Health Insurance Marketplace®, you have the right to get help and information in your language at no cost to you. To talk to an interpreter, call 1-800-318-2596.

Here’s a listing of the available languages and the same message provided above in those languages:

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can 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.

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. 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. TTY users can call 1-855-889-4325.