MARKETPLACE TRAINING
REFERENCE MATERIAL
MARKETPLACE APPLICATION
ONLINE HELP
Revised: October 1, 2013
MARKETPLACE APPLICATION ONLINE HELP
REFERENCE MATERIAL
OVERVIEW
The purpose of this reference material is to give you information to assist a consumer who is
completing an online application for the Health Insurance Marketplace, and who has questions
about the fields and other items on the application screens.
This document contains information that will be available later to the consumer in the online
application.
To best use this reference material:
Step 1. Work with the consumer to understand what section of the application he or she is
completing.
Step 2. Select the corresponding item in the index of this reference material, found on the
next page, to quickly access information about the section. The items in the index are
organized by the order in which the consumer views them as he or she completes the
Individual and Family online application. Selecting the appropriate section in the index
takes you directly to the reference material page for that section.
Step 3. If you have difficulty using the index to find the item the consumer is asking about, it
may be faster/easier to search this reference material for a field name or keyword the
consumer provides.
To use the Search function:
a) Select Edit > Find from the menu bar.
b) In the Search field, type the field or item name or any other possible keywords
the consumer gives you.
c) Select the Find button to see the first instance of the word in the PDF.
d) Select the Next button to see the next instance of the word. Each instance of the
word is highlighted.
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be
disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure
may result in prosecution to the full extent of the law.
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MARKETPLACE APPLICATION ONLINE HELP
REFERENCE MATERIAL
INDEX
Click an application section below to jump to that section of the Help document.
Getting Started
Assistance with Completing the Application
Help Paying for Coverage
Income
Family & Household
Change in Circumstances Questions
American Indian and Alaska Native Questions
Other Health Coverage Questions
Review & Sign
Your Eligibility Results & Next Steps
INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been
publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be
disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure
may result in prosecution to the full extent of the law.
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Getting started
What do I need to know about the Help Center?
Most of the articles in this Help Center are addressed to “you” as the applicant. But, on the application,
these questions and items may be asked to you and/or anyone else you enter on your application. For
example, the Help Center may ask “Are you married?” but the actual question on your application may
ask “Are any of these people married?” and have a list of people on your application.
Will I be asked all of the questions in the Help Center?
Each person’s application is unique. The Help Center may contain information that isn’t applicable to
you and/or your family, so you may not be asked some of these questions or items.
What information will I need to enter?
Once you’ve created a Marketplace account and started your application, you’ll need to enter some
personal information, including:
• Your contact information: This information will display automatically. If you need to make
changes, return to your Marketplace account, and edit the information there.
• Your home address:
o Your home address can’t be a P.O. box.
o If you don’t have a fixed address or you’re currently homeless, check the box that says
“No home address.” You still need to give an address for a place where someone knows
how to reach you, even if it’s not your own home. This way, we can help you get the
most benefits possible.
• Your mailing address: Your mailing address can be a street address or a P.O. box.
• Your phone number: Enter your cell phone number if you’d like to get text message alerts from
the Marketplace to let you know that you have a message in your Message Center. If you need
to change any of your information, you can do so here.
Do I need to answer “optional” questions?
You must answer all questions and items on your application unless they’re marked optional. If you
answer an optional question, your answer won’t impact your eligibility for health coverage, your plan
options, or your costs in any way.
Why am I being asked to enter my preferred spoken and written language?
Entering this information will help the U.S. Department of Health and Human Services (HHS) better
understand and improve the health and health care for all Americans. Providing this information won’t
impact your eligibility for health coverage, your health plan options, or your costs in any way.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
How can I read my notices on this website?
Whenever there’s new information for you, like about the health coverage you or anyone you list on this
application can get or when it’s time to renew coverage, the information will be available in your
Marketplace account. We’ll let you know by text message and/or email.
We need to know the best way to contact you when a notice is ready for you. You can be contacted by:
• Email: Select “Yes” when you’re asked about getting electronic notices, and enter or select your
email address. You’ll get an alert to let you know when notices are ready online.
• Text message: Select “Yes” when you’re asked about getting electronic notices, and enter or
select your cell phone number. Messaging rates will apply. You’ll get an alert to let you know
when notices are ready online.
• Both email and text message: Select “Yes” when you’re asked about getting electronic notices,
and enter or select your email address and cell phone number. Messaging rates will apply. You’ll
get an alert to let you know when notices are ready online.
• Paper notices in the mail: Select “No” when you’re asked about getting electronic notices, and
we’ll send paper copies to the mailing address you provided.
Do I need to name an authorized representative?
You don’t have to enter an authorized representative. If you do, the authorized representative will need
to create a Marketplace account to get notices and act on your behalf. If needed, we’ll send information
to this person on how to create an account. Even if this person hasn’t created their account yet, you can
still continue with the application.
Assistance with completing the application
Who’s helping me complete my application?
If you’re getting help completing this application from a professional, select the type from this list:
- Navigator
- Certified application counselor
- In-person assistance personnel
- Agent or broker
- None of these
See below for more information about each type of professional who can help you with your
application.
Navigators
The professional can be an individual or organization that’s trained to help consumers looking for health
coverage options through the Marketplace, including the completion of this application. You can ask to
see certification showing he or she is authorized to perform this work. He or she can help you complete
the section in the application where we ask for their information.
If you’re getting help from a navigator, enter the navigator’s name, organization, and identification (ID)
number on your application. The ID number is a unique alphanumeric ID (13 letters and numbers) given
to each navigator.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Certified application counselors
A certified application counselor is a staff member or volunteer of an organization who’s trained to help
consumers looking for health coverage options through the Marketplace, including the completion of
this application.
If you’re getting help from a certified application counselor, enter the counselor’s name, organization,
and identification (ID) number on your application. The ID number is a unique alphanumeric ID (13
letters and numbers) given to each counselor.
Another type of in-person assistance personnel
An in-person assister is an individual or organization that’s trained to help consumers looking for health
coverage options through the Marketplace, including the completion of this application. You can ask to
see certification showing that he or she is authorized to perform this work.
If you’re getting help from an in-person assister, enter the in-person assister’s name, organization, and
identification (ID) number on your application. The ID number is a unique alphanumeric (13 letters and
numbers) given to each in-person assister.
Agents and brokers
An agent or broker can help you apply for help paying for coverage and enroll in a Marketplace health
plan through the Marketplace. He or she can make specific recommendations about which plan you
should enroll in. They’re also licensed and regulated by states and typically get payments or
commissions from health insurance companies when they enroll consumers.
If you’re getting help from an agent or broker, enter these on your application:
• The agent’s or broker’s FFM User ID – a unique ID that the agent or broker creates when
registering with the Marketplace.
• The agent’s or broker’s National Producer Number (NPN) – a unique number (up to 10 digits)
that’s assigned to each licensed agent or broker. You can locate an NPN by visiting the National
Insurance Producer Registry.
Help paying for coverage
Do I want to find out if my family and I can get help paying for health
coverage?
You’ll be asked if you want to find out if you and/or your family can get help paying for health coverage:
• If you select “Yes,” you’ll answer questions about your income and household to see how much
help you might qualify for.
• If you select “No,” you’ll answer fewer questions, but won’t get help paying for health coverage.
What help is available?
You may be eligible for a free or low-cost plan or
a new kind of tax credit that can be used to lower your monthly premiums right away. See below for
more information on these types of help. You’ll answer questions to see if you qualify for a break on
costs.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Free or low-cost plans
Different health benefit programs are directly linked into the Marketplace. You and/or your family may
qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program
(CHIP), even if you’ve been turned down before. We’ll let you know what each person qualifies for after
you submit your application.
Tax credits
With most tax credits, you have to wait until you file your taxes to get the credit. But the tax credit
available through the Marketplace lets you get lower costs on your monthly premiums and out-ofpocket costs.
If you qualify, you can take the tax credit in the form of advance payments to lower your monthly health
plan premiums, which can help make insurance more affordable.
If you decide to enroll in a Marketplace health plan, you can control how much of the tax credit you
want to use to get lower costs on your monthly health plan premiums. The tax credit is sent directly to
your insurance company and applied to your premium, so you pay less out-of-pocket. Once you select
an amount of tax credit, you won’t be able to change this amount until [date].
Medicaid & CHIP
Medicaid and the Children’s Health Insurance Assistance Program (CHIP) pays for doctor visits, shots,
dental care, prescription drugs, hospital care, and more with little or no cost to families. To find out if a
child is eligible for Medicaid or CHIP through the Marketplace, the parent living with the child needs to
submit a Marketplace application and indicate that he or she wants to find out about help paying for
health coverage.
What’s Medicaid?
Medicaid provides health coverage to more than 50 million children, families, pregnant women, the
elderly, and people with disabilities. Medicaid pays for a full set of services including preventive care,
immunizations, screening and treatment of health conditions, doctor and hospital visits, and all children
and some adults also get vision and dental care. In most cases, these services are provided at no cost to
families.
What’s CHIP?
The Children's Health Insurance Program (CHIP) provides free or low-cost health coverage for more than
7 million children up to 19. In some states, pregnant women can also get CHIP coverage. CHIP covers
U.S. citizens and eligible immigrants. Each state CHIP program covers routine check-ups, immunizations,
hospital care, dental care, and lab and X-ray services. Children covered by CHIP get free preventive care,
but low premiums and other cost-sharing may be required for other services.
What’s my total household income?
You may be asked if your household income will be less than a certain amount this year. Your total
household incomes includes all the money that the people in the household earn for the whole year, all
added together. This includes money from jobs, Social Security, unemployment, self-employment,
retirement, and other income that might be reported on a tax return. Certain types of income specific
to American Indians and Alaska Natives (AI/ANs) and certain types of education grants and scholarships
are not included in your income. When answering this question, take your best guess.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
How many people are on my federal income tax return this year?
You may be asked how many people are on your federal income tax return this year. You don’t have to
file taxes now to get help paying for health coverage. If you do file taxes, your answer to this question
should include the total number of tax filers and dependents you listed on your last federal income tax
return.
What if I have a pre-existing condition?
Pre- existing conditions are health problems a person has before the date a new health insurance
policy starts. Insurers are legally prohibited from making you pay higher costs for pre-existing
conditions when you get coverage through the Marketplace.
Do I need to enter my Social Security number (SSN)?
You’ll be asked to enter the Social Security numbers (SSNs) for the people on your application. We’ll verify
the SSNs with Social Security, based on the consent you gave at the start of the application. Leave the field
blank if a person doesn’t have an SSN. Don’t enter ITINs or other numbers here.
Why am I asked to enter my SSN?
This information will only be used for eligibility for health coverage. It won’t be used for immigration
enforcement purposes (unless this person gets long-term care services from Medicaid). Some lawfully
present applicants may not have or be eligible for an SSN. They can still apply for health coverage and
can leave this field blank. If this person doesn’t have an SSN, but wants more information on how to get
one, they can visit socialsecurity.gov.
How do I verify the name on the SSN?
You’ll be asked if the name on the application is the same name on this person’s Social Security card.
Most people select “Yes” to this question, but sometimes people change their names, like when they get
married.
If the name on this person’s Social Security card is different than the name you already told us for this
application, select “No,” and we’ll ask you what name is on this person’s Social Security card. Enter the
name exactly as it appears on the Social Security card, even if there’s a mistake on the card. We’ll verify
this information with Social Security, based on the consent you gave at the start of the application.
To change the name and get a new card, visit socialsecurity.gov, or call Social Security at 1-800-7721213. TTY users should call 1-800-325-0778.
What if I get an error message after I enter an SSN?
If the SSN you enter is invalid, you’ll be asked to review the name, date of birth, and SSN, and make
changes, as needed. We’ll verify this information again with Social Security. If the information you
entered is correct, you can leave it the same but you may be asked to provide proof of this person’s
name, date of birth, and SSN at the end of the application if we can’t verify this information.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Income
Information about income you earned
Your Marketplace application may show information about income you earned. This is information we
got from a consumer reporting agency, and it reflects your current employment. If it’s accurate, check
“This information is correct.” If the information isn’t accurate, select “EDIT” or “REMOVE” to make
changes.
If you have more questions about where this information came from, call the Marketplace Call Center at
1-800-318-2596. TTY users should call 1-855-889-4325.
Why do we ask about income?
People with lower income and resources may qualify for more help paying for health coverage or be
eligible for programs like Medicaid. We need to know about your income to get you help if you need it.
Income from your job
You’ll be asked about how you’re paid:
• Income amount: If you’re asked about your income amount, enter the amount that’s shown on
your pay stub before taxes are taken out.
• How often? After you enter how much you earn, select how often. Choose one option, like
“hourly,” “daily,” or “weekly.” If you’re paid through a one-time contract, you can select “one
time only.”
• Hours per week? Enter the number of hours or days you work each week.
Amounts that change weekly
If your income amount changes each week, enter how much you expect to earn for the whole month, or
enter the average number of hours you’re working right now.
A one-time payment you got this month, like a bonus or severance
If you got, or will get, a one-time amount from a current or former employer this month, like a bonus or
a severance payment, select “add another job income” to enter it separately from normal job wage or
salary.
Tips and other cash income from jobs
Include all tip income, even if it’s not reported it to your employer. Include all jobs, even if they’re parttime or you’re paid in cash. You can add each job separately by selecting “add another job.”
Don’t count pre-tax deductions
You don’t have to include amounts that an employer takes out of your paycheck for child care, health
insurance, or retirement plans that are “not taxable.” Sometimes these are called “pre-tax deductions.”
The pay stub should list these deductions individually. Don’t include these amounts in the pay you list.
The pay stub may list your “federal taxable wages,” which subtracts the pre-tax amounts from your
gross wages. If this amount is listed on the pay stub, use it to report your pay.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Add other income
You’ll be asked if you have any of the following income. See below for more detailed information on
these income types.
• Self-employment
• Social Security benefits
• Unemployment
• Retirement
• Pension
• Capital gains
• Investment income
• Rental or royalty income
• Farming or fishing income
• Alimony received
• Other income
Check each income type you got or will get this month. Don’t include money from child support,
veteran’s payments, workers’ compensation, or Supplemental Security Income (SSI).
You can select “No” to this question if you’re a tax dependent of your parent, and you earn less than
$5,950 from job and self-employment income and less than $300 from other types of income each year.
Self-employment income
This is the net income a person earns from their own trade or business. For example, any net income
(profit) you earn from goods you sell or services you provide to others counts as self-employment
income. Self-employment income could also come from a distributive share from a partnership.
If you select “self-employment,” you’ll describe the kind of work this self-employment is. There’s no
special format – simply describe the work. For example, if you clean houses, enter “house cleaning.” If
you make jewelry, enter “jewelry making.” If you work on construction projects, enter “construction.”
For more information, visit IRS.gov to view “Instructions for Schedule C” or IRS Publication 334 (2012),
pages 30-39.
To enter the net income from self-employment, you’ll enter an amount that includes the net income or
net loss from self-employment. Net income is the excess of your receipts from your business over the
expenses deducted in operating the business. The net loss is the excess of allowable deductions from
the business over business receipts. (If you’re a partner, include your distributive share from the
partnership.) Expenses that may be able to be deducted include these expenses you paid to operate
your business:
• Car and truck expenses (for travel during the work day, not commuting)
• Depreciation
• Employee wages and fringe benefits
• Property, liability, or business interruption insurance
• Interest on loans for your business (including mortgage interest paid to banks)
• Legal and professional services
• Rent or lease of business property and utilities
• Commissions, taxes, licenses, and fees
• Advertising
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
•
•
•
Contract labor
Repairs and maintenance
Certain business travel and meals
Social Security benefits
These are the amount a person gets from Social Security disability, retirement (income railroad
retirement (RRB)), or survivor’s benefits each month.
If you select “Social Security benefits,” you’ll enter the amount you get from Social Security benefits.
You’ll also select how often you get this amount: one time only, monthly, or yearly. You can find the
amount on the cost-of-living increase letter you get each year. Enter the full amount before any
deductions, like Medicare premiums, income tax withholding, overpayments, child support, or alimony.
Don’t enter Supplemental Security Income (SSI) benefits.
If you’re getting an extra payment this month, include it when you enter your monthly amount.
Retirement
A retirement benefit is generally a payment or series of payments made to a person after he or she
retires from work. Generally, the amount of the income from a retirement account distribution depends
on the type of retirement account, how much was contributed to the retirement account, and whether
the amounts contributed were already taxed. You don’t have to include a qualified distribution from a
designated Roth account as income. For more information, see IRS Publication 575.
If you select “retirement,” you’ll be asked how much you get from retirement account distributions.
You’ll also be asked how often you get this amount. Enter what you receive as a distribution from
retirement investment, even if you aren’t retired.
Pension
A pension is generally a payment or series of payments made to a person after he or she retires from
work. Generally, the amount of the income from a pension account distribution depends on the type of
pension account, how much was contributed to the pension account, and whether the amounts
contributed were already taxed. You don’t have to include a qualified distribution from a designated
Roth account as income. For more information, see IRS Publication 575.
If you select “pension,” you’ll be asked how much you get from pension account distributions. You’ll
also be asked how often you get this amount. Enter what you receive as a distribution from your
pension, even if you aren’t retired.
Unemployment
Unemployment compensation includes any amount you get under an unemployment compensation law
of the United States or a state. You usually must include unemployment benefits (including from an
employer or union) as income. To see the limited exceptions, see IRS Publication 525, page 26.
If you select “unemployment,” you’ll enter the amount you get from unemployment, and how often
you get this amount. You’ll be asked which state or former employer provides you with unemployment
benefits. You’ll also be asked if there’s a date that unemployment benefits are set to expire.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Capital gains
Capital gains are the amount you profit from selling property. For example, if you buy stock for $1,000
and sell it for $1,250, you have a capital gain of $250. You don’t need to include a capital gain if it’s from
the sale of the main home you owned for at least 5 years (and the profit is less than $250,000). For more
information, see IRS Publication 17 (chapter 14, page 104) or IRS Publication 544.
If you select “capital gains,” you’ll be asked how much you expect to get from net capital gains this
month and this year. Enter your capital gains income after subtracting capital losses. You’ll select
“profit” or “loss” when you enter these amounts.
Investment income
Investment income is the income you get from an investment. Examples of investment income include
interest you get from a bank account or dividends from a person’s stock. For more information, see IRS
Publication 550.
If you select “investment income,” you’ll be asked to enter the amount you get from investment
income, like interest and dividends. You’ll also be asked how often you get this amount.
Rental or royalty income
Rental income is the amount someone pays you to use your property after you subtract your property
expenses. Royalty income includes any payments you get from a patent, copyright, or some other
natural resource you own. For more information, see IRS Publication 17 (chapter 9, pages 67-74).
If you select “rental or royalty income,” you’ll be asked how much you get from these types of income.
You’ll also be asked how often you get this amount. Enter your net rental or royalty income (your profit
after subtracting costs). You’ll select “profit” or “loss” when you enter this amount.
Farming or fishing income
If you have income from farming or fishing, you can enter it as “farming or fishing” income or “selfemployment” income, but you can only enter it once. A person is in the business of farming if he or she
cultivates, operates, or manages a farm for profit, either as owner or tenant. A farm can include
livestock, dairy, poultry, fish, or fruit. It can also include plantations, ranches, ranges, and orchards. For
more information on farming income, see IRS Publication 225 (2011), page 1 (farming), or page 15
(exclusions from income).
Fishing income includes amounts you get from catching, taking, harvesting, cultivating, or farming fish,
shellfish, crustacean, sponges, seaweeds, or other aquatic forms of animal or vegetable life, as well as
money from patronage dividends and fuel tax credits and refunds. For more information on fishing
income, visit the IRS Fishing Tax Center.
If you select “farming or fishing income,” you’ll be asked how much you get from these types of
income. You’ll also be asked how often you get this amount. Enter your net farming or fishing income
(your profit after subtracting costs). You’ll select “profit” or “loss” when you enter this amount.
Alimony received
Alimony received is money you get from a spouse you no longer live with, or a former spouse, if paid to
you as part of a divorce agreement, separation agreement, or court order. Payments designated in the
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
agreement or ordered as child support or as a non-taxable property settlement aren’t alimony. For more
information, see IRS Publication 504 (page 12).
If you select “alimony received,” you’ll be asked to enter the amount. You’ll also be asked how often
you get this amount.
Other income
You might have other types of income that aren’t listed above. If you do, select “other income.” If you’re
a member of the clergy or a religious order, exclude the same income excluded on your federal income
tax return.
If you select “other income,” you’ll be asked if you have income from any of the following sources. If
you do, enter the amount. You’ll also be asked how often you get that amount.
• Canceled debts: If you incurred a debt from a loan or from buying something on credit and a
portion of the amount you owed was discharged or forgiven, the amount of the forgiven
debt is generally income. For more information, see IRS Publication 17, chapter 12.
•
Court awards: If you were involved in and got money from a lawsuit, the money you got
may be taxable. Examples of money from lawsuits that isn’t taxable are amounts awarded
for personal physical injury or sickness and an amount you get as compensation for
damages to your property if the payment is less than the amount paid for the property.
Payments to compensate a person for lost wages or punitive damages awards are examples
of taxable court awards. For more information, see IRS Publication 17, chapter 12.
•
Jury duty pay: If you’re being paid for jury duty service, enter how much you’re getting,
including reimbursement for transportation. If the money you get from jury duty goes
straight to your employer, don’t enter it here.
•
Cash support: You’ll see this income type listed as an option if someone who isn’t your
parent or your spouse claims you as a dependent on their tax return, and they’re including
you on their application for health coverage. If so, enter the amount that you get from the
person who claims you as a tax dependent. For example, if the tax filer gives you $200 per
month to help pay for rent or other living costs, include that amount here. Don’t include inkind support that the tax filer provides, for example, the value of room and board, or clothes
purchased by the tax filer. Only enter cash support is you’re a tax dependent of someone
other than your parent or spouse.
•
Gambling, prizes, or awards: This includes lottery winnings. It doesn’t include prizes that
aren’t taxable, like most academic scholarships. For information about Indian gaming per
capita payments, see “Income Questions for American Indians and Alaska Natives,”
below.”
•
Other: If you have other types of income, you should still list it in your application. You don’t
need to tell us about child support, veteran’s payments, or Supplemental Security Income
(SSI). Some income types aren’t taxable, and whether or not you get them won’t affect
eligibility for help paying for health insurance. Here are some other types of income you
don’t need to tell us about:
o Workers’ compensation or other damage awards for physical injury or sickness
o Gifts, inheritances, and loans
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o
Public assistance benefits from programs like TANF, SNAP, and WIC
Individuals & Families: Applying for Coverage Help Text
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o
Federal tax refunds and credits like the Earned Income Tax Credit and Child Tax
Credit
If you select “other” from this list you’ll be asked if you get a scholarship or grant for
educational expenses. Many scholarships aren’t taxable, so you don’t need to enter amounts
from those scholarships. If the scholarship or grant is taxable, enter the amount and how often
you get it. Remember, this won’t count for your income for Medicaid and the Children’s Health
Insurance Program (CHIP), as long as you’re using the scholarship or grant to pay for expenses
like tuition and books. You’ll also enter any income you get from a work-study job.
Income deductions
You’ll answer questions about things that can be deducted on your tax returns. Telling us about them
could make the cost of health coverage a little lower.
What deductions should I enter?
These deductions are listed on the front page of an IRS 1040 form, including:
• Alimony you pay
• Student loan interest you pay
• Educator expenses if you’re a teacher and pay for supplies out-of-pocket
• Moving expenses if you’re moving to live much closer to your job
• Contributions to your individual retirement account if you don’t have a retirement account
through a job
• Tuition costs for school if you pay for the costs out-of-pocket and deduct them on your tax
return on line 34
When you tell us about deductions, you’ll enter the amount and also how often you pay it, like
“monthly” or “yearly.”
What deductions shouldn’t I enter?
Don’t tell us about things like charitable contributions or home mortgage interest, which can be
deducted in a different place on the IRS 1040 form. You shouldn’t enter a cost that you already
considered in your answer to net self-employment or rental income.
If you’re not sure how much you can deduct, see IRS Tax Topics - Adjustments to Income.
Income questions for American Indians and Alaska Natives
If you’re American Indian or Alaska Native, you’ll be asked if any of your income comes from these
sources:
• Per capita payments from your tribe that come from natural resources, usage rights,
leases or royalties: These are payments from certain legal settlements. Enter any per capita
payments that you get from certain settlements of tribal trust cases between the U.S. and
those Indian tribes.
• Payments from natural resources, farming, ranching, fishing, leases, or royalties from land
designated as Indian trust land by the Department of Interior (including reservations and
former reservations): Payments from land held in trust by the Interior Department for a
member of an Indian tribe. If you receive this, enter payments from natural resources,
farming, and ranching on allotted land held in trust for you by the Interior Department.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
•
Money from selling things that have cultural significance: These are payments from selling
tangible items that have cultural significance, like documents, art work, or clothing.
Your answers won’t be counted when we decide whether or not your family is eligible for Medicaid and
the Children’s Health Insurance Program (CHIP). This income will still be included when your yearly
income is calculated for purposes of your eligibility for tax credits to help you pay for health coverage.
You may need to send us proof of income.
For more information on American Indians and Alaska Natives, click here.
Information about income you’ll earn in 2014
Your application may show your income for the year and ask if you’ll make the same amount next year.
Or it may ask you to estimate what you think you’ll make. The amount of income on your tax return will
be used to decide how much you can get paying for health coverage. We’ll also consider any nontaxable Social Security benefits that you get now, which aren’t reported on a tax return.
You may be asked one or more of these
questions...
Based on what you told us, if your income is
steady month-to-month, then it’s about [your
amount] per year. Is this how much you think you
will get in 2014?
Do you expect your yearly income to be the same
as what was reported on your 2012 federal income
tax return?
Based on what you know today, how much do you
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
More information and/or how to answer…
Select “Yes” if:
• You think your income might change, but you
aren’t able to estimate how it will change.
Later on, if your income does change, you
report the change, or
• You don’t have a specific reason to think that
your income will be different in coming
months from what it is this year.
Select “No” if you know this your income will
change, for example because you only work some
months of the year, or your income is higher or
lower at certain times each year. You’ll be asked
another question to find out how the income will
change.
Select “Yes” if you expect your income in 2014 to
be about the same as in 2013.
Select “no” if:
• You know that your income in 2014 will be
higher or lower, for example because of a
change in job or a change in salary or wages.
Then, you’ll be asked to make an estimate for
the 2014 income amount.
• You get Social Security benefits now, and you
expect the amount to change in 2014. You can
include the correct estimate of your 2014
Social Security benefits.
If you know your income will change next year,
think you’ll make in 2014?
What do you expect your yearly income will be in
2014?
we’ll ask how much you think you’ll make. We ask
about this because some people can get tax credits
to help pay for their health insurance. To
determine the tax credit amount, you must enter a
yearly income estimate.
If you tell us that your income will be different in
2014, we’ll ask if you expect changes to income
you already told us about. We may also ask if you
expect a different kind of income that you didn’t
get before.
• If you’re not sure how much your income will
be, select the calculator for some help adding
it up.
• If you’re not sure if you’ll continue getting a
certain type of income or how it will change,
enter your best guess. You can tell us later if
something changes.
• If you’re American Indian or Alaska Native,
include income you told us about, even if it’s
from your tribe or tribal resources, as long as
that income is taxable.
When you’re totaling your income, include income
from jobs, self-employment, Social Security
(taxable and non-taxable, but not Supplemental
Security Income (SSI)), unemployment, retirement,
investments, pensions, rental income, and other
taxable income. Don’t include money you get as
child support, gifts, SSI, veterans’ disability
payments, or workers’ compensation. For more
information, see IRS Publication 525, pages 27-29,
31.
If you’re pretty sure how much your income will
be in 2014, enter your best estimate.
Is your monthly income (before taxes) more than a
certain amount? (See your application for the
specific dollar amount.)
If you don’t know how much will be earned in
2014, select “I don’t know,” and don’t enter an
amount.
When you total your income this month, include
income from jobs, self-employment, social security
(taxable and non-taxable), unemployment,
retirement, investments, pensions, rental income,
and other taxable income.
Don’t include money you get as child support,
gifts, SSI, or veterans’ disability payments, or
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Revised: 09/12/2013
workers’ compensation. For more information, see
IRS Publication 525, pages 27-29, 31.
Why do we ask for this information?
Some people, like seasonal workers, have a
different income each month. You may get extra
help paying for health coverage this month if you
aren’t working this month or earning less this
month for another reason. We need to know your
income to get you the help you may need.
Family & household
How do I apply for coverage for myself and/or my family?
You’ll be asked how many people in your family and household want health coverage, including
yourself. Count each person in the family or household who’s applying for health coverage today. For
example, if you’re the only person who wants health coverage, choose “1.” If a parent doesn’t need
coverage but his or her child does, choose “1.” If a couple, their 2 children, and another family member
all want coverage, choose “5.”
After you tell us how many people want coverage, you’ll fill out information for each person in your
family and household who wants coverage. Enter the name of each person who wants coverage. If this
person has only one name, enter “Unknown” for the first name, and enter their name as the “Last
name.”
What about the people on my application who aren’t applying for health
coverage?
If a question asks you about “someone else who isn’t applying for health coverage,” check the box if
there’s anyone in your household you haven’t told us about yet. This person may be submitting his or
her own Marketplace application or might already have health coverage. We’ll need to know about all
the people in your household to tell you how much help people who do want health coverage can get.
We won’t ask about citizenship or immigration for household members who don’t want health
coverage. It’s also optional for you to tell us their Social Security numbers (SSNs), although entering their
SSNs could speed up the process for family members who do want help paying for coverage.
What do I need to enter about each person?
You’ll be asked questions about you and your family. These questions may ask about your federal
income tax returns.
You may be asked...
Do you plan to file a federal income tax return for
2014?
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
More information and/or how to answer…
If you’ll file a federal income tax return for 2014,
you may be able to get help paying for health
coverage through a new tax credit. If you don’t file
a tax return, you or your family may be eligible for
other types of free or low-cost health benefits. Tell
us if you plan to file so we know what you’re
eligible for.
Most people file a federal income tax return each
year, even if they have a limited income. If you’re
not sure if you need to file a tax return, click here.
If you file taxes, we need to know more about who
you claim as dependents on your tax return. If you
don’t file taxes, we need to know who you live
with.
Are you married?
Do you plan to file a joint federal income tax
return with your spouse for 2014? (You may be
asked this if you’re married.)
Which tax return?
The tax return for 2014 means the tax return on
which you report your income in 2014. Most
people file this return during 2015.
• If you’re separated but not divorced,
select “Yes.”
• If you live with your partner, but aren’t
legally married, select “No.”
• If you have a same-sex spouse, select
“Yes.” Each state has its own rules about
same-sex marriage. Click here for a fact
sheet to help same-sex couples navigate
the Marketplace.
If you’re a married couple and you agree to file a
joint federal income tax return, you and your
spouse report combined income information on
one tax return. To be eligible for a tax credit to
help pay for health coverage for your family, you
and your spouse must file a joint federal income
tax return for the year you want health coverage.
If you’re a married couple, but you haven’t filed
joint returns in the past, but you plan to file
jointly, you can select “Yes.” Spouses may file a
joint return even if just one of them had income
for the year.
If you’re a married couple and you want to file
federal income tax returns separately, you can
still get help paying for health coverage if you
qualify for Medicaid or the Children’s Health
Insurance Program (CHIP).
Information for same-sex couples
Under current law, married same-sex couples can
file joint federal income tax returns. If this samesex couple plans to file a joint tax return, select
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“Yes.” Click here for a fact sheet to help same-sex
couples navigate the Marketplace.
Do you live with your spouse? (You may be asked
this if you’re married.)
Will you (and your spouse, if you’re married) claim
dependents on your federal income tax return for
2014?
Which tax return?
The tax return for 2014 means the tax return on
which you report the income received in 2014.
Most people send in this return during 2015.
You live with your spouse if you spend most nights
in the same household. You can still count as living
with your spouse if you’re away temporarily, like
for school or a short-term job, if you’re expected
to return.
A dependent is someone who gets most of his or
her financial support from someone else. Children,
other family members, or other people who live
with the tax filer can be dependents.
Most tax filers claim their own children as their
dependents if the children are 19 or younger, fulltime students younger than 25, or are disabled.
Tax filers also might claim other people as
dependents when they pay for most of their costs,
like housing, food, and clothing.
To find out more about dependents, click here.
Will you (and your spouse, if you’re married) claim
different dependents on your 2015 tax return?
The rules for who qualifies as a person’s tax
dependent are in Table 5 on page 12 of IRS
Publication 501. This person’s child, stepchild,
foster child, or sibling (if younger) is likely to be his
or her dependent if they live with this person,
don’t provide more than half of their own support
for the year, and is younger than 19 or a full-time
student younger than 25.
If you and/or your family want health coverage for
next year, tell us about any expected differences
between who you claim as dependents now, and
why you’ll claim on the tax return for 2015.
Sometimes dependents change from one year to
another if:
• Parents alternate claiming children as
dependents.
• A child turns 19 or 25 next year and won’t
be claimed.
• A dependent moved out of the home
recently and won’t live with the tax filer
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•
next year.
A dependent has a new job and will
support his or herself next year.
You don’t need to tell us here about a child that
you expect to be born, or a dependent that may
pass away.
Will you be claimed as a dependent on someone
else’s federal income tax return for 2014?
If you’re not sure about changes, you can select
“No,” and report the change when it happens.
A dependent is someone who gets most of his or
her financial support from someone else. Children,
other family members, or other people who live
with the tax filer can be dependents.
For example, you might be claimed as a dependent
if you live with someone who pays for most of
your costs, like housing, food and clothing. Even if
you don’t live with the person who pays these
costs, they may be able to claim you as a
dependent if they’re related to you and your
income is less than a certain amount.
The rules for who qualifies as a person’s tax
dependent are in Table 5 on page 12 of IRS
Publication 501.
Who is the tax filer who will claim you on their
income tax return? (This will be asked if you
selected “Yes” to the item above.)
How are you related to the tax filer?
To find out more about dependents, click here.
If a couple is married and plans to file a joint
federal income tax return, you can select 2 tax
filers.
A tax filer is someone who files a federal income
tax return to report their own income (and their
spouse’s income if filing a joint return), and enters
their name(s) at the top of the tax return form.
Relationships between people can affect how we
count family size, which makes a difference for
how much help you and your family can get paying
for health coverage.
If the dependent is this person’s legally adopted
child, choose “son/daughter” from the relationship
choices, even if another relationship also applies.
Who’s a dependent?
When you file a tax return, your child, stepchild,
foster child, or sibling (if younger) is likely to be
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your dependent if he or she lives with you, doesn’t
provide more than half of his or her own support
for the year, and is younger than 19 or a full-time
student younger than 25.
What should I select?
• Domestic partner: Select this if these 2
household members are registered
domestic partners of same-sex spouses
according to state law. Each state has its
own rules about domestic partners.
Domestic partners aren’t considered
married for purposes of federal law.
• Son/daughter: Select this for biological
sons and daughters, as well as legally
adopted sons and daughters. For a legally
adopted son or daughter, select this
relationship option even if another option
is also true, like grandparent or cousin.
• Brother/sister: Select this for brothers,
sisters, half-brothers, or half-sisters.
Do you want to provide the claiming tax filer’s
information, so the tax filer can apply for a tax
credit?
For more information on relationships, click here.
The claiming tax filer (or tax filer) is the main
person filing a household’s federal income tax
return. If a spouse files a joint return with this
person, he or she is a tax filer, too. Anyone claimed
as a dependent on this person’s federal income tax
return is a “tax dependent.”
Select “Yes” if you can get the tax filer’s
information, for example, if he or she lives with
you. This will give the tax dependent the best
chance of getting help paying for coverage.
If it’s hard to get the tax filer’s information, for
example, if the tax filer won’t share it, you can
select “No” and continue. Later, the tax filer can
submit his or her own Marketplace application to
get help paying for health coverage for his or her
household.
If a tax dependent and the family members that
the tax dependent lives with have a low income,
then they may be eligible for health coverage
through Medicaid or the Children’s Health
Insurance Program (CHIP).
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
You can continue with this application now to see
if you can get a tax credit to pay for health
insurance for your dependent instead.
If you select “No,” this dependent won’t get a tax
credit, but he or she might still be eligible for other
help paying for health coverage, including
Medicaid and CHIP. The dependent won’t get a tax
credit because we need details about the claiming
tax filer’s income and other dependents to
determine eligibility for tax credits. If the claiming
tax filer’s information isn’t included here, the tax
filer can submit his or her own Marketplace
application to get help paying for health coverage
for his or her whole household, including this
dependent.
If you see this statement, you can continue with
your Marketplace application now to see if you can
get a tax credit to help pay for this child’s health
insurance instead of Medicaid or CHIP.
If the child is enrolled in Medicaid or CHIP, you
can’t get a tax credit to help pay for the child’s
health coverage.
You may also be asked these questions:
If all of these apply to you…
You may be asked…
• You’re a claiming tax filer If you want to enter your SSN.
You may choose not to enter
(the person who claims
your SSN.
another person as a
dependent on his or
her tax return).
• You didn’t enter your
Social Security number
(SSN) on your
application.
• Some of your family
members may be eligible
for a premium tax credit.
• You don’t expect to file If you want to change your
taxes or be claimed as a answers about how you (or
dependent on someone other people on your
application) will file their taxes.
else’s tax return.
• You may be eligible for a
If you want to go back and
premium tax credit.
change your previous answer,
select “Yes.” If you select “No,”
you won’t be eligible for lower
costs.
If you want to change your
• You’re married.
• You don’t expect to file a answer about how you will file
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Why?
SSNs are used to verify your
identity and obtain data to help
with your eligibility
determination.
For more information on SSNs,
click here.
You’re being asked this question
because you indicated you won’t
be filing a federal income tax
return or be claimed as a
dependent on another person’s
tax return. To qualify for a
premium tax credit, you must
file a federal income tax return
or be claimed as a dependent on
someone else’s tax return.
You’re being asked this question
because you indicated that you
•
•
•
•
joint tax return.
You may be eligible for a
premium tax credit.
You’re living outside the
state.
You didn’t enter a city,
ZIP code, and/or county.
You may be eligible for a
premium tax credit or
enrollment in a
Marketplace health plan.
your taxes.
If you want to go back and
change your previous answer,
select “Yes.” If you select “No,”
you won’t be eligible for lower
costs.
You’ll be asked to enter your
city, ZIP code, and county, if
applicable.
and your spouse file your federal
income tax returns separately.
To qualify for a premium tax
credit, you must file jointly.
You previously indicated that
you’re living outside the state.
Tell us where you live in this
state so we can figure out what
programs are available to you. If
you don’t enter this information,
you won’t be able to get
coverage in this state.
Tell us more about each person, including disability questions
You may be asked...
Do you have a physical disability or mental health
condition that limits your ability to work, attend
school, or take care of your daily needs?
Do you need help with the activities of daily living
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
More information and/or how to answer…
Select “Yes” if one or more of these conditions
applies to you:
• You’re blind, deaf, or hard of hearing.
• You get Social Security Disability Insurance
(SSDI) or Supplemental Security Insurance
(SSI).
• You have a physical, cognitive, intellectual,
or mental health condition, which causes
one or more of these:
o Difficulty doing errands like visiting
a doctor’s office or shopping.
o Serious difficulty concentrating,
remembering, or making
decisions.
o Difficulty walking or climbing
stairs.
If we ask this question about a child, select “Yes” if
one or more of these conditions applies to the
child:
• They have limited ability to do the things
most children of the same age can do.
• They need or use more health care than is
usual for most children of the same age.
• They get special education services or
services under a Section 504 plan.
Activities of daily living include seeing, hearing,
through personal assistance services, a nursing
home, or other medical facility?
walking, eating, sleeping, standing, lifting, bending,
breathing, learning, reading, communicating,
thinking, and working.
If a person has a cognitive or mental health
condition, they may need help with these activities
of daily living through coaching or instruction.
Are you a full-time student?
Do you have a parent living in the same state
where you go to school? (You may be asked this if
you’re a full-time student.)
Are you American Indian or Alaska Native?
If a person only needs help because he or she is
too young to be able to do these activities without
help, select “No.”
If you aren’t sure whether you’re a full-time
student, check with your school.
A parent can be a birth, adoptive, step, or foster
parent.
Why are we asking this question?
We want to make sure people get health coverage
in the right state. Sometimes full-time students get
health coverage in the state where their parents
live instead of the state where they go to school.
American Indians and Alaska Natives can still get
services from the Indian Health Services, tribal
health programs, or urban Indian health programs,
and the results of this application won’t change
that.
For more information on questions asked to
American Indians and Alaska Natives, click here.
Are you pregnant?
How many babies are you expecting during this
pregnancy?
Were you ever in foster care?
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
Why are we asking this question?
American Indians and Alaska Natives may get extra
help—they may not have to pay cost sharing and
may get monthly Special Enrollment Periods.
Some pregnant women get extra help paying for
health coverage, depending on the family’s
income.
If any of the women on your application are
pregnant, telling us here will help the whole
household get the most help possible paying for
health coverage.
If you’re pregnant, telling us how many babies
you’re expecting during this pregnancy will help
the whole household get the most help possible
paying for health coverage.
Why are we asking this?
Were you getting health care through your state
Medicaid program?
Sometimes young adults who were in foster care
can get extra help paying for health coverage.
Why are we asking this?
Sometimes young adults who were in foster care
can get extra help paying for health coverage.
Parent and caretaker relative questions
Some parents and other adults can get more help paying for health coverage if they take care of a child
under a certain age. People who don’t take care of children may still be able to get help paying for
health coverage. You should continue with the application no matter how you answer this question. You
may also be asked these questions:
You may be asked...
If you live with one or more child or children under
a certain age and if you’re the main person taking
care of that child or children.
More information and/or how to answer…
To be the main person taking care of a child, you
must live with the child, pay for necessary items
(like the child’s food and clothing), and help the
child with daily activities (like school and
transportation).
Only one person can be the main person taking
care of a child, except if 2 spouses or domestic
partners take care of a child together. In that case,
both adults in that relationship are considered the
“main person.”
Who do you live with and take care of?
Select your relationship to the child.
Do any of these children live with more than one
parent, through birth or adoption?
If you don’t take care of children, you may still be
able to get help paying for health coverage. You
should continue with the application no matter
how you answer this question.
List the child’s name, or choose their name from
the list under the question.
Only adults with certain relationships to the child
they care for can be considered the caretaker of
the child for eligibility for help paying for health
coverage.
If you don’t take care of children, you may still be
able to get help paying for health coverage. You
should continue with the application no matter
how you answer this question.
If this child is living with one parent and one
stepparent, select “No.”
If this child is living with one parent and one
stepparent who’s legally adopted the child, select
“Yes.”
Individuals & Families: Applying for Coverage Help Text
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Address questions
Where you live can affect what health coverage you’re eligible for. Health coverage programs require
people in their programs to be residents in the state where they can get help paying for health coverage.
You may be asked...
What’s your home address?
What’s your mailing address?
Are you living outside of the state temporarily?
More information and/or how to answer…
We’ll use this address to indicate whether or not
you’re a resident of the state where you’re seeking
health coverage.
If we’re asking this question about a child who
splits time between 2 parents who don’t live
together, choose the address where the child
spends most of his or her nights.
We may use this address for health insurance plan
rating, so pick a mailing address in the state you
live in, if you can.
Sometimes people leave their homes for a period
of time, like to go to school, for a short-term job,
or for a short-term military deployment. Children
may sometimes live in a different state for a
period of time if they’re staying with a family
member during a summer break or attending
boarding school.
To decide whether the period of time is
temporary, we’re asking whether there’s a plan for
you to return to the state in the question. If you do
plan to return, select “Yes.”
Where will you live in the state?
Why are we asking this?
If you’re living out of the state temporarily, you
can still be considered a resident of the
state. Generally, people must live in the state to be
residents in the state where they get help paying
for health coverage.
To explain that you’re temporarily out of state, tell
us where you’ll live in the state.
Race and ethnicity questions
We ask for your race, ethnicity, and preferred language so we can make sure everyone gets the same
access to health care. This information is confidential, and it won’t be used to help decide what health
programs people are eligible for. Providing your race and ethnicity is optional, so you don’t need to
answer these questions to complete your application.
Relationship questions
You’ll be asked to define the relationships between the people on your application. When asked to
define the relationship, you can choose from this list:
• Spouse
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•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Domestic partner: An unrelated adult household partner who doesn’t have a legal marriage
commitment.
Parent
Stepparent
Parent’s domestic partner: An unrelated adult household partner of a parent who doesn’t have
a legal marriage commitment.
Son/daughter
Stepson/stepdaughter
Child of domestic partner: A child of an unrelated adult household partner who doesn’t have a
legal marriage commitment.
Brother/sister
Uncle/aunt
Nephew/niece
First cousin
Grandparent
Grandchild
Other relative: Other relationship by blood or marriage.
Other unrelated: Other relationship not by blood or marriage.
If you select “other relative” or “other unrelated,” you’ll be shown an additional list of relationships.
Then, you can choose the relationship from this list:
• Adopted son/daughter
• Foster child: A person up to age 21 who’s been placed in an institution, group home, or private
home of a state-certified caregiver referred to as a "foster parent" by the state. In some cases, a
child living with someone under a pre-adoption agreement may qualify as a foster child.
• Guardian: A person who’s responsible for the care and management of a minor child.
• Court-appointed guardian: An adult who’s been given legal responsibility by the court to
manage the affairs of another person. Usually this is an adult who’s given legal responsibility to
care for a child by the court, but a guardian can also be an adult with a legal responsibility to
manage the affairs of another adult.
• Former spouse: An ex-husband or ex-wife.
• Collateral dependent: A relative by blood or marriage who lives in the home and is dependent
on another person for a major portion of their support.
• Sponsored dependent: A person between 19-25 that relies on another adult for support, and
isn’t attending school. (Note: Health plans may define the age range differently.)
• Dependent of a minor dependent: A child of a parent under 18.
• Ward: A person who’s under the care or responsibility of a parent or court-appointed guardian.
Wards may be either minor children or disabled adults.
• Unrelated: Related by blood or marriage.
• None of these relationships
Citizenship and immigration status questions
Are you a U.S. citizen or U.S. national?
• A U.S. citizen is someone who’s born in the United States or has been naturalized as a U.S.
citizen (became a U.S. citizen after birth).
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•
A U.S. national is someone who’s a U.S. citizen or a person who isn’t a U.S. citizen, but owes
permanent allegiance to the U.S. (like people born in American Samoa or Swains Island).
You don’t have to be a U.S. citizen or U.S. national to qualify for health coverage. When you’re asked if
you’re a U.S. citizen or U.S. national, you can select “No” to view a list of other eligible immigration
statuses, and check the box if you have one of those eligible immigration statuses.
We’ll verify this information with Social Security, based on the consent you gave at the start of your
application.
Are you a naturalized or derived citizen?
• A naturalized citizen:
o A person who became a U.S. citizen after birth.
o Can have either a “Certificate of Naturalization” (Form N-500) or a “Certificate of
Citizenship” (Form N-560 or N-561).
• A derived citizen:
o A person who was adopted or born abroad to at least one U.S. citizen parent.
o Citizenship may be conveyed to children through the naturalization or parents, to
foreign-born children adopted by U.S. citizen parents, or through birth abroad to at least
one U.S. citizen parent.
o A person who acquires U.S. citizenship may have a “Certificate of Citizenship” (Form N560 or N-561).
Document types for naturalized or derived citizens
If you’re a naturalized or derived citizen, select the document to show your status:
If you have a:
Naturalization certificate
Certificate of Citizenship
You’ll need these numbers from your document:
•
Alien registration number
•
Naturalization certificate number
•
Alien registration number
•
Certificate of Citizenship number
If you need help finding information on your document or help completing this section, call the
Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325.
To verify your naturalized citizen status, enter the alien number (also called the alien registration
number). This number starts with an “A” and ends with 8-9 numbers. The alien number can be found at
the top, right-hand corner of the “Certificate of Naturalization” (Form N-500). Also enter the “Certificate
of Naturalization” number. The Naturalization Certificate number can be found at the top, right-hand
corner of the “Certificate of Naturalization” (Form N-550).
To verify your citizenship status, enter the alien number (also called the alien registration number). This
number starts with an “A” and ends with 8-9 numbers. The alien number can be found at the top, righthand corner of the “Certificate of Citizenship” (Form N-560 or N-561). Also enter the “Certificate of
Citizenship” (Form N-560 or N-561) number. Also enter the “Certificate of Citizenship” number. This
number can be found at the top, right-hand corner of the “Certificate of Citizenship” (Form N-560 or N561).
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Immigration status questions
You may be asked if you have eligible immigration status. Here’s the list of eligible immigration statuses
for health coverage through the Marketplace:
• Lawful permanent resident (LPR/Green Card holder)
• Asylee
• Refugee
• Cuban/Haitian entrant
• Paroled into the U.S.
• Conditional entrant granted before 1980
• Battered spouse, child, or parent
• Victim of trafficking and his or her spouse, child, sibling, or parent
• Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or
under the Convention against Torture (CAT)
• Individual with non-immigrant status (including worker visas, student visas, and citizens of
Micronesia, the Marshall Islands, and Palau)
• Temporary Protected Status (TPS)
• Deferred Enforced Departure (DED)
• Deferred Action Status (Deferred Action for Childhood Arrivals (DACA) isn’t an eligible
immigration status for applying for health coverage.)
• Applicant for:
o Special Immigrant Juvenile Status
o Adjustment to LPR Status with an approved visa petition
o Victim of trafficking visa
o Asylum who has either been granted employment authorization, OR is under 14 and has
had an application for asylum pending for at least 180 days.)
o Withholding of Deportation or Withholding of Removal, under the immigration laws or
under the Convention against Torture (CAT) who has either been granted employment
authorization, OR is under 14 and has had an application for withholding of deportation
or withholding removal under the immigration laws or under the CAT pending for at
least 180 days.)
• Certain individuals with employment authorization document:
o Registry applicants
o Order of supervision
o Applicant for Cancellation of Removal or Suspension of Deportation
o Applicant for Legalization under IRCA
o Applicant for Temporary Protected Status (TPS)
o Legalization under the LIFE Act
• Lawful temporary resident
• Granted an administrative stay of removal by the Department of Homeland Security (DHS)
• Member of a federally recognized Indian tribe or American Indian born in Canada
• Resident of American Samoa
If you have one of the statuses above, check the box on the application.
If you check this box and are applying for help paying for health coverage, your information will only be
used for determining access to health coverage through the Marketplace.
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If you check this box and aren’t applying for help paying for health coverage, your information will only
be used for determining access to health coverage in the Marketplace and won’t be used for
immigration enforcement purposes. Also, use of health care services through the Marketplace won’t be
considered to be a public charge.
If there are people on your application who aren’t applying for health coverage, you don’t need to
provide their citizenship or immigration status.
If you’re status isn’t listed above, you may still be able to get help paying for emergency services,
including for labor and delivery of a baby. In some states, pregnant women may also be able to get
health coverage.
If you’re not sure which status applies to you (or someone on your application), call the Marketplace Call
Center at 1-800-318-2596 for help with this section. TTY users should call 1-855-889-4325. For more
information on the statuses above, visit uscis.gov/glossary.
Immigration document types
Here’s a list of the documents that can be used to show your immigration status. Select the document
type from the list that corresponds with your most current documentation.
If you have a:
Permanent Resident Card, “Green Card,” (I-551)
Reentry Permit (I-327)
Refugee Travel Document (I-571)
Employment Authorization Card (I-766)
Machine Readable Immigrant Visa (with temporary
I-551 language)
Temporary I-551 Stamp (on passport or I-94/I-94A)
Arrival/Departure Record (I-94/I-94A)
Arrival/Departure Record in foreign passport (I-94)
Foreign passport
Certificate of Eligibility for Nonimmigrant Student
Status (I-20)
Certificate of Eligibility for Exchange Visitor Status
(DS2019)
Notice of Action (I-797)
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You’ll need this information from your
document:
• Alien registration number
• Card number
• Alien registration number
• Alien registration number
• Alien registration number
• Card number
• Expiration date
• Category code
• Alien registration number
• Passport number
• Alien registration number
• I-94 number
• I-94 number
• Passport number
• Expiration date
• Country of issuance
• Passport number
• Expiration date
• Country of issuance
• SEVIS ID
•
SEVIS ID
•
Alien registration number or an I-94
number
•
Other
Alien registration number or an I-94
number
• Describe the type or name of the
document.
See below for more detailed information on these document types.
If you need help finding information on your document or help completing this section, call the
Marketplace Call Center at 1-800-318-2596.
More information about these document types
• Permanent Resident Card (“Green Card,” I-551):* I-551 Permanent Resident Cards (or “Green
Cards”) are issued to eligible immigrants who enter the U. S. to permanently live. To verify your
eligible immigration status, enter the alien number (also called the alien registration number),
which starts with an “A” and ends with 8-9 numbers. Also enter the card number, which is listed
on the card. On the I-551, this number is listed under the heading “A#” or “USCIS#.”
•
Reentry Permit (I-327): Re-entry permits (or I-327s), when valid, allow permanent residents to
leave and re-enter the U.S. These permits are located in multi-purpose booklets called “U.S.
Travel Documents.” Enter the alien number (also called the alien registration number), which
starts with an “A” and ends with 8-9 numbers. This number is located at the top, right-hand side
of the document.
•
Refugee Travel Document (I-571): Refugee Travel Documents (or I-571s) may be issued to
refugees and asylees for travel purposes. These permits should be located in multi-purpose
booklets called “U.S. Travel Documents.” Enter the alien number (also called the alien
registration number), which starts with an “A” and ends with 8-9 numbers. This number is
located at the top, right-hand side of the document.
•
Employment Authorization Card (EAD, I-766):* Employment Authorization Cards (or I-766s) are
issued to people who are authorized to work temporarily in the U.S. Enter the Alien number
(also called the alien registration number), which starts with an “A” and ends with 8-9 numbers.
Also enter the care expiration date, as listed on the card.
•
Machine Readable Immigrant Visa (with temporary I-551 language):* Machine-readable
immigrant visas (MRIVs) with temporary I-551 language are documents indicating permanent
resident status. Enter the Alien number (also known as alien registration number), which may
start with an “A” and end with 8-9 numbers. Some MRIVs may not have an “A” before the
number. Also enter the passport number.
•
Temporary I-551 Stamp (on passport or I-94, I-94A):* Temporary I-551 stamps can be used to
attest to permanent resident status. A temporary I-551 stamp will have a handwritten or
stamped issue date and a “valid until” date. This stamp can be found on the front of an I-94
form or in the foreign passport. Enter the alien number (also called the alien registration
number), which starts with an “A” and ends with 8-9 numbers.
•
Arrival/Departure Record (I-94, I-94A):* I-94 Arrival/Departure Records are issued to people
when they enter the U.S. The bottom portion of the I-94 should be stapled to the passport.
Enter the I-94 number, which is usually found at the top, left-hand side of the form. The I-94
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paper form will no longer be provided upon arrival to the U.S., except in limited circumstances.
If a person doesn’t have a paper version of the I-94, they can get a copy at cbp.gov/I94.
•
Arrival/Departure Record in foreign passport (I-94):* I-94 Arrival/Departure Records are issued
to non-immigrants when they enter the U.S. The bottom portion of the I-94 should be stapled to
the foreign passport. Enter the I-94 number, which is usually found at the top, left-hand side of
the form. Also enter the passport number and expiration date.
•
Foreign passport: Passports from foreign countries are used when non-immigrants enter the
U.S. Enter the passport number and passport expiration date.
•
Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20): I-20 Certificates of
Eligibility for Non-immigrant Student Status are the documents that support applications for
student visa statuses (F-1s or F-2s). Enter the SEVIS ID number, which is located at the top, righthand side of the document.
•
Certificate of Eligibility for Exchange Visitor (J-1) Status (DS2019): Certificates of Eligibility for
Exchange Visitor Status (DS-2019s) are the documents that support applications for exchange
visitor visa statuses (J-1s or J-2s). Enter the SEVIS ID number, which is located at the top, righthand side of the document.
•
Notice of Action (I-797):* Notices of Action (I-797s) are communication from U.S. Citizenship
and Immigration Service about immigration benefits. I-797s can be used for different purposes,
like an approval notice, receipt notice, or a replacement for an I-94. Sometimes these notices
have other documents attached to them, like I-360s (petitions for Amerasian, widow(er), or
special immigrant statuses).
If you need help finding information on your document or help completing this section, call the
Marketplace Call Center at 1-800-318-2596.
How do I enter document types?
When you enter your document type, you may need to enter one or more of these fields:
• Alien number: The alien number (also called the alien registration number) can be found on the
immigration document. It starts with an “A” and ends with 8-9 numbers.
• I-94 number: The I-94 number (also called the admission number) is printed on the I-94 or I-94A.
This is an 11-digit number and is usually found at the top, left-hand side of the document.
• Passport or document number: The passport or document number can be found on the
passport.
• Country of issuance: Select the country where the passport was issued.
• Passport expiration date: Enter the date the passport will expire. The expiration date should be
listed on the document.
• SEVIS ID number: The SEVIS ID is located at the top, right-hand corner of the document.
• Document expiration date: Enter the expiration date listed on the document.
• Category code: Enter the 3-digit code listed on the employment authorization document. This
code starts with an “A,” “B,” or “C.”
If you need help finding information on your document or help completing this section, call the
Marketplace Call Center at 1-800-318-2596.
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Other document and status type questions
If you said you had another document or status type (that wasn’t on the list above), you’ll be asked to
select which of these document types you have:
• Document indicating a member of a federally recognized Indian tribe or American Indian born in
Canada
• Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee
Resettlement (ORR)
• Office of Refugee Resettlement (ORR) eligibility letter (if under 18)
• Cuban/Haitian Entrant
• Document indicating withholding of removal
• Resident of American Samoa**
• Administrative order staying removal issued by the Department of Homeland Security
• Other
• None of these
See below for more detailed information on these other document and status types.
More information about other document types
• Document indicating a member of a federally recognized Indian tribe or American Indian born
in Canada: There are a several documents that can show you’re a member of a federally
recognized Indian tribe or that you’re an American Indian born in Canada, including membership
cards, letters, or other tribal documents. For American Indians born in Canada, this could also
include a birth certificate or other evidence of being born in Canada. You’ll need to upload your
document later on in the application process.
•
Certification from U.S. Department of Health and Human Services (HHS) Office of Refugee
Resettlement (ORR): This is a certification letter from the U.S. Office of Refugee Resettlement
that’s issued to an individual who is a victim of a severe form of trafficking. These letters state
victims are eligible for benefits and services.
•
Office of Refugee Resettlement (ORR) eligibility letter (if under 18): This is a letter from the U.S.
Office of Refugee Resettlement and indicates a child is a victim of a severe form of trafficking.
These letters state victims are eligible for benefits and services. You’ll need to upload your
document later on in the application process.
•
Cuban/Haitian entrant: People who are “Cuban or Haitian entrants” must be Cuban or Haitian
and may include one of these, for example:
o Granted parole into the U.S.
o Have an application pending for asylum.
o Granted special status under the immigration laws for nationals of Cuba or Haiti.
o Are a subject of removal proceedings.
If you’re Cuban or Haitian or you’re not sure, you can select this, and we can check our data
sources.
•
Document indicating withholding of removal (or “withholding of deportation”): There are
several documents that might show withholding of removal or deportation.
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•
Resident of American Samoa: A document showing you’re a resident of, or live in, American
Samoa. You’ll need to upload your document later on in the application process.
•
Administrative order staying removal issued by the Department of Homeland Security: A
document from the Department of Homeland Security (DHS) or a DHS Immigration Judge
showing you got an order staying removal or deportation. There are several documents that
might show you have an administrative order staying removal issued by DHS.
•
Other: If you don’t see your document or status type listed, describe or name another type of
immigration document issued by the U.S. Citizenship and Immigration Services, Immigration and
Customs Enforcement, or Customs and Border Protection. You if select “Other,” you’ll be asked
to enter:
o Description: Provide the name or describe the type of document you have.
o Alien number or I-94 number: Enter either the alien number (also called the as alien
registration number), which starts with an “A” and ends with 8-9 numbers or the I-94
number, which is 11 digits, listed on the immigration document.
•
None of these: Select this if nothing on this list applies to you. You can continue through the
application without selecting a document or status.
More questions about citizenship and immigration status
You may be asked more questions about your citizenship/immigration status, including:
• If your name on your application is the same name as on your document: If your name on your
immigration document is different than what’s shown, select “No,” and enter your name as it’s
listed on your document. We’ll use this to check this information with DHS.
•
If you’ve lived in the U.S. since 1996: To have lived “continuously in the U.S. means you haven’t
had a break or breaks of living in the U.S. for more than 90 consecutive days. If you came to live
in the U.S. before August 22, 1996, and have taken trips outside the U.S. for less than 30 days
per trip, or less than 90 days total, select “Yes.”
•
If you, your spouse, or your parent is an honorably discharged veteran or active-duty member
of the military: Select “Yes” if one of these applies to you (or your spouse, including surviving
spouse, or parent, if you’re an unmarried dependent child):
o You’re a veteran with honorable discharge.
o You’re on active duty in the Armed Forces of the U.S.
A spouse of a veteran or person on active duty can be a current spouse or an unmarried
surviving spouse.
•
If you forgot to check the immigration status:
o If you select “Yes,” you’ll have a chance to check the “eligible immigration status” box.
See above for the list of eligible immigration statuses.
o If you select “No,” you can continue with the application. You may still be able to get
help paying for emergency services, including for labor and delivery if you have a baby.
In some states, pregnant women may also be able to get health care coverage.
If you’re not applying for health coverage for yourself, we don’t need information about your
citizenship or immigration status.
Individuals & Families: Applying for Coverage Help Text
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Change in circumstances questions
You may be asked questions about life changes on your application to see if you (and anyone else on
your application) qualify for a Special Enrollment Period:
You may be asked…
Did any of these people lose health coverage in
the last 60 days?
If you selected a name for the question above,
you’ll be asked when this person lost their health
coverage.
If you answered the question above, you’ll be
asked if this person lost their health coverage
because he or she didn’t pay premiums.
Are any of these people going to lose their health
coverage in the next 60 days?
If you selected a name for the question above,
you’ll be asked when this person’s health coverage
will end.
Have any of these people been adopted or placed
for adoption in the last 60 days?
Did any of these people gain eligible immigration
status in the last 60 days?
If you selected a name for the question above,
you’ll be asked when this person gained eligible
immigration status.
Did any of these people move in the last 60 days?
If you selected a name for the question above,
you’ll be asked for the ZIP code (and possibly
county) of this person’s last address.
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More information and/or how to answer…
Select the name of anyone who lost health
coverage in the last 60 days for any reason.
Reasons for losing health coverage can include
losing or leaving a job that offered health
coverage, end of COBRA or Medicaid coverage, or
turning 26 and no longer being on a parent’s plan.
Tell us the last day this person could get health
services paid for by health coverage that ended.
Select “Yes” if the reason this person’s health
coverage ended was because he or she stopped
paying their premiums or voluntarily chose to
terminate their health coverage.
Select the name of anyone who’s going to lose
health coverage in the next 60 days for any reason.
Reasons for losing health coverage can include
leaving a job that offers health coverage or end of
COBRA, Medicaid, or school coverage.
Tell us the last day this person (or these people)
will get health services paid for by health coverage
that’s ending.
Select the name of anyone who’s been adopted or
placed for adoption in the last 60 days. A person is
“placed for adoption” if they’re a child who’s living
with a family and is in the process of being
adopted.
Select the name of anyone who’s gained eligible
immigration status in the last 60 days. Click here
for more information on eligible immigration
status.
This date may be listed on their immigration
documentation. For example, this may be the date
you received your green card, received your visa,
or were authorized to work.
Select the name of anyone who’s permanently
moved to another home within or outside of the
state.
Enter the ZIP code of the address this person
recently moved from.
American Indian and Alaska Native questions
American Indians and Alaska Natives may qualify for special benefits through the Marketplace. If you or
anyone else on your application is American Indian or Alaska Native, select “Yes” when you’re asked this
question.
How will enrolling in coverage through the Marketplace affect me?
American Indians and Alaska Natives who enroll in Medicaid, the Children’s Health Insurance Program
(CHIP), or the Marketplace can get or continue to get services from the Indian Health Service, tribal
health programs, or urban Indian health programs. They also may not have to pay cost sharing and may
get monthly Special Enrollment Periods.
How do I know if my tribe is “federally recognized?”
You’ll be asked if you’re a member of a federally recognized tribe. A federally recognized tribe is an
Indian or Alaska Native tribe, band, nation, pueblo, village, or community, or an Alaska Native Claims
Settlement Act (ANCSA) Corporation Shareholder (regional or village), that’s acknowledged by the
U.S. Department of the Interior as an Indian tribe.
How should I enter my state and tribe?
You’ll be asked to select your state and tribe. To select the state, use the drop-down menu to select the
state where the tribe is located. To select the tribe, use the drop-down menu to select the name of your
federally recognized tribe.
What’s the Indian Health Service?
The Indian Health Service is a federal agency that administers health programs and facilities for
American Indians and Alaska Natives.
What’s a tribal health program?
A tribal health program is a health care program operated by an Indian or Alaska Native Tribe or Tribal
organization. They are also known as tribal 638 programs or tribal health clinics.
What’s an urban Indian program?
American Indians and Alaska Natives living in urban areas that have urban health programs get Indian
Health Service urban program services. Urban health programs serve these people:
• Members or descendants of federally recognized tribes, bands, or other organized groups of
Indians, including those tribes, bands, or groups terminated since 1940
• Members of descendants (in the first or second degree) of state recognized tribes
• Eskimos, Aleuts, other Alaska Natives, or their descendants
Health services through Indian programs
You’ll be asked if you’ve ever gotten a health service from the Indian Health Service, a tribal health
program, or urban Indian health program or through a referral from one of these programs. Even if
you’ve only gotten a service once, select “Yes.” It doesn’t matter how long ago you got the service(s).
You also may be asked if you’re eligible to get health services through the programs listed above. In
addition to members of federally-recognized Tribes (as defined above), Indian health services are
available to people of federally recognized American Indian descent, including those of any Alaska Native
village or group, belonging to the American Indian community served by the local facilities and
programs. Non-American Indian/Alaska Native children under 19 who are the natural children, adopted
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children, stepchildren, foster children, legal wards, or orphans or eligible Indians are also eligible. NonAmerican Indian/Alaska Native spouses are also eligible if the federally recognized tribe of their spouse
passes a tribal resolution that makes spouses eligible.
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For information on American Indians and Alaska Natives regarding income, click here.
Other health coverage questions
What if I currently have health coverage?
You’ll be asked if you (or anyone else on your application) currently have health coverage. Some people
who already have health insurance can still get more help paying for health coverage. Other people who
already have insurance may not be able to get more help.
Even if some people on your application aren’t applying for coverage, we need to make sure they also
have health coverage. Sometimes parents and other people caring for children need to help children get
coverage to be eligible for Medicaid themselves.
If you have health coverage, you’ll be asked what coverage you have now. Select “limited-benefit
coverage (like a school accident plan)” if one of these applies to you:
• You’re enrolled in a health plan that doesn’t cover basic medical benefits.
• You don’t have access to the coverage because the covered services aren’t available in your
geographic area.
If you’re currently enrolled in a Pre-Existing Condition Insurance Plan (PCIP), select “Other limitedbenefit coverage” because this coverage will end in December.
What’s my policy number or member ID?
If you currently have health coverage, you may be asked for your policy number or member ID. This
number is usually on your insurance card. On the Medicare care example below, the policy
number/member ID is the “MEDICARE CLAIM NUMBER:”
Do I want help paying for medical bills for the last 3 months?
You may be asked if you want help paying for medical bills for the last 3 months. Medicaid may be able
to help you pay for medical care from the last 3 months, even if you weren’t enrolled in Medicaid at the
time you got medical care. Payment will depend on your family’s income at the time.
If someone on your application has medical bills and is eligible for Medicaid, the Medicaid agency will
follow-up to ask more about their medical bills.
Should I enter my Social Security number (SSN) for work history purposes?
Someone on your application who’s applying for coverage may be eligible for Medicaid of CHIP, but
because of eligibility requirements in the state related to eligible immigration status, he or she must
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have enough work history to qualify. The person can provide the SSN of a parent or spouse so we can
also check their work history too. This won’t have any impact on anyone’s immigration status. If you
have questions about your work history record or need to correct your work history, call Social Security
at 1-800-772-1213. TTY users should call 1-800-325-0778.
If you want to give your SSN, enter your 9-digit SSN – We’ll verify it with Social Security, based on the
consent you gave at the start of your application. If you don’t have an SSN, leave the field blank. Don’t
enter ITINs or other numbers here.
Did I have health coverage that ended recently?
If you have health coverage through a job that ended in the last certain number or months, select “Yes.”
Also, select “Yes” to this question if it’s asked about a child whose coverage through an employersponsored health insurance plan recently ended. For example, many children get coverage through a
parent’s job, but coverage may end for different reasons, including:
• The parent loses their job.
• The employer stops offering coverage.
• The parent thinks the plan is too expensive and stops paying or cancels the coverage.
What if my coverage ended?
If your coverage ended, you may be asked why. We’re asking this because sometimes children have a
waiting period between ending employer-sponsored coverage and starting coverage through the
Children’s Health Insurance Assistance Program (CHIP). There may be exceptions to that waiting period,
based on the reason that the employer-sponsored coverage ended.
What if I’m offered a state employee health benefit plan?
If you’re offered a state employee health benefit plans through a job or a family member’s job, select
“Yes.” Most people who work for the state or local government have the option to be covered through
the state employee health benefit plan. These workers can usually cover their spouses and children
through the plan. People who work at state universities may also be able to get this plan. If you could
get that state employee plan because of your job or your relative’s job, select “Yes.”
What if I have other health coverage?
You may be asked if you have health coverage through any of these:
• State Medicaid program
• State Children’s Health Insurance Assistance Program (CHIP)
• Medicare
• TRICARE (Don’t choose this if you have Direct Care or Line of Duty.): A health care program for
uniformed services members, retirees, and their families.
• VA health care program: Health coverage for veterans (and, in certain circumstances, their
dependents or survivors) who served in the active military, naval, or air service and were
honorably discharged or released.
• Peace Corps: Health coverage provided to Peace Corps volunteers during service.
• Individual insurance (non-group coverage): Health coverage people pay for themselves that’s
not through an employer.
What if I have coverage through an employer?
You may be asked…
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More information and/or how to answer…
Are you currently eligible for health coverage
through a job (even if it’s from another person’s
job, like a spouse or parent/guardian)?
You’re eligible for health coverage if you could get
health coverage through a job, even if you’re not
currently enrolled.
Select “Yes” if:
• You have or could get health coverage
now through a job.
• You have or could get health coverage
now through another person’s job.
• You’re currently in a waiting period for
health coverage to start.
Will you be eligible for health coverage from a job
during 2014 (even if it’s from another person’s job,
like a spouse or parent/guardian)?
This is item 13 on the “Employer Coverage Tool.”
You’re eligible for health coverage if you could get
health coverage through a job, even if you’re not
currently enrolled.
Select “Yes” if:
• You could get health coverage in the next
3 months through your job or another
person’s job.
• You’re currently in a waiting period for
coverage to start.
Select “No” if you won’t have health coverage in
the next 3 months through your job or another
person’s job.
Select “I don’t know” if you’re not sure. If you
select this, the Marketplace won’t be able to
determine your eligibility for a premium tax credit,
but may be able to enroll you in a Marketplace
health plan or other programs.
Tell us which employer(s) offer(s) health coverage
to you.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
If you’re using the “Employer Coverage Tool,” this
is item 13.
Check each box that applies to you. Include:
• Employers that offer coverage to you,
even if that coverage is through a spouse,
parent, or other family member.
• All employers that offer health coverage if
you’re eligible for health coverage through
more than one employer.
• Count each offer of health coverage
whether or not you’re enrolled in coverage
through this job. For example, if you’re
part of a couple and could get coverage
Enter your employer’s address.
Enter your employer’s phone number.
through multiple employers, but are only
enrolled in coverage through one
employer, you should list both employers.
If you need help with this item, ask your employer.
If you’re using the “Employer Coverage Tool,”
these are items 5, 7, 8, and 9.
If this information is pre-populated, we got this
information from our data sources. If it’s not
correct, enter the correct contact information for
the employer.
If you need help with this item, ask your employer.
Enter the Employer Identification Number (EIN).
Tell us about your employer:
• Employer name
• Employer address
• Employer phone number
• Employee Identification Number (EIN)
Who can we contact about an employer’s health
coverage? If you’re not sure, ask your employer.
Are you currently enrolled in an employer’s health
coverage?
What’s your current work status at an employer?
Is the coverage from your employer COBRA
coverage?
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
If you’re using the “Employer Coverage Tool,” this
is item 6.
You can find the Employer Identification Number
(EIN) on a pay stub or W-2 from this employer. If
you don’t know this number, ask your employer.
If you’re using the “Employer Coverage Tool,” this
is item 4.
If you need help with these items, ask your
employer.
If you’re using the “Employer Coverage Tool,”
these are items 4-9.
If this employer gave you the contact information
for the person at the job or a third party
administrator that helps with providing health
benefits, include the person’s contact information.
If your employer didn’t give you this information,
leave this blank.
If you’re using the “Employer Coverage Tool,”
these are items 10, 11, and 12.
You’re “enrolled” if you can use your health
benefits.
Select “Yes” if you’re a retiree and are accepting
money from a Health Reimbursement
Arrangement (HRA).
If you’re retired, select “Retired” – don’t select
“No longer working at this employer.”
COBRA gives employees the right to continue to
pay to keep themselves and their family on
employee health coverage for a limited time
(usually 18 months) after their employment ends
or they otherwise lose coverage.
Is the coverage from your employer a retiree
health plan?
Does your employer offer a health plan that meets
the minimum value standard?
If you’re currently enrolled in COBRA and plan to
keep COBRA coverage during the coverage year,
you won’t qualify for premium tax discounts
through the Marketplace, but may be eligible to
enroll in a Marketplace health plan or other
programs.
A retiree health plan is an employer-provided
health care plan that carries over to retirement.
If you’re currently enrolled in a retiree health plan
and plan to keep the retiree health plan during the
coverage year, you won’t qualify for premium tax
discounts through the Marketplace, but may be
eligible to enroll in a Marketplace health plan or
other programs.
A 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% of
such costs.
If you select “I don’t know,” the Marketplace
won’t be able to determine your eligibility for a
premium tax credit, but you may be eligible to
enroll in a Marketplace health plan or other
programs.
If you need help with this item, ask your employer.
For the lowest-cost plan available only to the
employee that meets the minimum value
standard: (Only tell us about plans that aren’t
family plans.)
If you’re using the “Employer Coverage Tool,” this
is item 14.
These items are asking about the lowest-cost plan
offered by the employer that would cover the
employee only. Don’t include information for
family coverage. Only include plans that meet the
minimum value standard. The employee may or
may not be enrolled in this particular plan.
These questions help the Marketplace determine if
the employee is offered an affordable health plan
by the employer.
If you need help with this item, ask your employer.
If you’re using the “Employer Coverage Tool,” this
is item 15.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
How much would the employee have to pay in
premiums for this plan?
This item is asking about the premium amount of
the lowest-cost plan offered by the employer that
would cover the employee only. Don’t include
information for family coverage. Only include
plans that meet the minimum value standard.
Enter the regular amount the employee would
have to pay for coverage (the premium). The
employee may or may not be enrolled in this
particular plan.
If this employee is offered an amount through a
Health Reimbursement Arrangement (HRA) that
the employee may use to help with premiums,
make sure the employer counts this amount
towards the amount the employee must pay for
coverage when responding to this question.
These items help the Marketplace determine if the
employee is offered an affordable health plan by
the employer.
If you select “I don’t know,” the Marketplace
won’t be able to determine your eligibility for a
premium tax credit, but you may be eligible to
enroll in a Marketplace health plan or other
programs.
If you need help with this item, ask your employer.
How often would you plan this amount?
Do you expect the employer to make any of these
changes to the coverage offered to you in 2014?
If you’re using the “Employer Coverage Tool,” this
is item 15(a).
If you need help with this item, ask your employer.
If you’re using the “Employer Coverage Tool,” this
is item 15(b).
Select “I don’t know” if you don’t know if your
employer will make any changes. This won’t affect
your eligibility results.
If you need help with this item, ask your employer.
Will the employer no longer offer health
coverage?
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
If you’re using the “Employer Coverage Tool,” this
is item 16.
If you’re losing your health coverage, you can buy
health coverage through the Marketplace. You
may also qualify for a premium tax credit.
If the employer will no longer offer a plan that
meets the minimum value standard, check the
box.
If you need help with this item, ask your employer.
What will be the last day the employer offers
coverage?
If you’re using the “Employer Coverage Tool,” this
is item 16.
Enter the last day that you could get health
benefits under the employer plan.
“The employer will change the cost of premiums
for the lowest-cost plan available to the employee
that meets minimum value:” This item is asking
about the premium amount of the lowest-cost
plan offered by the employer that would cover the
employee only. Don’t include information for
family coverage. Only include plans that meet the
minimum value standard. Enter the regular
amount the employee would have to pay for
coverage (the premium). The employee may or
may not be enrolled in this particular plan.
If this employee is offered an amount through a
Health Reimbursement Arrangement (HRA) that
he or she may use to help with premiums, make
sure the employer counts this amount towards the
amount the employee must pay for coverage
when responding to this question.
If you need help with this item, ask your employer.
How much will the employee have to pay in
premiums for this plan? (This will be asked if you
selected “The employer will change the cost of
premiums for the lowest-cost plan available to the
employee that meets minimum value” for the
question above.)
If you’re using the “Employer Coverage Tool,” this
is item 16.
This item is asking about the premium amount of
the lowest-cost plan offered by the employer that
would cover the employee only. Don’t include
information for family coverage. Only include
plans that meet the minimum value standard.
Enter the regular amount the employee would
have to pay for coverage (the premium). The
employee may or may not be enrolled in this
particular plan.
If this employee is offered an amount through a
Health Reimbursement Arrangement (HRA) that
the employee may use to help with premiums,
make sure the employer counts this amount
Individuals & Families: Applying for Coverage Help Text
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towards the amount the employee must pay for
coverage when responding to this question.
If you need help with this item, ask your employer.
How often would you have to pay this amount?
(This will be asked if you entered an amount for
the question above.)
When will the employer make this change? (This
will be asked if you selected “The employer will
change the cost of premiums for the lowest-cost
plan available to the employee that meets
minimum value.”)
Do you expect to drop the employer’s health
coverage in 2014?
What’s your last day of coverage through this
employer? (This will be asked if you selected “Yes”
to the question above.)
What’s the first day you’ll be covered by the
employer’s health plan?
If you’re using the “Employer Coverage Tool,” this
is item 16.
If you need help with this item, ask your employer.
If you’re using the “Employer Coverage Tool,” this
is item 16(b).
If you need help with this item, ask your employer.
If you’re using the “Employer Coverage Tool,” this
is item 16(b).
Select “Yes” if you’re going to cancel your health
coverage.
Enter the last day you could get health benefits
through your employer’s plan.
Enter the first day that you’ll be able to use health
services under your employer’s plan.
Review & sign
Agreement statements
Before you sign and submit your application for coverage, you’ll be asked to check that you agree or
disagree with a few agreement statements (also called attestations). Here’s more information on what
each of these statements means:
Statement:
I know that if Medicaid pays for a medical
expense, any money I get from other health
insurance or legal settlements will go to Medicaid
in an amount equal to what Medicaid pays for the
expense.
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 the agency and won’t have to cooperate.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013
More information:
If you enroll in Medicaid and have any other health
coverage or legal settlements that pay medical
expenses, the money you get will need to go to
Medicaid because Medicaid is paying for your
medical bills or as much as it can. Medicaid will
then pay the rest of the medical bill.
If your child or children can get medical support
from a parent living outside the home, you’ll need
to cooperate with the Medicaid agency and the
child support agency to get that support when
needed. But, if you think that cooperating to
collect medical support will harm you or your
children, you can tell Medicaid when it contacts
you, and you won’t have to cooperate. Whether or
No one applying for health coverage on this
application is incarcerated (detained or jailed).
To make it easier to determine my eligibility for
help paying for health coverage in future years, I
agree to allow the Marketplace to use income
data, including information from tax returns, for
the next 5 years (the maximum number of years
allowed). The Marketplace will send me a notice,
let me make any changes, and I can opt out at any
time.
I know that I must tell the program I’m enrolled in
if information I listed on this application changes.
Individuals & Families: Applying for Coverage Help Text
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not you cooperate won’t affect your child’s
eligibility, but a parent needs to cooperate or have
a good reason not to cooperate to be able to get
Medicaid for herself or himself.
When a person is incarcerated, they’re being held
involuntarily in a prison, jail, detention center, or
police lock-up. People who are incarcerated aren’t
eligible for certain programs in the Marketplace.
If someone on your application is incarcerated, you
can disagree with this statement. You’ll then be
asked to enter or select the name of the person
who’s incarcerated. You’ll also be asked if this
person is pending disposition. Select “Yes” if one
of these applies:
• This person is in jail but hasn’t been
convicted of any crime. For example, if a
judge or jury hasn’t found the person
guilty of the charges, and the person
hasn’t pled guilty to the charges.
• This person is in jail because of an alleged
technical violation of the terms of
probation or parole, and it hasn’t yet been
decided if the person will be sent to prison
or kept in jail because of the technical
violation.
Agreeing to this statement allows the Marketplace
to use available income information from the IRS
for up to 5 years for renewing your application. If
you enroll in coverage through the Marketplace,
we want to help you keep your coverage. One way
to do that is to allow us to check electronically
available income data to make sure you’re still
eligible, instead of asking you to prove that your
income still qualifies. You can give us permission
here to check your federal income tax return data
for next year, and for up to 5 years.
You can give permission for your eligibility for help
paying for health coverage to be renewed for a
period of: 1, 2, 3, 4, or 5 years. You can also not
give permission for your tax data to renew your
eligibility for help paying for health coverage.
Selecting this option may impact your ability to get
help paying for health coverage at renewal.
You must report any changes that might affect
your health coverage, like if you or a member of
your household move, have any income changes,
get married, get divorced, become pregnant, or
have a child. If you’re enrolled in Medicaid or the
Children’s Health Insurance Program (CHIP), you
can report these changes by calling your state
Medicaid or CHIP program.
I’m signing this application under penalty of
perjury, which means I’ve provided true answers
to all of the questions 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.
If you’re enrolled in a Marketplace health plan and
need to report a change, log in to your
Marketplace account on this website, or call the
Marketplace Call Center at 1-800-318-2596. TTY
users should call 1-855-889-4325.
It’s unlawful to commit insurance fraud. Signing
this application means you’ve provided true
answers to all questions to the best of your
knowledge. If you’re not truthful, there may be a
penalty.
Signature
For your electronic signature, type in your name to confirm the information you entered for this
application. You’ll be submitting the final application on this page and able to view your eligibility
results.
Your eligibility results & next steps
Programs & savings you may be eligible for
Here’s more information on the programs and savings you may be eligible for, which will appear on your
eligibility results:
•
Marketplace health plans (also called Qualified Health Plans (QHPs)): You may be able to enroll
in a Marketplace health plan. When you go to the next page, you’ll be given tasks to enroll in a
plan.
•
Advanced premium tax credits: A new tax credit in the Marketplace that can be used right away
to lower your monthly premium costs. You can choose how much of the tax credit to apply to
your premiums each month. Any amount that’s left over at the end of the year, you get back as
a credit when you file your federal income tax return. If your income changes during the year,
however, you could get more or less tax credit.
•
Cost-sharing reductions
•
State Medicaid Program: Medicaid is a joint federal and state health coverage program that
helps with medical costs for children, pregnant women and adults with limited incomes,
including many elderly adults and individuals with disabilities. All state Medicaid programs must
cover certain benefits such as preventive care, immunizations, screening and treatment of
health conditions, doctor and hospital visits, dental care for children, and in some states, adult
Individuals & Families: Applying for Coverage Help Text
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dental care. States may cover additional benefits as well. In most cases, these services are
provided at no cost to families. Children who are enrolled in Medicaid also qualify for the Early
and Periodic Screening, Diagnosis and Treatment (EPSDT) benefit that provides comprehensive
and preventive health care services for children under age 21.
•
State emergency Medicaid program: Emergency Medicaid is a medical program for treating
people when there’s an emergency service to treat an emergency medical condition. People are
eligible for Emergency Medicaid when they qualify for Medicaid based on their income and
other requirements in the state, but they don’t have eligible immigration status for Medicaid.
Some people may be eligible for Emergency Medicaid but can also choose to enroll in a
Qualified Health Plan and get a tax credit to help pay for insurance. Other people are only
eligible for Emergency Medicaid.
•
Refugee Medical Assistance: Refugee Medical Assistance is a federally funded program that
helps with medical costs for certain protected groups, like refugees and asylees with limited
incomes. Refugee Medical Assistance is available for the first 8 months of admission to the U.S.,
grant of asylum, or certification as a victim of human trafficking. Refugee Medical Assistance
pays for a full set of services including preventive care, immunizations, screening and treatment
of health conditions, and doctor and hospital visits. In most cases, these services are provided at
no cost.
•
Children’s Health Insurance Assistance Program (CHIP): CHIP is an insurance program jointly
funded by state and federal government that provides health coverage to low-income children
and, in some states, pregnant women in families who earn too much income to qualify for
Medicaid but can’t afford to purchase private health insurance coverage. All state CHIP
programs cover routine check-ups, immunizations, hospital care, dental care, and lab and X-ray
services. States may also cover additional benefits. Children get free preventive care, but
premiums and other cost-sharing may be required for other services. Some states may require a
waiting period before enrollment in CHIP, if a child previously had other health insurance.
•
State Medicaid based on disability or age program name: Some people may qualify to get more
health services and pay less for their care if they have special health care needs, like:
o A medical, mental health, or substance abuse condition that limits their ability to work
or go to school
o A need to help with daily activities, such as bathing or dressing
o Is getting long-term care at home or in the community
o Is living in a long-term care facility or nursing home
o Is blind or terminally ill
Other lists on your eligibility results
•
Not eligible for: This list tells you the programs that each person was not eligible for. Click on
“More info” to find out the reasons they’re not eligible. If you think your results are wrong, you
can file an appeal.
•
Separate application required: These people need to file their own separate application
because they’re not in the application filer’s tax household, don’t live with the application filer,
Individuals & Families: Applying for Coverage Help Text
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and/or can’t be on the same health plan with other people applying for health coverage on this
application.
•
Not applying for coverage: These people aren’t applying for coverage on this application. To
apply for health coverage, they’ll need to submit a change for this application or submit a
separate application.
Should I have my information sent to the state Medicaid agency?
You may be asked if any of the people on your application want us to send their information to their
state Medicaid agency, so they can check on their Medicaid and/or CHIP eligibility: This question is asking
if you want the Medicaid agency to review your application and make a decision about your eligibility.
You may qualify to get more health services and pay less for your care. You could also get help paying for
past medical bills.
You should check the box next a person’s name if he or she:
• Has a medical, mental health, or substance use condition that limits the ability to work or go to
school
• Needs or gets long-term care in your home or lives in a long-term care facility or nursing home
• Is terminally ill or needs special medical services
• Needs a lot of medical services or has high medical bills
• Has a family income close to the Medicaid income limit or if you think the household has less
income than was calculated in the income section of this application
If you don’t ask for the Medicaid agency to review your application and make a formal decision about
whether or not you’re eligible for Medicaid, you won’t be able to appeal the fact that you’re not being
enrolled in the Medicaid program.
You must check the box next to a person’s name to ask the Medicaid agency to review his or her
application in order to have the right to appeal a denial of Medicaid. You can check off more than one
person’s name. If you’re not sure, you can check the box next to the person’s name, just in case it will
help them.
More information for people with special health care needs
A person may qualify to get more health services if he or she has special health care needs. If the person
pays for care, he or she may also qualify to pay less. Special health care needs include if a person:
• Has a medical, mental health or substance abuse condition that limits his or her ability to work
or go to school
• Needs help with daily activities, like bathing or dressing
• Regularly gets medical care, personal care, or health services at home or in another community
setting, like adult day care
• Lives in a long term care facility, group home, or nursing home
• Is blind
• Is terminally ill
If a person has any of these special health care needs, and wants to see if he or she qualifies, let us know
by checking the box next to that person’s name.
Individuals & Families: Applying for Coverage Help Text
Revised: 09/12/2013