I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.
I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2023 tax year. If I’m married at the end of 2023, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2023 federal income tax return. I’ll claim a personal exemption deduction on my 2023 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and whose premium for coverage is paid in whole or in part by advance payments of the premium tax credit.
I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2023 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I understand that if the income on my tax return is lower than the amount of income on my application, I may be eligible to get an additional premium tax credit amount. On the other hand, if the income on my tax return is higher than the amount of income on my application, I may owe additional federal income tax.
I know that I must tell the program I’ll be enrolled in if the information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center. I know a change in my information could affect eligibility for member(s) of my household. I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay the full cost for their Marketplace plan.
To make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt-out at any time.
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost.
I understand by submitting this form that I am authorizing a licensed health insurance agent to enroll me in a marketplace plan. I also understand that my plan will be auto renewed for 2024.
I give my permission to Peace Tree Insurance LLC to serve as the health insurance agency for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by telephone only for the purposes of one or more of the following:
1.Searching for an existing Marketplace application;
2.Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums;
3.Providing ongoing account maintenance and enrollment assistance, as necessary; or
4.Responding to inquiries from the Marketplace regarding my Marketplace application.
I understand that the Agent will not use or share my personally identifiable information PI for any purposes other than those listed above. The Agent will ensure that my PI is kept private and safe when collecting, storing, and using my Pl for the stated purposes above.
I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by written or verbal request.
Accept & Submit
