Privacy Act Statement
Permission for information submitted By submitting this application, you represent that you have permission from all of the people whose information is on the application to both submit their information to the Marketplace, and receive any communications about their eligibility and enrollment.
Privacy Act Statement – effective 10/1/2013 We are authorized to collect the information on this form and any supporting documentation, including social security numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
We need the information provided about you and the other individuals listed on this form to determine eligibility for: (1) enrollment in a qualified health plan through the Federal Health Insurance Marketplace, (2) insurance affordability programs (such as Medicaid, CHIP, advanced payment of the premium tax credits, and cost sharing reductions), and (3) certifications of exemption from the individual responsibility requirement. As part of that process, we will verify the information provided on the form, communicate with you or your authorized representative, and eventually provide the information to the health plan you select so that they can enroll any eligible individuals in a qualified health plan or insurance. affordability program. We will also use the information provided as part of the ongoing operation of the Marketplace, including activities such as verifying continued eligibility for all programs, processing appeals, reporting on and managing the insurance affordability programs for eligible individuals, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information. While providing the requested information (including social security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the Marketplace, advanced payment of the premium tax credits, cost sharing reductions, or an exemption from the shared payment responsibility. If you don't have an exemption from the shared responsibility payment and you don't maintain qualifying health coverage for three months or longer during the year, you may be subject to a penalty. If you don't provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action.
In order to verify and process applications, determine eligibility, and operate the Marketplace, we will need to share selected information that we receive outside of CMS, including to: 1. Other federal agencies, (such as the Internal Revenue Service, Social Security Administration and Department of Homeland Security), state agencies (such as Medicaid or CHIP) or local government agencies. We may use the information you provide in computer matching programs with any of these groups to make eligibility determinations, to verify continued eligibility for enrollment in a qualified health plan or Federal benefit programs, or to process appeals of eligibility determinations. Information provided by applicants won't be used for immigration enforcement purposes; 2. Other verification sources including consumer reporting agencies; 3. Employers identified on applications for eligibility determinations; 4. Applicants/enrollees, and authorized representatives of applicants/enrollees; 5. Agents, Brokers, and issuers of Qualified Health Plans, as applicable, who are certified by CMS who assist applicants/ enrollees; and Anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013).
Privacy Law
Permission to Submit Information By submitting this application, you are telling us that you have permission from everyone whose information appears on the application to both submit their information to the Marketplace and to receive any communications about your eligibility and enrollment.
Privacy Act Statement (Effective 10/1/2013) We are authorized to collect the information on this form and any supporting documentation, including Social Security numbers, under the American Health Care and Patient Protection Act. Low Price (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
We need the information provided about you and others listed on this form to determine eligibility for: (1) enrollment in a health plan authorized through the Marketplace, (2) low-cost insurance programs (such as Medicaid, CHIP, Advance Premium Tax Credit Payment, and Cost Sharing Reduction), and (3) certifications of exemptions from individual responsibility requirements. As part of that process, we will verify the information provided on the form, contact you or your authorized representative, and ultimately provide the information to the health plan you have selected so that they can enroll any eligible person. in a licensed health plan or low-cost insurance program. We also use the information provided as part of an operation that is carried out in the Insurance Marketplace, which includes activities such as verifying continued eligibility for all programs, processing appeals, giving information and administering the insurance programs under price for eligible individuals, develop monitoring and quality control activities, combat fraud and respond to any concerns about the security or confidentiality of information. Although providing the requested information (including Social Security numbers) is voluntary, failure to do so may delay or prevent you from obtaining health coverage through the Marketplace, payment of the advance premium tax credit, or exemption. of shared responsibility payments. If you are not exempt from shared responsibility payments and do not maintain qualifying health coverage for three months or more during the year, you may be subject to a penalty. If you do not provide the correct information on this form, or knowingly and intentionally provide false or fraudulent information, you may be subject to a penalty or other legal action.
In order to verify and process applications, determine eligibility, and operate the Marketplace, we need to share some of the information we receive with entities outside of CMS, including: 1. Other federal agencies, (such as the Internal Revenue Service , the Social Security Administration and the Department of Homeland Security), state agencies (such as Medicaid or CHIP), or local government agencies. We may use the information you provide in computer programs to match any of these groups to make eligibility determinations, to verify continued eligibility to enroll in an authorized health plan or federal benefit programs, or to process appeals. eligibility determination; Information provided by applicants will not be used to verify compliance with immigration laws; 2. Other verification sources include credit reporting agencies; 3. Employers identified on applications for eligibility determination; 4. Applicants/registrants, and authorized representatives of applicants/registrants; 5. Agents, brokers, and entities that launch licensed health plans, as applicable, that are certified by CMS and assist applicants/enrollees; 6. CMS Contractors engaged in the performance of a function for the Marketplace; and 7. Any other person as required or permitted by law pursuant to the Privacy Act System Registry Notice associated with this collection (CMS Health Insurance Exchanges (HIX), CMS System No. 09-70-0560, as amended, Federal Register 78, 8538, March 6, 2013, and Federal Register 78, 32256, May 29, 2013).
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Acknowledgment
I acknowledge that I have read and reviewed (or it has been read to me) all the information on this application. I Acknowledge, as represented as represented by my signature or electronic signature below, the information that I provided above is true, voluntarily given by me, and that I have not intentionally provided false or fraudulent information. I have voluntarily, knowingly and willingly provided the insurance agent the above information to assist me in enrolling on and off the exchange.
I Hereby Authorize the above mentioned Insurance Agent/broker to use information provided herein to help me purchase life, health, annuity insurance and other services.
Recognition
I acknowledge that I have read and reviewed (or had read to me) all of the information on this application. I acknowledge, as represented as presented in my signature or electronic signature below, that the information I have provided above is true, that I have provided it voluntarily, and that I have not knowingly provided false or fraudulent information. I have voluntarily, knowingly and voluntarily provided the above information to the insurance agent to assist me in enrolling on and off the exchange.
I hereby authorize the insurance agent/broker named above to use the information provided herein to help me purchase life, health, annuity and other services.