Renewal of Eligibility

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.

Tax Attestation

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 2024 tax year.
• If I’m married at the end of 2024, 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 2024 federal income tax return.
• I’ll claim a personal exemption deduction on my 2024 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.

If any of the above changes:

• I understand that it may impact my ability to get the premium tax credit.
• I also understand that when I file my 2024 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.

Consent Agreement

I give my permission to MyHealth Coverage Connect, Licensed Agent(s) to serve as the Health Insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace or Georgia Access. 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 phone only for one or more of the following:

• Searching for an existing Marketplace application.
• 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.
• Providing ongoing account maintenance and enrollment assistance, as necessary.
• Responding to inquiries from the Marketplace regarding my applicaiton.

I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII for the stated purposes above.

I confirm that the information I provided 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 contacting my agent.

If you currently have an application on the Marketplace you must call 855-889-4325 to change your agent of record.

I agree to have my information used and retrieved from data sources for this application. I have consent for all people I'll list on the application for their information to be retrieved and used from data sources.

I understand that I'm required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period, if I qualify. If I don't, I may face penalties, including the risk of losing my eligibility for coverage.