ACA Applicant General Release and Approval

Affordable Care Act Applicant General Release and Approval

 

I authorize Benefit Next, Inc. to provide the information I have given on this application to a licensed insurance agent and for that licensed insurance agent to submit my financial assistance and health insurance application on my behalf.

 

I understand that I will be notified of the final results of this application via the email I provided in this application.

 

I understand that if necessary, a licensed insurance agent, or their authorized represent may contact me via email or telephone regarding any questions or need for clarification regarding the information provided.

 

I understand that it is my responsibility to update my information on the federal Marketplace via my Marketplace account or by calling the Marketplace at 1.800.318.2596, (TTY) 1-855-889-4325. I understand that a change in information could affect my eligibility or the member(s) of my household.

 

I give permission to the Marketplace to access my federal tax filings for up to five (5) years to verify my income for subsidy purposes.  I may revoke this permission at any time and I understand in so doing I will be required to complete a new application for financial assistance every year.

 

I certify that:

  • No one applying for health coverage on this application is incarcerated (detained or jailed).
  • No one applying for health coverage on this application is an American Indian or Alaskan Native.
  • All members on the application are United States citizens or US nationals.
  • All members on the application reside at the same address.
  • No one else can claim me as a dependent on a separate 2016 federal income tax return.
  • Everyone applying for coverage is using the same name that appears on their Social Security Card.
  • No one applying for health coverage is a caretaker of an individual not listed on this application.
  • I will claim a personal exemption deduction on my 2016 federal income tax for any individual listed on this application as a dependent whose premium in full or part is paid through a federal subsidy.

 

I understand that since the premium, in full or in part, is being paid through a federal subsidy, that I must file a tax return for the tax year 2016 and if I am married at the end of 2016 that I must file a joint return with my spouse.

 

I understand that at 2016 tax filing that my actual income will be reconciled with my estimated income provided on this application.  This reconciliation may result in additional taxes due to the federal government (generally for understated income) or a refund of money (generally for overstated income).

 

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 changes, and I can opt out at any time. This will make it easier to determine my eligibility for help paying for health coverage in future years.

 

I am freely and willingly signing this application under penalty of perjury and to my best knowledge, I have provided true answers to all of the questions. I understand I may be subject to penalties under federal law if I intentionally provide false information.