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"). Depending on your application information, you may not see all of these attestations. If you disagree with any of the attestations, you may be asked to provide additional information.
Here are the attestations you may see and more information on what they mean:
If anyone on this application enrolls in Medicaid, I'm giving the Medicaid agency the right to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.
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 a child on this application has a parent living outside the home, 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 I may not have to cooperate.
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 may not have to cooperate. Whether or 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.
No one applying for health coverage on this application is incarcerated (detained or jailed).
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.
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.
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 coverage at renewal or require you to provide more information.
I know that I must tell the program I’m enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling 1-800-318-2596. TTY users should call 1-855-889-4325. I understand that a change in my information could affect my eligibility for member(s) of my household.
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.
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: 1-855-889-4325).