CMS toolkit rows and workbook IDs before evidence claims.

Coverage State

Coverage Year

1. 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. 2. 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.

Name

What's your home address?

No home address

Is this also your mailing address? [Display home address]

Enter your mailing address

What's your contact information?

What's your preferred language?

How would you like to get notices about your application?

How should we let you know when there's a new notice in your account?

Which mobile number should we use?

Phone number

Is a professional helping you complete your application?

Which type of professional is helping you?

N/A

N/A

N/A

N/A

Do you want to find out if you can get help paying for health coverage?

How many people are on your federal income tax return this year? (If you aren’t filing taxes, tell us how many people live with you, including yourself.) You don’t have to file taxes to apply for coverage.

Based on your best guess, do you expect your total household income to be less than [Equivalent to 400% of the federal poverty level in dollars for family size listed plus buffer] for this year?

N/A

N/A

N/A

Who needs health coverage?

Add a person applying for coverage: Name DOB Sex How is this person related to [Application filer FNLNS]? How is this person related to [other applicant FNLNS]? How is this person related to [other applicant FNLNS]? (repeat as needed for each applicant with unknown relationship to new applicant)

What is [FNLNS]'s Social Security Number (SSN)?

What is [FNLNS]'s Social Security Number (SSN)? (Optional)

Are you sure? It's important to enter the SSN for everyone on your application, if they have them.

Is [FNLNS] the same name that appears on their Social Security card?

Enter the same name as shown on [FNLNS]'s Social Security card

If more than one applicant: Is every person applying for coverage a U.S. citizen or U.S. national? If one applicant: Is [FNLNS] a U.S. citizen or U.S. national?

Which of these people aren't U.S citizens or U.S. nationals?

Is [FNLNS] a naturalized or derived citizen?

Does [FNLNS] have one of these documents? Optional

[FNLNS]'s Document Information

[FNLNS]'s Document Information

Does [FNLNS] have eligible immigration status?

N/A

Select the document type that corresponds with [FNLNS]'s most current documentation and status. Optional

N/A

N/A

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

[FNLNS]'s Document Information

Update [FNLNS]'s information so that it matches their [document type from Items 49, 51, 52, 54, and 55]. Documents types: card or passport

Does [FNLNS] also have any of these document types or statuses? Optional.

Has [FNLNS] lived in the U.S. since 1996? Optional

Are any of these people an honorably discharged veteran or active duty member of the military? Optional

Are you sure? It's important to enter as many fields from your immigration documents as possible, even though some fields may be labeled "optional." Entering all of your document information makes the application process go smoother and faster, helps make sure your eligibility results are correct, and may prevent you from needing to come back later and provide information.

When did [FNLNS] get their current immigration status? Optional

What's [FNLNS]'s marital status?

Who is [FNLNS]'s spouse?

Enter [FNLNS]'s spouse's information.

Does [FNLNS] plan to file a federal income tax return for [coverage year]? You don’t have to file taxes to apply for coverage, but you'll need to file next year if you want to get a premium tax credit to help pay for coverage now.

Does [FNLNS] plan to file a joint federal income tax return with their spouse for [coverage year]?

Will [FNLNS] [and spouse name (if married and filing jointly)] claim any dependents on their [joint] federal income tax return for [coverage year]?

Who are [FNLNS]'s [and spouse name (if married filing jointly)] dependents?

Enter dependent information

You told us [Dependent FNLNS] lives with [Parent FNLNS]. Does [Dependent FNLNS] also live with another parent at this address? [Display [Parent FNLNS's] home address]

Does [FNLNS] plan to file as Head of Household?

Will [FNLNS] be claimed as a dependent on someone else's tax return for [coverage year]?

Who is the tax filer that will claim [FNLNS] on their income tax return?

Enter claiming tax filer information

Does [Applicant FNLNS] live with this parent?

If it is unknown [Dependent FNLNS] has another parent who is not the claiming tax filer on the application: Does [Dependent FNLNS] live with any parent or stepparent? If it is known [Dependent FNLNS] has another parent who is not the claiming tax filer on the application: Does [Dependent FNLNS] live with [existing parent FNLNS]?

To determine eligibility for tax credits or free or reduced cost health coverage, we need more information about the person who claims [Dependent FNLNS]. Do you want to provide more information about the person who claims [Dependent FNLNS]?

Is the person who claims [Dependent FNLNS] married?

Does [Tax filer claiming applicant FNLNS] plan to file a joint federal income tax return with [spouse] for [coverage year]?

Who is [Tax filer claiming applicant FNLNS]'s spouse?

Enter tax filer claiming applicant's spouse information

Will [Tax filer claiming applicant FNLNS] claim any other tax dependents?

Who will [Tax filer claiming applicant FNLNS] claim as tax dependents?

Enter name and DOB of tax dependents

Do any other family members live with [FNLNS] at [FNLNS's address]? You don't need to include these people: [Display household member names who previously attested to living with the non-filer applicant or has the resideTogetherIndicator set to true with the non-filer applicant]

Can you provide more information about the family members who live with [FNLNS]?

It's known they live with only 1 parent: Does [Applicant FNLNS] live with another parent and/or stepparent? It's unknown if the applicant lives with either parent: Does [Applicant FNLNS] live with either of their parents and/or stepparents?

Select [FNLNS]'s parents and stepparent(s) that live with [FNLNS].

Name of parent or stepparent:

If it is known they live with siblings: [Display applicant siblings that live with them.] Does [Applicant FNLNS] live with any other brothers or sisters who are under age [State Medicaid Age]? (Include stepbrothers, stepsisters, half-brothers, half-sisters). If it is unknown if they live with or have siblings: Does [Applicant FNLNS] live with brothers or sisters who are under age [State Medicaid Age]? (Include stepbrothers, stepsisters, half-brothers, half-sisters).

Who is a brother or sister living with [Applicant FNLNS]?

Enter brother or sister information.

Does [FNLNS] live with [FNLNS's spouse]?

It is unknown if they live with sons/daughters: Does [FNLNS] live with their son, daughter, stepson, or stepdaughter? It is known they live with sons/daughters: [Display applicant's children that live with them.] Does [FNLNS] live with any other sons, daughters, stepsons, or stepdaughters?

Who is son, daughter, stepson, or stepdaughter living with [FNLNS]?

Enter son, daughter, stepson, or stepdaughter information.

Your Household [Display household] Is [FNLNS] the main person taking care of any of these children?

Does [FNLNS] live with and take care of any other children age 18 or younger?

Is [FNLNS] the main person taking care of this child (or children)?

Tell us about this child

Do any of these children live with more than one parent, through birth or adoption? (optional)

What's [FNLNS]'s home address?

Enter [FNLNS]'s home address

Enter [FNLNS]'s mailing address

Is [FNLNS] living outside [state of application] temporarily?

Where will [FNLNS] live in [state of application]?

Is [FNLNS] of Hispanic, Latino, or Spanish origin? (optional)

What's [FNLNS]'s specific origin?

What's [FNLNS]'s race?

Do any of these people have a physical disability or mental health condition that limits their ability to work, attend school, or take care of their daily needs? Optional.

Do any of these people need help with daily activities like dressing or using the bathroom, or live in a medical facility or nursing home? Optional.

Were any of these people found not eligible for [state Medicaid program name] or [state CHIP name] by [state] since [date of 90 days ago]?

When was [FNLNS] denied Medicaid or CHIP coverage?

Was [FNLNS] also denied on the date entered above?

Did any of these people apply for health coverage between [most recent OE start date] – [most recent OE end date]?

Did [FNLNS] apply through the Health Insurance Marketplace after a qualifying life event?

Did [FNLNS] have [state Medicaid program name] or [state CHIP program name] that will end soon or that recently ended?

Has the household income or household size changed since [FNLNS] was told their coverage was ending?

What's the last day of [FNLNS]'s Medicaid or CHIP coverage?

If multiple applicants attested to eligible immigration status: Were any of these people found not eligible for [state Medicaid program name] or [state CHIP program name] based on their immigration status since [current year minus 5 years]? If one applicant attested to eligible immigration status: Was [FNLNS] found not eligible for [state Medicaid program name] or [state CHIP program name] based on their immigration status since [current year minus 5 years]?

Has [FNLNS] had their current immigration status since [current year minus 5 years]?

Has [FNLNS] had a change in their immigration status since they were not found eligible for [state Medicaid program name] or [state CHIP program name]?

If more than one applicant: Which of these people are full-time students? If one applicant: Is [FNLNS] a full-time student?

If more than one applicant or non-applicant: Which of these people are American Indians or Alaska Natives? If one applicant or non-applicant: Is [FNLNS] American Indian or Alaska Native?

If there is more than one female applicant or non-applicant: Which of these people are pregnant? If there is one female applicant or non-applicant: Is [FNLNS] pregnant?

How many babies is [Name selected in item #147] expecting during this pregnancy?

If more than one applicant: Which of these people were in foster care? If one applicant: Was [FNLNS] in foster care?

In what state was [Name selected in item #149] in the foster care system?

Was [Name selected in item #150] getting health care through [state Medicaid program name selected in item #150]?

How old was [Name selected in item #151] when they left the foster care system?

Will any of these people have income this month?

Select a type of income [FNLNS] currently gets this month.

N/A

How much does [FNLNS] usually work per week at this job?

N/A

N/A

How much net income (profits once expenses are paid) will [FNLNS] get from self-employment this month? You can enter a positive number (profit) or a negative number (loss). Not sure? Make your best estimate. Learn how to report self-employment income.

N/A

N/A

N/A

How much does [FNLNS] expect to get from net capital gains this year? Enter their capital gains income after subtracting capital losses. You can enter a positive number (profit) or a negative number (loss). Not sure? Make your best estimate.

How much does [FNLNS] get from alimony?

N/A

How much does [FNLNS] get from investment income, like interest and dividends?

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Do any of these people pay student loan interest, alimony, educator expenses, or contribute to an IRA in [coverage year]?

Select [FNLNS]'s current expense.

N/A

N/A

N/A

Is any of this income from these sources? • Per capita payments from the tribe that come from natural resources, usage rights, leases or royalties. • Payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian land by the Department of Interior (including reservations and former reservations). • Money from selling things that have cultural significance.

N/A

We calculated this expected yearly income amount based on what you entered for [FNLNS]'s monthly income and expenses. Is this correct?

Is [FNLNS]'s income for [coverage year] hard to predict?

Enter your best estimate of [FNLNS] expected yearly income for [coverage year].

That's okay. Make your best estimate of [FNLNS]'s total income for [coverage year].

The income you entered for [Employer Name] is lower than what our records show. Is there a reason why?

[FNLNS]'s or (and [FNLNS's Spouse] if married)'s household income in [coverage year] seems like it'll be lower than records for the past 2 years show. Why do you expect it to be lower?

Why is [FNLNS]’s income in months during [coverage year] different than this month’s income?

[FNLNS]'s (and [FNLNS's Spouse] if married)'s household income in [coverage year] seems like it'll be higher than records for the past 2 years show. Why do you expect it to be higher?

Are any of these people currently enrolled in health coverage?

What type of coverage does [FNLNS] have?

Are any of these people also enrolled in this coverage?

Tell us about [FNLNS]'s Medicare coverage.

Tell us about [FNLNS]'s TRICARE coverage.

Tell us about [FNLNS]'s VA Health Care Program coverage.

Tell us about [FNLNS]'s full benefit coverage.

Tell us about [FNLNS]'s limited benefit coverage.

Tell us about [FNLNS]'s coverage.

Will any of these people be offered health coverage through their own job? Tell us about coverage offers that apply to them starting [January 1st, [coverage year] if during OE and before 1/1 of coverage year, or first day of following month after coverage year begins].

Which of [Name selected in Item #200]'s employers offer [Name selected in Item #200] health coverage?

Enter the name of the employer who offers this insurance.

Does [Employer Name] also offer coverage to any of these people?

Who can we contact about [employer name]'s health coverage?

Do the plans offered by [Employer name] meet the minimum value standard?

How much would [Name selected in Item #200] pay for the lowest-cost health plan at [Employer name] just for themself?

Tell us more about [FNLNS]'s employer.

If more than one applicant or non-applicant: Which of these people are members of a federally recognized tribe? If one applicant or non-applicant: Is [FNLNS Name selected in Item 146] a member of a federally recognized tribe?

Where's [Name selected in Item 210] tribe located?

Did any of these people lose qualifying health coverage between [60 days prior to current date] - [current date]? Learn more about qualifying health coverage

When did [FNLNS] lose coverage?

Enter the name of the plan. Optional

Was anyone else on this plan?

Did any of these people also lose coverage on [date provided for loss of coverage]?

Will any of these people lose qualifying health coverage between [current date] - [60 days after current date]?

When will [FNLNS]'s coverage end?

What was the name of [FNLNS]'s health coverage? (optional)

Were any of these people on this plan?

Will any of these people lose coverage on [date provided] too?

Has [FNLNS] had any of these changes since [date 60 days from current date]?

When did [FNLNS] (include spouses name if added to the application) get married?

Did [FNLNS] or [their spouse] have qualifying health coverage at any time in the 60 days before the marriage?

Did [FNLNS] or their spouse live in a foreign country or a U.S. territory for at least one of the 60 days before the marriage?

Which of these people were adopted, placed in foster care, or became a dependent through a child support or other court order on or after [date 60 days from current date]?

When did [FNLNS] become a dependent?

When did [FNLNS] gain eligible immigration status?

What's the ZIP code of [FNLNS]'s previous address?

Check this box if [FNLNS] moved from a foreign country or U.S. territory. If so, you don’t need to enter a ZIP code above.

When did [FNLNS] move?

Did [FNLNS] have qualifying health coverage at any time in the 60 days before they moved?

When was [FNLNS] released from incarceration?

If [FNLNS] got the premium tax credit in 2023* and 2024,* did they file a tax return using information from their Form 1095-A to reconcile those payments for at least one of those years? * See Column O for date requirements

Has [FNLNS] ever gotten a health service from the Indian Health Service, a tribal health program, or urban Indian health program or through a referral from one of these programs?

Is [FNLNS] eligible to get health services from the Indian Health Service, a tribal health program, or an urban Indian health program or through referral from one of these programs?

Would any of these people like help paying for medical bills from the last 3 months?

Do any of these people have health coverage now?

Does [Child name] have a parent living outside the home?

How many hours per week do [Child’s name]’s parents work?

Did any of these people have coverage through a job that ended in the last [waiting period] months?

Why did [FNLNS]'s coverage end?

Is [FNLNS] offered the [state of application] state employee health benefit plan through a job or a family member’s job?

Review application

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 a child on this application has a parent living outside of 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 more than one applicant: Which of these people are incarcerated? If one applicant: Is [FNLNS] incarcerated?

Is [FNLNS] only incarcerated pending disposition of charges?

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 and let me make changes. I can opt out at any time.

How long would you like your eligibility for help paying for coverage to be renewed?

I know that I must tell the program I’ll be enrolled in if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325). I know a change in my information could affect eligibility for member(s) of my household.

If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will end their Marketplace plan coverage. They will get a notice before the Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they’re responsible for paying the full cost for the Marketplace plan premium and covered services.

I’m signing this application under penalty of perjury, which means I’ve provided true answers to all of the questions to the best of my knowledge. I know I may be subject to penalties under federal law if I intentionally provide false information.

N/A

[FNLNS], type your full name below to sign electronically.

Does one or more of [Applicant name selected above]'s parents or guardians live in [State of application]?

We weren't able to verify [FNLNS]'s information. Please confirm the information below is correct and try again. Does this match the name and date of birth on [FNLNS]'s Social Security card? [Display applicant name and DOB (birthDate)]

Enter this person's information exactly as it appears on their Social Security card.

Re-enter [FNLNS]'s Social Security Number (SSN).

N/A

Tell us about [FNLNS]'s coverage.

Do any of these situations apply to any of the people in your household?

Which federally recognized tribe does [Name selected in Item 210] belong to?

Choose the statement that best describes the legal relationship between [applicant FNLNS] and [applicant FNLNS], if any apply.

Remove, or change coverage needs?

Remove [FNLNS], or keep them on the application and change their coverage needs?

Why are you removing [FNLNS] from the application?

Is [claiming tax filer FNLNS] married?

If multiple applicants or any non-applicant tax filers are on the application: [display all applicants and any non-applicant tax filers] Do all of these people live together at this address? [Display application filer's address]

Select everyone who lives at this address with [Household contact].

What's [FNLNS]'s home address?

What's [FNLNS]'s new address in [state of application]?

[List all applicants and non-applicant tax filers living at each address] If applicant or non-applicant tax filer attested to home address: [FNLNS]'s home address: [Display attested home address] If applicant or non-applicant tax filer attested to mailing address (no home address): [FNLNS]'s mailing address: [Display attested mailing address] If applicant or non-applicant tax filer attested to transient address: [FNLNS]'s home address in [state of application]: [Display attested transient address]

Does [Spouse FNLNS] live with [Tax filer FNLNS] at this address?

Tell us about [Dependent FNLNS]'s parent.

Does [Applicant name selected in Item #144] go to school in [Application state]?

Is [FNLNS] enrolled in the [state of application] state employee health benefit plan through a job or family member's job (like a parent)?

Do any of these people have an individual coverage Health Reimbursement Arrangement (HRA) through their job, or through the job of another person, like a spouse or parent?

Have any of these people been offered an individual coverage Health Reimbursement Arrangement (HRA) they haven't yet accepted through their job, or through the job of another person, like a spouse or parent?

On [date 60 days from current date or January 1 if applying on November 1], will [FNLNS] be able to use this HRA?

Which employers offer [FNLNS] an individual coverage HRA?

Tell us about this employer.

Who works for this employer?

Tell us about the ICHRA offered by [employer (FNLNS's job)].

What's the maximum self-only amount of reimbursement offered by [employer (FNLNS's job)]?

Tell us how to contact [employer (person's job)].

Have any of these people been offered an individual coverage HRA or Qualified Small Employer Health Reimbursement Arrangement (QSEHRA) with a start date between [current date - 60 days] and [current date + 60 days]?

Which type of HRA coverage has [FNLNS] been offered?

Enter the date [FNLNS]'s [individual coverage HRA/QSEHRA] will start.

Enter the notice date on [FNLNS]'s [individual coverage HRA / QSEHRA] offer.

Is [FNLNS] currently enrolled in an [individual coverage HRA / QSEHRA] through this employer?

Will [FNLNS] stay enrolled in the current [individual coverage HRA / QSEHRA] until the new one begins on [attested start date]?

[Display [Dependent FNLNS's] home address] Can you provide more information about [Dependent FNLNS]'s parent?

How is this person related to [Dependent FNLNS]?

Does any plan meet the minimum value standard?

How much would the lowest-cost health plan at [Employer Name] that covers [list all members selected in Items #200 and #203 for this employer] cost?

SSN couldn't be verified The member's SSN couldn't be verified. Go back and make sure that the member's name, date of birth, and SSN are correct. If the SSN still isn't verified, contact the Marketplace Call Center Agent/Broker line at 1-855-788-6275 (TTY: 1-855-889-4325) for next steps. The consumer you're helping must be on the call with you. Or, the consumer can create or log in to their own account on HealthCare.gov or an Enhanced Direct Enrollment site to complete their application.

A Social Security Number (SSN) is required for U.S. citizens You'll need to do one of these: - Return to the previous section to provide this applicant's SSN. - Contact the Marketplace Call Center Agent/Broker line at 1-855-788-6275 (TTY: 1-855-889-4325) for help. The applicant you're helping must be on the call with you. - The applicant can create or log into their own account on HealthCare.gov or an Enhanced Direct Enrollment partner site to complete their application.

A Social Security Number (SSN) or immigration document details are required You'll need to do one of these: - Return to the previous section to provide this applicant's SSN, or choose a document type, below. - Contact the Marketplace Call Center Agent/Broker line at 1-855-788-6275 (TTY: 1-855-889-4325) for help. The applicant you're helping must be on the call with you. - The applicant can create or log into their own account on HealthCare.gov or an Enhanced Direct Enrollment site to complete their application.

Provide as much information from [FNLNS]'s immigration documentation as possible. Continuing without an SSN requires immigration document details. If you continue without providing [FNLNS]'s immigration document information, you may be blocked from continuing the application.

Immigration details couldn't be verified The applicant's immigration document details couldn't be verified. Contact the Marketplace Call Center Agent/Broker line at 1-855-788-6275 (TTY: 1-855-889-4325) for help. The applicant you're helping must be on the call with you. Or, the applicant can log into their own account on HealthCare.gov or an Enhanced Direct Enrollment partner site to complete their application.

Are any of these people currently enrolled in Medicare, or will be in the next 3 months?

Enter [FNLNS]'s Medicare start date.

If [FNLNS] enrolls, or stays enrolled, in a Marketplace plan, it will be active until their Medicare coverage begins. To view other coverage options, check this box.

Confirm [FNLNS]'s Marketplace coverage needs.

We've updated [FNLNS]'s coverage needs to avoid an overlap in Medicare and Marketplace coverage. Though it’s not recommended, you can choose to keep Marketplace coverage after Medicare begins. To select dual enrollment, check this box.

Do you need to add anyone else who needs coverage?