Silver Access 2021

2021 Silver Access Application
Complete this application form after you have selected your health insurance plan.

You will need to have a copy of your Health Insurance Marketplace application nearby to answer some of the questions.

If you have any questions about the this application or the application process, please call Silver Access at 331-716-7573.

After submitting your application, you will receive an email confirmation and copy of your application. All applications submitted before 12/15 will recieve an approval of deinal letter before January 1st.
Step 1. Household Information
What is your name? *

First Name Middle Initial Last Name
What is your date of birth? *

Month Day Year
How many people are in your household? You must write the same number as you wrote on your 2019 Health Insurance Marketplace application. *
How many people in your family will be insured under the Marketplace plan you selected? *
What is the name of Family Member 2?

First Name Middle Initial Last Name
What is the date of birth of Family Member 2?

Month Day Year
What is the name of Family Member 3?

First Name Middle Initial Last Name
What is the date of birth of Family Member 3?

Month Day Year
What is the name of Family Member 4?

First Name Middle Initial Last Name
What is the date of birth of Family Member 4?

Month Day Year
What is the name of Family Member 5?

First Name Middle Initial Last Name
What is the date of birth of Family Member 5?

Month Day Year
What is your annual household family income? You must write the same number as you wrote on your 2021 Health Insurance Marketplace application. *

Step 4. Current Health Insurance Information
Look at the Health Insurance Marketplace application you recently completed for 2021. Which of the Silver Access participating insurance companies did you choose on your application? *
Which of the plans offered by Blue Cross Blue Shield of Illinois did you select?
Please provide the name of your Blue Cross Blue Shield Plan
Which of the plans offered by Cigna Healthcare did you select?
Please provide the name of your Cigna Healthcare Plan
Which of the plans offered by Ambetter Insured by Celtic did you select?
Please provide the name of your Ambetter Plan
Which of the plans offered by Bright Health did you select?
What is your member number for your health plan? If you don't have a member number yet, leave this question blank.
Member Number
What is your Health Insurance Marketplace (HealthCare.gov) application number?
Health Insurance Marketplace Application Number
Did you choose to use all of the Advance Premium Tax Credit on your marketplace application? (You are not able to select the "Use Some" option and be eligible for financial help from Silver Access.) *

Yes No
Look at your Health Insurance Marketplace application. How much is your monthly health insurance premium before tax credit? *
(The full price of your monthly premium.)
Find the Advance Premium Tax Credit section. How much of the health insurance tax credit are you eligible for? *
(The Health Insurance Marketplace will tell you the amount of the Advance Premium Tax Credit you can receive to lower the cost of your premium.)
How much is your monthly health insurance premium including your tax credit? *
(This is how much you are expected to pay per month.)
What is the date that your health insurance plan begins on? *
(This is also known as your plan's effective date. This will be found on your Marketplace application.)
Please attach the summary page(s) from your Marketplace application. One or more files can be uploaded. We recommend uploading this as a scanned document, screenshot, or picture.