Marketplace Attestations Agreement
The Centers for Medicaid & Medicare Services (CMS) now requires two forms of consent from our clients. You have already completed the first form of consent. Please read the attestations and sign that you understand. Select whether you agree or disagree to adhere to Marketplace regulations. Each year we inform you that you must file your taxes, how eligibility works, and how tax credits are reconciled. Please note that we cannot enroll you without your consent. Disagreeing with any of the below attestations may hinder the ability to enroll in a plan. Please ask your agent if you need further explanation on any of the following.
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.
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Agree
Disagree
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.
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Agree
Disagree
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. • 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.
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Agree
Disagree
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.
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Agree
Disagree
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.
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Agree
Disagree
If anyone on your application is enrolled in Marketplace coverage and is later found to have other qualifying health coverage (like Medicare, Medicaid, or Children's Health Insurance Program (CHIP)), the Marketplace will automatically end their Marketplace plan coverage. This will help make sure that anyone who’s found to have other qualifying coverage won’t stay enrolled in Marketplace coverage and have to pay full cost. Either • I agree to allow the Marketplace to end the Marketplace coverage of the people on my application in this situation. Or • I don’t give the Marketplace permission to end Marketplace coverage in this situation. I understand that the affected people on my application will no longer be eligible for financial help and must pay full cost for their Marketplace plan.
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Agree
Disagree
Name
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First Name
Last Name
Signature
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I am 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.
DateTime
Submit
Submit
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