Marketplace Income & Coverage Review Form

Marketplace Income & Coverage Review Form

Thank you for taking a few moments to complete this important update. This helps us ensure your health coverage through the Marketplace remains accurate, compliant, and uninterrupted.
🛑 Why This Matters
The Centers for Medicare & Medicaid Services (CMS) requires all Marketplace enrollees to keep their income and household details up to date. Failure to do so may result in:
- Unexpected tax bills or reduced refunds (reported on IRS Form 1095-A)
- Loss of subsidies or coverage
- Potential eligibility issues in the future
Let's keep everything current to protect your plan and benefits.

💵 Income & Household Updates
Has your household income changed since you last applied?*

YesNo
If yes, what is your current estimated annual household income (before taxes)?
(Include all tax filers in the household)
Have there been any household changes (marriage, divorce, birth, death, or someone moving in/out)?*

YesNo
If yes, please describe:
Have you been satisfied so far with your plan?

YesNoSomewhat
If you answered anything other than "Yes," can you briefly share what has or hasn’t worked well for you?(Please include any specific issues with doctors, prescriptions, costs, or coverage so we can help better.)

🧾 Update Status
Have you already reported these changes to the Marketplace?*

Yes, I updated my info myselfNo, I need help updating itI'm not sure-please verify for me
Do you understand that accurate information is required for tax purposes?*

Yes, I understand this may affect my IRS Form 1095-A and tax filingNo, I’d like more information sent to me

📆 Policy Expiration & Renewal

Your current health plan is set to expire on 12/31/2025. We’ll need to review your plan and re-enroll after November 1st to ensure coverage continues into 2026.
Would you like to go ahead and request your renewal appointment?*

Yes, please contact me after November 1I’ll reach out when I’m readyI no longer need coverage next year
🔄 Looking Ahead to 2026

Please note: Some plan options, subsidies, and networks may change for 2026. Staying ahead of these updates helps ensure you’re always in the right plan at the right time. Please let us know if you have any questions regarding your coverage and/or options.

🛑 Why This Matters