• I understand I must give the Arkansas Department of Human Services complete and true information to the best of my knowledge.
• I understand that I may have to provide proof that what I've told the Department is true.
• I understand I must tell the Department about any changes to the information I gave on my application.
• I agree to cooperate with state or federal reviewers.
• I understand I will have to repay any benefits I should not have received, even if it is the Department's error.
• I understand that if I am admitted to a nursing facility based on conditional Health Care approval and my application is denied, I, or my family, will be responsible to repay any costs I owe from living in the nursing facility.
• I will use my benefits legally and will not sell, trade, or give away my benefits online or in person.
• I understand that if required, I must cooperate with the Office of Child Support Enforcement as a condition of receiving benefits.
• I authorize the Arkansas Department of Human Services (DHS) to get information from other state agencies, financial institutions, employers, federal agencies, and other sources to prove my statements are true and correct.
• I understand that if differences are found between what I report and information given by the sources listed above, my household's eligibility for benefits may be affected.
• I authorize the Arkansas Department of Human Services (DHS) to get information from the Immigration Services (USCIS) through the Systematic Alien Verification and Eligibility (SAVE) System to verify the status of any non-U.S. citizen who is seeking benefits for themselves.
• I have received, reviewed, and agree to the information about my responsibilities included in this application.

If you do not check any box, you will be considered to have decided to not register to vote at this time. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided, or your eligibility. Your decision to register to vote or not will be kept confidential. If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. If you have additional people in your household that would like a voter registration application, please let us know. If you believe that someone has interfered with your right to register or to decline to register to vote, or your right to privacy in deciding whether to register; you may file a complaint with the: Arkansas Secretary of State, Elections Division, 500 Woodlane, Ste. 26, Little Rock, AR. 72201 or Toll free 800-482-1127.

Sign Here for Health Care YOUR SIGNATURE: Information on this form is subject to verification by federal, state, and local officials and through the state Income and Eligibility Verification System and computer cross matching with other agencies. Information may also be submitted to the Immigration & Naturalization Service (INS) for verification. If information is found to be incorrect, your eligibility and benefit level may be affected, your benefits may be stopped, and you may be subject to criminal prosecution for knowingly providing incorrect information. Under penalties of perjury, I state that I have reviewed this application, and to the best of my knowledge and belief, the answers I gave within this application are true, including household, citizenship and non-citizenship information, and I have listed all amounts and sources of income I received and property I own. Note: An Authorized Representative may sign this document so long as you have provided the information required in Appendix 1, attached.

Health Care reimburses providers for covered medical services that are provided to eligible needy individuals through the Medicaid program. Eligibility is determined based on income, resources, Arkansas residency, and other requirements. Covered services also vary among Medicaid categories. The Arkansas Health and Opportunity for Me (ARHome) Program is not a perpetual federal or state right or a guaranteed entitlement program, and it may be ended at any time upon appropriate notice. Your Rights 1. You have the right to seek job search and job training services from Arkansas Workforce Connections (AWC), but it is not a requirement to receive Medicaid or the Arkansas Health and Opportunity for Me (ARHome) Program. 2. You do not have the perpetual federal or state right or a guaranteed entitlement to ARHome, and it may be ended at any time upon appropriate notice. 3. You are giving DHS your rights to seek and get money from other health insurance, legal settlements, or other third parties. 4. You are giving the Medicaid agency rights to pursue and get medical support from a spouse or parent.

Your Responsibilities 1. General Responsibilities You have the responsibility to notify the Department of Human Services of any changes that occur in your circumstances, including, but not limited to, the addition of new household members who get additional income, acquire, or dispose of property. You circumstances. have the responsibility to give as much of the needed information as you can about your You knowledge. have the responsibility to fully complete forms with true information to the best of your If receiving healthcare in a nursing facility, Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID), or under a home/community-based waiver, you have the responsibility to have the amount of Health Care benefits that DHS paid on your behalf to be recovered from your estate or grantee of a beneficiary deed after your death. You have the responsibility to cooperate with the Office of Child Support Enforcement (OCSE) in establishing paternity and getting medical support for each child who has a parent absent from the home if the program you have applied for asks you to do so. 2. Penalty Warnings: If you get Health Care benefits, you must follow the rules listed below: DO NOT give false information or hide information in order to become eligible for benefits. DO NOT put your money or property in someone else's name in order to get Health Care benefits. If you get benefits to which you or your household are not entitled because you gave false information or hid information, assistance will be subject to recovery by DHS, any assistance you get in the future may be reduced to recover this overpayment, and you may be subject to prosecution for fraud, fined or imprisoned.

Under the Department of Human Services (DHS) policy, Medicaid cannot deny you eligibility or benefits based on your race, age, sex, disability, national origin, or political or religious beliefs.

Privacy Notice The PRIVACY ACT of 1974 requires the Department of Human Services (DHS) to tell you: 1. Whether disclosure is voluntary or mandatory; 2. How DHS will use your SSN; and, 3. The law or regulation that allows DHS to ask you for the SSN. We are authorized to collect from your household certain information including the social security number (SSN) of each eligible household member. For the Supplemental Nutrition Assistance Program this authority is granted under the Food and Nutrition Act of 2008 as amended, 7 U.S.C. 2001-2036. For both the Medicaid Program and the TEA Program, this authority is granted under Federal laws codified at 42 U.S.C. §§ 1320b-7(a1) and 1320b-7(b2 This information may be verified through computer matching programs. We will use this information to determine program eligibility, to monitor compliance with program rules, and for program management. This information may be disclosed to other Federal and State agencies and to law enforcement officials. If claim arises against your household, the information on this application, including all SSNs may be provided to Federal or State officials or to private agencies for collection purposes. Important Estate Recovery Notice If you receive Health Care assistance in a nursing facility, ICF/IID facility, or under a home and community-based waiver program, the total amount of the Health Care benefits paid on your behalf will be owed to DHS and may be recovered from your estate or from the grantee of a beneficiary deed after your death. Your estate is the property you own at the time of your death. DHS will not make a claim against your estate while you are living. DHS will not make claim against your estate after your death if your spouse is still living or if you have dependent minor children under age 21 or blind or have children with disabilities. DHS will collect the debt, if any, by filing a claim in your estate. Collection may not be made if it is not cost-effective to DHS or if your heirs apply and are granted a hardship waiver after your death. A hardship may exist if the estate property is the only source of income for your heirs if that income is limited, or if there are other compelling circumstances. Quality Control Your case may be selected for a Quality Control (QC) review. If so, the QC worker will check your case to see if you have given us the correct information. They will also check to make sure the DHS county office processed your case correctly. If your case is selected for a QC review, the QC worker will contact you for an interview. You are required to give information to prove your statements are true and correct. The QC worker may contact your employer, your bank, other agencies, your landlord, etc., for information. If you do not cooperate during a QC review, your SNAP case will close. You will not be eligible to get SNAP benefits until you cooperate with QC or until February of the following year, whichever comes first. Your Right to Appeal If you think that DHS has made a mistake, you can appeal its decision. To appeal means to tell someone at DHS that you think the action was incorrect and that you want a fair review of the action. You can be represented in the process by someone other than yourself. You can request an appeal in the following ways: In person: Talk to staff of any DHS county office. By phone: You can call the Office of Appeals and Hearings at (501) 682-8622, or you may call your local county office. By email: DHS.Appeals@dhs.arkansas.gov By mail: Arkansas Department of Human Services Office of Appeals and Hearings Slot S101 P.O. Box 1437 Little Rock, AR 72203-1437 How to File a Complaint You have the right to make a complaint if the Department of Human Services has discriminated against you. You can make a complaint orally or in writing by contacting the Office of Program and Grant Management- Civil Rights Unit, P.O Box 1437 Slot S335, Little Rock, AR 72203-1437, by emailing DCOCivilRightsComplaints@dhs.arkansas.gov or by calling (501) 534-4119.

ANY CHANGE OF INCOME, ADDRESS, OR HOUSEHOLD SIZE NEEDS TO BE REPORTED TO DHS.

YOU MAY REPORT CHANGES TO YOUR LOCAL DHS OFFICE OR CALL DHS AT 1-855-372-1084.

Disclaimers and Acknowledgments Privacy Act Statement-Permission for Information Submitted You represent that you have permission from all the people whose information is on the application to both submit their information to the Marketplace and receive any communications about their eligibility and enrollment. We are authorized to collect the information and any supporting documentation, including Social Security numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act. We need the information provided about you and the other individuals listed on the application to determine eligibility for: (1) enrollment in a qualified health plan through the Federal Health Insurance Marketplace, (2) insurance affordability programs (such as Medicaid, CHIP, advanced payment of the premium tax credits, and cost-sharing reductions), and (3) certifications of exemption from the individual responsibility requirement. While providing the requested information (including Social Security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the Marketplace, advanced payment of the premium tax credits, cost-sharing reductions, or an exemption from the shared responsibility payment. If you don't have an exemption from the shared responsibility payment and you don't maintain qualifying health coverage for three months or longer during the year, you may be subject to a penalty. If you don't provide correct information on the application or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action. To verify and process applications, determine eligibility, and operate the Marketplace, we will need to share selected information that we receive to the Federal Marketplace and/or Arkansas Department of Human Services. Your information may be shared with other federal and state agencies to complete the marketplace application. Other federal agencies (such as the Internal Revenue Service, Social Security Administration, and Department of Homeland Security), state agencies (such as Medicaid or CHIP, Arkansas Department of Correction, and Arkansas Community Correction) or local government agencies may use the information you provide in computer matching programs with any of these groups to make eligibility determinations, to verify continued eligibility for enrollment in a qualified health plan or federal benefit programs, or to process appeals of eligibility determinations. Information provided by applicants won't be used for immigration enforcement

Selected information may also be shared with other employees of our broker agency; other verification sources including consumer reporting agencies; employers identified on applications for eligibility determinations; applicants/enrollees and authorized representatives of applicants/enrollees; agents, brokers and, issuers of Qualified Health Plans, as applicable, who are certified by CMS who assist applicants/enrollees; CMS contractors engaged to perform a function for the Marketplace; and anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013 Identity Verification

To protect your privacy, you will need to complete Identity Verification successfully before requesting higher account privileges. You are providing consent to Experian, an external identity verification provider, to access your personal information to conduct ID Verification on behalf of CMS. Below are a few items to keep in mind: Ensure that you have entered your legal name, current home address, primary phone number, date of birth, and email address correctly. CMS will collect personal information only to verify your identity with Experian. Identity Verification involves Experian using information from your consumer report profile to help confirm your identity. As a result, you may see an entry called a "soft inquiry" on your Experian consumer report. Soft inquiries are visible only to you, will never be presented to third parties, and do not affect your credit score. The soft inquiry will be titled "CMS Proofing Services" and will be removed from your Experian consumer report after 25 months.

Eaton AgencyPO BOX 94368North Little RockAR72190888-608-1541FAX: 501-421-9970License# 6624853

You may need to have access to your personal and consumer report information, as the Experian application will pose questions to you based on data in their files. This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e3 You can learn more about how CMS handle your information at: https://www.healthcare.gov/how-we-use-your-data

Off-Exchange, Tax Subsidies, Traditional Medicaid, and ARHOME

Off-Exchange - I understand that I may purchase a health insurance policy without going through the Federal Marketplace and answering questions about my income and family situation. I understand that I cannot be turned away for health reasons if my application is submitted during open enrollment. I understand that if purchased off the Federal Marketplace I will be paying the full premium price. Tax Subsidies - I understand that I may go through the Federal Marketplace, and if my family income is less than 400% of the poverty level, I may be entitled to tax subsidies to help defray the premium costs. Expanded Medicaid - I understand that if my family income is less than 138% of the poverty level (or higher if I am pregnant and certain other conditions) that I may qualify for Expanded Medicaid in Arkansas. Traditional Medicaid - I understand that if I am approved for Expanded Medicaid that I may be placed by the Department of Human Services in Traditional Medicaid if I am pregnant, medically frail, a Native American Indian, am drawing some form of disability, or certain other conditions. ARHOME - I understand that if I am approved for the ARHOME program that I will be asked to select an insurance plan. I understand that this plan will not be effective until the effective date of the policy, I have received the insurance card, and I have received a copy of the policy, and until the insurance policy is effective, I may be covered by Traditional Medicaid. Estimated Subsidies

Estimates Only - I understand that any quotes given are estimates only and that additional information will be required that may substantially change any quote given. Estimated Annual Income - I have estimated that my modified adjusted gross income for 2025 will be the ESTIMATED ANNUAL INCOME as shown in my application and agree that this amount will be used to calculate my advanced premium tax credit, my eligibility for Traditional Medicaid, and/or the ARHOME program. I acknowledge that if my 2025 modified adjusted gross income is greater than the ESTIMATED ANNUAL INCOME as shown in my application that I could possibly have to pay back a portion or all of the advanced premium tax credit. Estimated Household Size - I have estimated that my HOUSEHOLD SIZE will be used to calculate my advanced premium tax credit and/or eligibility for Traditional Medicaid or the ARHOME program. I acknowledge that if my 2025 household size is less than the HOUSEHOLD SIZE as shown above that I could possibly have to pay back a portion or all of the advanced premium tax credit. Tax Return Required for Subsidies - I acknowledge that if I take an advanced premium tax credit I must file a tax return for 2025. Tax Subsidy Optional - I acknowledge that taking the advanced premium tax credit is optional and is not required. I acknowledge that I have the option to not take the advanced premium tax credit and wait until I file my 2025 return to receive whatever if any tax credit is due to me. Tax Subsidies and Group Health Insurance

Do Not Have Access to Affordable Group Insurance - I acknowledge that I do not have access to affordable group coverage as defined by the Affordable Care Act and/or my group coverage does not have minimum essential coverage as defined by the Affordable Care Act. Group Insurance Becomes Available - I acknowledge that if group insurance becomes available to anyone in my family that it is my responsibility to contact the Federal Marketplace immediately. I acknowledge that if group insurance is/or becomes available to me in 2025 and the government considers it affordable coverage and has minimal coverage that I could possibly have to pay back a portion or all of the advanced premium tax credit.

Not Effective Until Approved and Plan Issued - I understand that I may have been shown various insurance plans and I may have expressed my preference as to which plan I desired. I acknowledge that the plan will not be effective until the Federal Marketplace or Department of Human Services has approved my application, the premium (if any) has been paid, and I have received the policy and insurance card from the insurance company. Plan May Change Based Upon Additional Information - I understand that additional information that will be required may change my expressed insurance plan preference and may change whether I qualify for tax subsidies, whether I qualify for Traditional Medicaid, and/or whether I qualify for the ARHOME program. Changed Circumstances

Locked Into Plan - I acknowledge that I may be locked into the insurance plan I choose until the next Open Enrollment or unless I have a Qualifying Life Event. List of Qualifying Life Events - I understand that some but not all Qualifying Life Events are New Family Member Substantial Change in Family Income Marriage, Divorce, or Legal Separation I understand that a change in my health condition is NOT a Qualifying Life Event. Changed Circumstances: Tax Subsidies - I acknowledge that it is my responsibility to contact the Federal Marketplace immediately if I believe that the estimated 2025 household income will be greater than the estimated household income listed above. I acknowledge that it is my responsibility to contact the Federal Marketplace immediately if I believe that the estimated 2025 household size will be less than or greater than estimated household size above that was initially used to calculate my advance premium tax credit. I understand that my eligibility for Traditional Medicaid or the ARHOME program is based upon my income from month to month. I understand that it is my responsibility to contact the Department of Human Services if my monthly income were to change. How to Report Life Changing Events - I acknowledge that I have been shown where I can go on the marketplace website to find information on qualifying events. I further acknowledge that if I decide to make a change to my policy due to a qualifying event that it must be done within a specified time of the qualifying event. I acknowledge that I have been shown where to find this information on the marketplace website regarding qualifying events and time limitations to exercise a qualifying event. I acknowledge that I have answered all questions that were asked to me by the agent truthfully. I acknowledge that I have the legal right to enroll all dependents that were listed on the policy application.

2025 Arkansas Insurance Companies and Contact Info

Ambetter of Arkansas www.ambetterofarkansas.com 1-877-617-0390 Arkansas BlueCross and BlueShield www.arkansasbluecross.com 1-800-800-4298 QualChoice Health Insurance of Arkansas

1-888-608-1541 Fax: 501-421-9970 PO BOX 94368 North Little Rock, AR 72190  License# 6624853