Silver Access 2024

2024 Silver Access Application
Complete this application form after you have completed your Marketplace application and selected your health insurance plan.

*1 APPLICATION PER ACTIVE POLICY*

If multpiple people are in one policy, then only 1 application is needed. If different policies in 1 family, then multiple applications will need to be completed.

Application submitted before the 15th of the month, will recieve confirmation of approval before the end of the month. Applications submitted after the 15th, will recieve approval notice by the end of the following month.

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

If you have any questions about the this application or the application process, please email Vanessa Corpus at vcorpus@accessdupage.org
Step 1. Household Information
What is your name?*

First NameMiddle InitialLast Name
What is your date of birth?*

MonthDayYear
How many people are in your household? You must write the same number as you wrote on your 2024 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 NameMiddle InitialLast Name
What is the date of birth of Family Member 2?

MonthDayYear
What is the name of Family Member 3?

First NameMiddle InitialLast Name
What is the date of birth of Family Member 3?

MonthDayYear
What is the name of Family Member 4?

First NameMiddle InitialLast Name
What is the date of birth of Family Member 4?

MonthDayYear
What is the name of Family Member 5?

First NameMiddle InitialLast Name
What is the date of birth of Family Member 5?

MonthDayYear
What is your annual household family income? You must write the same number as you wrote on your 2024 Health Insurance Marketplace application.*

Step 2. Contact Information
Home Address*

Street Address

Apt/Unit

CityState

Zip Code
What is your primary language?*
In addition to your primary language, Do you also speak English?

YesNo
Silver Access's preferred contact method is email for monthly updates. Only enrollment and financial updates will be mailed if an email is not provided.
What is your Email Address? *
Do you prefer to opt out of email communications and receive Enrollment and Financial updates via mail ?*

Send me emailsMail paper updates
Phone Number*

Step 4. Current Health Insurance Information
Look at the Health Insurance Marketplace application you recently completed for 2024. Which insurance company 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 Molina Health did you select?
Please provide the name of your Molina Health Plan
Which of the plans offered by UnitedHealthcare did you select?
Please provide the name of your UnitedHealthcare Plan
Which of the plans offered by Oscar Health Plan did you select?
Please provide the name of your Oscar Health Plan
Which Aetna CVS Health Plan did you choose?
Please type chosen plan
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? (If you selected partial use or "Use Some" option for Tax Credit then you will not be eligible for financial help from Silver Access.)*

YesNo
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 after 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 Eligibility Notice of your Marketplace Application. One or more files can be uploaded. We recommend uploading this as a scanned document, screenshot, or a picture.

Browse Files
Eligibility Notice is required for 2024 application Cancelof