2021 AEP Health Renewal Quote Sheet

Your Name *

First Name Last Name

Your Agent's Name

Your Birthdate

Date

Email *

example@example.com

Phone Number

Area Code Phone Number

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

What county do you live in? *

Are you a smoker or non-smoker? *

Smoker Non-smoker

Do you currently receive a premium subsidy credit? *

Yes No

Are you anticipating a change in income for 2021 that you feel you may qualify for a premium subsidy credit? *

Yes No

YOUR Estimated 2021 Annual Income/Wages/Tips (before taxes). If you are married, we will ask for your spouse's income separately. *

What is the amount you receive ($)

How Often are you receiving this income (hr, weekly, monthly, annually) If hourly, hourly, please include how many hours weekly

What is the Source of your income (Employer Name, Self Employed - type of work, Social Security, Retirement, etc.)

.

Marital Status? *

Single Married

Spouse's Name *

First Name Last Name

Spouse's Birthdate

Date

Is your spouse a smoker or non-smoker? *

Smoker Non-smoker

If your household receives a premium subsidy credit, we will need your Spouse's Estimated 2021 Annual Income/Wages/Tips (before taxes) *

What is the amount you receive ($)

How Often are you receiving this income (hr, weekly, monthly, annually) If hourly, please include how many hours weekly

What is the Source of your income (Employer Name, Self Employed - type of work, Social Security, Retirement, etc.)

.

Does your spouse need to be covered under your plan? *

Yes, my spouse also NEEDS coverage under my plan. No, my spouse DOES NOT need coverage under my plan.

Will there be anyone else in your household for 2021 (children, step children)? *

Yes No

*

Child's Legal Name

Birthdate

Relationship

Sex (M/F)

Do they need coverage?

Are you claiming them on your 2021 taxes?

.

What provider/network group(s) do you prefer? *

Affinity/Ascension Aurora Bellin Prevea ThedaCare

Are you or anyone listed on the application offered health coverage from a job? Check yes even if you don't accept the coverage? *

Yes No

If yes, explain:

Due to the coronavirus outbreak, it might not be possible to have an in-person meeting. Which of these alternatives would you prefer if necessary?

Phone Call Virtual E-mail me my options

Do you agree to allow the Marketplace to use income data, including information from tax returns, for the next 5 years? *

Yes, I agree No (Selecting no may impact your ability to get help paying for coverage at renewal.)

Medicaid

If anyone on this application is eligible for Medicaid:

I'm giving to the Medicaid agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties. I'm also giving to the Medicaid agency rights to pursue and get medical support from a spouse or parent.
If any child on this application has a parent living outside of the home, I know I'll be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell Medicaid and I may not have to cooperate.
I'm signing this application under penalty of perjury, which means I've provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I intentionally provide false or untrue information.
I know that I must tell the Health Insurance Marketplace within 30 days if anything changes (and is different than) what I wrote on this application. I can visit HealthCare.gov or call 1-800-318-2596 to report any changes. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.
I know that under federal law, discrimination isn't permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity, or disability. I can file a complaint of discrimination by visiting www.hhs.gov/ocr/office/file .
I know that information on this form will be used only to determine eligibility for health coverage, help paying for coverage (if requested), and for lawful purposes of the Marketplace and programs that help pay for coverage. We need this information to check your eligibility for help paying for health coverage if you choose to apply. We'll check your answers using information in our electronic databases and databases from the Internal Revenue Services (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn't match, we may ask you to send us proof.

What should I do if I think my eligibility results are wrong?

If you don't agree with what you qualify for, in many cases, you can ask for an appeal. Please review your eligibility notice to find appeals instructions specific to each person in your household who applies for coverage, including how many days you have to request an appeal. Here's important information to consider when requesting an appeal:

You can have someone request or participate in your appeal if you want to. That person can be a friend, relative, lawyer, or other individual. Or, you can request and participate in your appeal on your own.
If you request an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.
The outcome of an appeal could change the eligibility of other members of your household.

To appeal your Marketplace eligibility results, visit www.HealthCare.gov/marketplace-appeals/. Or call the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325. You can also mail an appeal request form or your own letter requesting an appeal to Health Insurance Marketplace, Dept. of Health and Human Services, 465 Industrial Blvd., London KY 40750-0001. You can appeal eligibility for purchasing health coverage through the Marketplace, enrollment periods, tax credits, cost-sharing reductions, Medicaid, and CHIP, if you were denied these. If you qualify for tax credits or cost-sharing reductions, you can appeal the amount we determined you're eligible for. Depending on your state, you may be able to appeal through the Marketplace or you may have to request an appeal with the state Medicaid or CHIP agency.

Health Insurance Checklist

By signing below, you acknowledge the following:

I understand:

• It is my responsibility to confirm that my current medications are on my plan’s drug list.
• It is my responsibility to review the Summary of Benefits for the plan I have selected.
• There is limited coverage for foreign travel under my policy.
• I should not cancel any existing health insurance coverage until your policy is approved.
• It is my responsibility to cancel my prior health insurance coverage. A company will not “back date” a cancellation request so I must take steps to make sure my policy was cancelled, even if a representative of ISC assisted you with the cancellation. ISC will NOT be notified of the cancellation of your prior policy.
• ISC will not discuss your policies with anyone unless requested by you in writing.
• I understand that my agent will typically not receive copies of correspondence sent to me by the insurance company or the Marketplace. I will need to call or email my agent if I have any questions about correspondence I have received.
• It is my responsibility to work directly with the insurance company for any billing issues, including initial set up.
• I understand that ISC cannot accept health insurance payments. I will need to make all payments directly with the insurance company.
• It is my responsibility to work directly with the insurance company regarding claims related issues.

• My plan has a Provider Network and it is my responsibility to verify that my doctors(s) and or facilities are in my network. If I go to a doctor or facility outside of my network, I understand that it is very likely there may not be coverage.
• I need to pre-certify for surgery (including some outpatient procedures), hospitalization, and durable medical equipment.

Authorized Representative

I understand that I can give a trusted person permission to talk about this application on my behalf with the Health Insurance Marketplace, to see my information, and to act on my behalf with regard to related to this application, including getting information about your application and signing my application on my behalf. This person is called an “authorized representative.”

By signing this form, I am giving Insurance Service Center, LLC – De Pere, Karen VanDenBusch (NPN# 6463972), Brenda Vander Logt (NPN# 9017507), or their licensed assistants, to be my “authorized representative” as it pertains to assisting with my Marketplace application. I understand that I am able to change or remove my authorized representative by contact the Marketplace at 1-800-318-2596.

Signature *

Clear