APPLICATION REVIEW & CONSENT

AS REQUIRED UNDER THE 2023 CMS-9899-F AMENDMENT OF 45 CFR § 155.220

By signing below, I confirm that I have read and agree to the following terms.

1. I know that I must tell the Health Insurance Marketplace in my state within 30 days if anything changes (and is different than) what I wrote on this application. If my state uses Healthcare.gov, I can visit the Healthcare.gov website or call 1-800-318-2596 to report any changes. Alternatively, I can use this link to find the contact information for my particular state and report any changes directly to the Marketplace. I understand that a change in my information could affect my eligibility as well as eligibility for member(s) of my household.

2. If anyone on my 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 is found to have other qualifying coverage will not stay enrolled in Marketplace coverage and have to pay full cost.

3. I have reviewed my eligibility application information. I confirm it to be accurate in compliance with § 155.227. This includes, but is not limited to, information related to my contact profile (email, phone, and address) as well as my income reported to the exchange.

4. I am signing this application under penalty of perjury, which means I have 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.

Your agreement