Rates are standardized for Texas exchange plans so these are the best rates available with full tax credit based on your submitted information.
As Certified agents with the Federal Exchange, there is no cost for our service. We can help you throughout the year with your account and coverage.
There is no obligation with online app submittal. Simply do not pay first month's premium to cancel the policy never effective. The first payment activates the policy.
I know that I must tell the program I'll be enrolled in if
information I listed on the this application changes. I know
I can make changes in my Marketplace account or by calling the
Markeplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325).
I know a change in my information could affect eligibility for
member(s) of my household.
I'm signing this application under penalty of purgury, which means
I've provided true answers to all of the questions to the best of
my knowledge. I know I may be subject to penalties under
federal law if I intentially provide false information
By signing, you agree to the following:
To file a federal income tax return on or before the due date for the return (including extensions of time for filling) to claim the Advanced Premium Tax Credit (APTC), if applicable.
To report changes to the Federal Exchange anything that affects my eligibility, including: income, household size and address. These changes could affect the plans and APTC for which I am eligible.
I cannot switch plans outside of the Open Enrollment Period unless I have a qualifying life event. Some of the qualifying life events are a permanent move that results in access to new plans, birth or adoption of a child, marriage or domestic partnership.
1. I understand that every participating health plan has its own rules for resolving disputes or claims, including, but not limited to, any claim asserted by me, my enrolled dependents, heirs, or authorized representatives against a health plan, any contracted health care providers, administrators, or other associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or items, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), or premises liability.
2. I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept, and agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law) and give up my right to a jury trial and cannot have the dispute decided in court, except as applicable law provides for judicial review of arbitration proceedings.
3. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plan's coverage document, which is available online at https://www.healthcare.gov/ for my review, or I can call my carrier for more information.
1. The Federal Exchange checks other agencies'
computer records to verify citizenship, satisfactory immigration
status, tax information, and other information related only to
eligibility to see if you and other people on this application qualify
for health insurance.
2. The Federal Exchange may partner with credit
agencies for identity verification. These credit agencies will use
information from other agencies to help check your identity. This
information will never be presented to outside parties. This
information will not affect your credit score.
3. Your signature is consent to access your identity
information through the Federal Data Services Hub Remote ID Proofing
Service
Special Enrollment
You can
apply for free or low cost health care through Medicaid at any time of
the year. To enroll in a health plan through the Federal Exchange, you
must have a qualifying life event during the special enrollment period
(outside of the Open Enrollment Period). If you are eligible for
Medicaid, you can enroll through the year. Please make sure your
application is true and correct. If you provide false information,
your coverage may be cancelled. The U.S. Department of Health and
Human Services may also fine you for providing false information.
You may
be fined up to $25,000 if you negligently or with intentional
disregard for the rules provide false information in your application.
You may be fined up to $250,000 if you knowingly lie on your
application.
The
Federal Exchange may request that you provide documents to show you
qualify for coverage.
Medicaid Estate Recovery Alert
The
Medicaid program must seek repayment from the estates of certain
deceased Medicaid members for payments made, including managed care
premiums, for nursing facility services, home and community-based
services, and related hospital and prescription drug services provided
to the deceased Medicaid member on or after the member's 55th
birthday. If a deceased member does not leave an estate or owns
nothing when they die, nothing will be owed.
Federal Exchange Nondiscrimination Policy
The
Federal Exchange complies with applicable federal civil rights laws
and does not discriminate on the basis of race, color, national
origin, age, disability or sex. The Exchange does not exclude people
or treat them differently because of race, color, national origin,
age, disability or sex.
The
Federal Exchange provides free aids and services to people with
disabilities to communicate effectively with us, such as qualified
sign language interpreters and written information in other formats
(large print, audio, accessible electronic formats and other formats).
The
Federal Exchange also provides free language services to people whose
primary language is not English, such as qualified interpreters and
information written in other languages.
If you
believe that the Exchange has failed to provide these services or
discriminated in another way on the basis of race, color, national
origin, age, disability or sex, you can file a grievance with the
Civil Rights Coordinator.
You can
file a civil rights complaint with the Office for Civil Rights at the
U.S. Department of Health and Human Services.
Mail:
U.S. Department of Health and Human Services, 200 Independence Ave.
SW, Room 509F, HHH Building, Washington, DC 20201
Phone: (800) 868-1019 or TTY: (800) 537-7697
Online:
Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available on the U.S. Department of Health and
Human Services Office for Civil Rights website.
I certify (or declare) under penalty of perjury under the laws of the
State of California that the foregoing is true and correct.
If you
are found eligible for Medicaid, you must tell your county eligibility
worker about any changes that may affect your eligibility for health
insurance within 10 days of the change.
These changes include, but are not limited to:
I have
understood all the questions on this application and provided true and
correct answers to such questions to the best of my knowledge. Where I
do not have personal knowledge of an answer, I have made every
reasonable attempt to verify (or confirm) the information with someone
who has personal knowledge of the answer.
I know
that if I am not truthful there may be a civil and/or criminal penalty
for perjury.
I know
that all information disclosed on this application will be used to
determine eligibility of every person applying for health insurance on
this application. The information will be kept private as required by
federal law.
I
understand that if I have received advanced premium tax credits for
health coverage through the Exchange during the previous benefit year,
I must have filed or will file a federal income tax return for that
benefit year.
By
entering my full name on the application, I agree that this digital
signature shall have the same force and effect as if I signed this
application by my own hand.