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Location:
Fort Lauderdale, Florida, United States
Salary:
65,000
Posted:
January 06, 2018

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

*** ********** *********

LONDON, KENTUCKY 40750-0001

1092632484082404113 1

yamil macias Nov 16, 2017

**** ******** * ***

Apt G

Margate, FL 33063-5246

Application Date: November 16, 2017

2018 Application ID: 262*******

Eligibility notice: Take action to enroll & use your financial help Family member(s) Results Next steps

Important: You must send documents.

This notice includes deadlines and details.

yamil macias • Eligible to buy a 2018 Marketplace plan

• Eligible for advance payments of the premium

tax credit to help pay for a Marketplace plan.

You can use up to this much of the tax credit:

• $653.00 each month, which is $7,836.00

for the year, for your tax household.

• This is based on the yearly household income

of $15,996.00 the amount that you put on

your application, or that came from other

recent information sources.

• Can choose a Silver plan with lower

copayments, coinsurance, and deductibles

(cost-sharing reductions).

• Choose a plan and pay your first month's

premium.

• Choose a plan and pay the first month's

premium. You must choose a Silver plan to get

the extra savings on out-of-pocket costs.

Choosing a Silver plan instead of a Bronze plan

may save you thousands of dollars if you use a

lot of medical services.

• By February 14, 2018, send documents to

confirm:

• yamil macias's your household income

If your "Results" say you're eligible for advance payments of the premium tax credit or cost-sharing reductions, it means that you don't appear to be eligible for Medicaid based on your application information. However, you could still be eligible for Medicaid if you have a disability or special health care needs that you didn’t report on your application. To learn more, visit HealthCare.gov/people-with-disabilities or call your state Medicaid agency to ask about rules for your state. 1092632484082404113 2

Why don't I qualify for other programs?

yamil macias – You don't qualify for Medicaid or CHIP because you don’t meet the current criteria in your state.

What should I do next?

If your “Next steps” tell you to send more information, follow instructions for sending it. If you don’t, you could lose what you qualify for now because your information doesn't match the data we have, or we can't verify all of the information in your application. 1. Continue to plan selection, and choose a plan.

2. Upload or mail documents as soon as possible.

See the next section of this notice for a list of documents you can submit and how to submit them. 3. Pay your premium.

Send household income information

yamil macias - Send documentation by February 14, 2018. We need confirmation of your household’s annual income, including income earned by every member of your household, even if they’re not seeking health coverage. If you don't send it, you may have to pay more for coverage and covered services, because Marketplace financial help will change or end. You may need to submit more than one document depending on your household’s situation (for example, you’ll submit multiple documents if more than one person has income in the household).

The document you send should reflect the income amount shown on your Marketplace application. Examples of documents you can send include:

• 1040 tax return (federal or state versions) - Must contain first name, last name, income amount, and year.

• W2s and/or 1099s (includes 1099 MISC, 1099G, 1099R, 1099SSA, 1099DIV, 1099S, 1099INT) - Must contain first name, last name, income amount, year, and employer name (if applicable)

• Pay stub - Must contain first name, last name, income amount, and pay period or frequency of pay with date of payment. If a pay stub includes overtime, indicate average overtime amount per paycheck.

• Self-employment documentation (includes 1040 Schedule C, most recent quarterly or year-to-date profit and loss statement, or self-employment ledger) - Must contain first name, last name, company name, and income amount. If submitting a self-employment ledger, include dates covered by the ledger, and the net income from profit/loss

• Social Security Administration statements (Social Security Benefits Letter) - Must contain first name, last name, benefit amount, and frequency of pay

• Unemployment benefits (unemployment benefits letter) - Must contain first name, last name, source/ agency, benefit amount, and duration (start and end date, if applicable) How to submit documents to confirm eligibility

Uploading your documents is the fastest way to get them to us. Log into your Marketplace account and 1092632484082404113 3

select "Start a new application or upload an existing one." Then select your current application, and click on

"Application details." You'll see a button for each item to resolve. Click the button, then choose a document and start your upload. Or, you can mail copies. Keep the original documents and send copies with your name and Application ID on each page, along with the bar code page included with this notice. Send copies to: Health Insurance Marketplace

Attn: Coverage Processing

465 Industrial Boulevard

London, Kentucky 40750-0001

For more information about choosing documents and uploading or mailing them to the Marketplace, visit HealthCare.gov/submit-documents. To find in-person help, visit LocalHelp.HealthCare.gov. Enroll in coverage

yamil macias - Enroll in coverage by December 15, 2017. Online: You can enroll right after you complete your application, or return to HealthCare.gov later to compare plans and enroll. You’ll need to create a Marketplace account if you don’t already have one. Go to HealthCare.gov, click the “Log In” button in the top right of your screen, and then click “Create Account” to create a Marketplace account before choosing your plan. By phone: Compare plans and enroll over the phone. Call the Marketplace Call Center for help.

• If you don’t already have a Marketplace account, you’ll need the Application ID that’s printed on this notice.

• Open enrollment for the Marketplace ends on December 15, so you must enroll in a plan and pay the first month’s bill (the “premium”) by then.

• If you miss the deadline, you may not be able to enroll in a health insurance plan through the Marketplace until the next Open Enrollment Period, unless you qualify for a Special Enrollment Period.

• Anyone in your household who doesn’t have qualifying health coverage for 3 months or more could owe a penalty, unless you qualify for an exemption.

• For more information, visit https://www.healthcare.gov/apply-and-enroll/how-to-apply/. When will Marketplace coverage begin?

If you’re eligible to buy a Marketplace plan, your plan's coverage will start January 1. What if information from my application changes during the year? If you have life changes and the information you gave us when you applied is no longer correct, you need to let us know within 30 days of the change. Changes may affect your eligibility for:

• Premium tax credits

• Cost-sharing reductions that lower your copayments, coinsurance, and deductibles

• Coverage through Florida Medicaid or Florida KidCare (CHIP) If you enroll in a Marketplace plan and later become eligible for other qualifying coverage, like Medicaid, CHIP, Medicare, or coverage through a job, you won’t be eligible for advance payments of the premium tax credit, although you can keep your Marketplace plan and pay the full premium. If you become eligible for other 1092632484082404113 4

qualifying coverage, you must contact the Marketplace to end your advance payments of the premium tax credit and let the Marketplace know if you also want to end your health plan. If you don’t stop the advance payments of your premium tax credit to your health insurance company, you may need to pay back the payments paid on your behalf.

What should I do if I think my eligibility results are wrong? If you think we made a mistake, you can appeal a final determination of eligibility to the Marketplace Appeals Center. This includes your eligibility to purchase health coverage through the Marketplace, and for premium tax credits, cost-sharing reductions, and enrollment periods. See below for more information about appealing your eligibility for Florida Medicaid or Florida KidCare (CHIP). Please note that:

• If you need health services right away and a delay could seriously jeopardize your health, you can ask for a fast (expedited) appeal using the Appeal Request form or by sending a fax or a letter to the address below.

• You can represent yourself or appoint a representative to help you with your appeal. This person can be a friend, relative, lawyer, or someone else.

• You can ask to keep your eligibility during your appeal. If you were previously eligible for Marketplace coverage or financial assistance and your eligibility is changed, you can appeal this change. In this case, you may be able to keep your previous eligibility during your appeal.

• The outcome of an appeal could change the eligibility of other members of your household even if they don’t ask for an appeal.

How much time do I have to request an appeal?

Generally you have 90 days from the date of your eligibility notice to request an appeal. However, if this notice says that someone needs to submit documents, then you must follow instructions for sending them. Until you submit documents and your issue is resolved, your eligibility notice isn’t a final determination of eligibility and it can’t be appealed.

How do I request an appeal?

• Visit HealthCare.gov/marketplace-appeals to get the Appeal Request form for your state; or

• Write a letter requesting an appeal. Include your name, address, and the reason you’re requesting the appeal. If you’re requesting an appeal for someone else (like your child), also include their name.

• Then, fax your appeal request to a secure fax line: 1-877-***-****, or mail it to: Health Insurance Marketplace

ATTN: Appeals

465 Industrial Blvd.

London, KY 40750-0061

Appealing your eligibility for Medicaid or CHIP

If this notice says that you may be eligible for Medicaid or CHIP, or that your state is reviewing your eligibility for Medicaid or CHIP, your state Medicaid or CHIP agency will send a notice to let you know if you qualify for these free or low-cost programs.

If your state determines that you're not eligible for Medicaid or CHIP: 1092632484082404113 5

• Your state will tell you how to ask for a Medicaid fair hearing through the state fair hearing process.

• You may also be able to resubmit your Marketplace application for health coverage through the Marketplace and help with costs. If you then disagree with your updated Eligibility Results, you can request an appeal through the Marketplace Appeals Center. For more information about your Medicaid or CHIP eligibility, including your right to appeal if your state determines you're not eligible for Medicaid or CHIP, contact your state Medicaid or CHIP agency at the phone number included at the end of this notice.

For more help

• Visit HealthCare.gov. Or call the Marketplace Call Center at 1-800-***-****. TTY users should call 1-855-***-****. You can also make an appointment with an assister who can help you. Information is available at LocalHelp.HealthCare.gov.

• Contact your state’s Medicaid agency at toll-free: 1-866-***-**** (TTY: 1-800-***-****) for information about Florida Medicaid. For more information about Florida KidCare (CHIP), contact the Florida Healthy Kids Corporation at toll-free: 1-800-***-**** (TTY: 1-877-***-****).

• Get language assistance. If you need help in a language other than English, you have the right to get information in your language at no cost. Information about how to access these language assistance services is included with this notice. You can also call the Marketplace Call Center to get information on these services.

• Call the Marketplace Call Center to request a reasonable accommodation if you have a disability. These accommodations are provided at no cost to you.

For information including more about advance payments of the premium tax credit, lower out-of-pocket costs, and Medicaid eligibility, visit HealthCare.gov.

Sincerely,

Health Insurance Marketplace

Department of Health and Human Services

465 Industrial Boulevard

London, Kentucky 40750-0001

The determinations or assessments in this letter were made based upon 45 CFR 155.305, 155.410, 155.420-430 and 42 CFR 435.603, 435.403, 435.406 and 435.911.

Privacy Disclosure: The Health Insurance Marketplace protects the privacy and security of the personally identifiable information (PII) that you have provided (see HealthCare.gov/privacy/). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45 CFR part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace. The Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on your application. If you have questions about this data, contact the Marketplace at 1-800-***-**** (TTY: 1-855-***-****). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1207. 1092632484082404113 6

Nondiscrimination: The Health Insurance Marketplace doesn't exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, sex, or age. If you think you've been discriminated against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-***-**** (TTY: 1-800-***-****), visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S. Department of Health and Human Services/200 Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201. 1092632484082404113 7

How to submit documents

If your notice tells you that you need to submit more information, you can upload OR mail copies of your documents. Uploading is faster.

Include a copy of this bar code page to be sure your documents can be associated with your application. How to upload:

1. Log into your Marketplace account

2. Select "Start a new application or upload an existing one" 3. Select your current application and click on "Application details" 4. You'll see a button for each item to resolve

5. Click the button, then choose a document & start your upload How to mail:

1. Send copies only (not originals)

2. Write your name and Application ID on each page. Your Application ID is on the first page of your notice, under your address.

3. Mail to:

Health Insurance Marketplace

Attn: Coverage Processing

465 Industrial Boulevard

London, Kentucky 40750-0001

FL,262*******

1092632484082404113 1

Understanding Your Eligibility Notice

Am I eligible for

coverage?

Your Eligibility Notice tells you which people on your application qualify to get health coverage through the Health Insurance Marketplace, Medicaid or the Children's Health Insurance Program (CHIP). Medicaid and CHIP provide free or low-cost coverage to people with limited income, disabilities, and in some other situations. Almost anyone can enroll in Marketplace coverage, but you can only enroll at certain times.

What to do next Look at the Eligibility Results table that starts on page 1 of your notice. Each person listed on your application needs to follow instructions in the

“Next steps” column.

Medicaid & CHIP People who have health coverage through Medicaid or the Children's Health Insurance Program (CHIP) will pay little or nothing for health services and probably don't need a Marketplace plan. If your notice says that you or your family members are eligible for Medicaid or CHIP, you'll get a notice from your state agency telling you about these programs.

What if I miss a

deadline?

If you miss a deadline in your notice to submit information or enroll in a plan, you may not be able to enroll in a Marketplace plan until the next yearly Open Enrollment Period, for coverage starting January 1 of the next year.

Paying my premium You'll pay your premium directly to your health plan, not the Marketplace. Your plan will send you information on when and how to pay. If you don't hear from your health plan, you should call or visit their website. Special Enrollment

Periods

If your notice says you qualify for a Special Enrollment Period, this means you have a chance to enroll in Marketplace coverage outside the Open Enrollment Period. You may qualify for a Special Enrollment Period if you've had a life event like losing health coverage, moving, getting married, having a baby, or adopting a child. For some Special Enrollment Periods, you may need to submit documents to confirm your eligibility. If you qualify for a Special Enrollment Period, you usually have up to 60 days after the life event to enroll in a plan. If you miss that window, you have to wait until the next Open Enrollment Period to enroll or until you have another qualifying life event.

1092632484082404113 2

You should re-apply

for Marketplace

coverage every year

Even if you're already enrolled, you should re-apply for Marketplace coverage every year to make sure your information is up to date. If you chose to let the Marketplace use tax information to help with your renewal, your information updates automatically.

If you have Medicaid, you'll get a letter from your state agency if you need to provide more information at renewal time.

Why do I need to

report my income?

You don't have to report your income to get Marketplace coverage, but if you do, the Marketplace will check to see if you qualify for tax credits, cost-sharing or other programs that could lower your costs. Bronze, Silver,

Gold & Platinum

levels

Health plans sold in the Marketplace are divided into 4 categories: Bronze, Silver, Gold, and Platinum. They range from Bronze plans with lower premiums and higher out-of-pocket costs, to Platinum plans with higher premiums and lower out-of-pocket costs.

All plans cover all essential health benefits, and there are no dollar limits on the care you can get.

Catastrophic plans A “catastrophic plan” is a plan with lower monthly premiums that mainly protects you from very high medical costs. People under 30 years old and people with hardship exemptions can buy a catastrophic plan through the Marketplace. These plans aren't eligible for premium tax credits. Cost-sharing

reductions

If your notice says you qualify for cost-sharing reductions, it means you can enroll in a Silver plan with discounted copayments, coinsurance, and deductibles.

Eligibility for most cost-sharing reductions is based on household income. If you're a member of a federally recognized tribe, you can get income- based cost-sharing reductions when you enroll in a Bronze, Silver, Gold, or Platinum plan, and you may also be eligible for additional cost-sharing reductions.

What does the

Marketplace count

as income?

When you apply for help with costs for Marketplace coverage, “income” includes things like wages, self-employment, cash income, Social Security benefits, unemployment, and withdrawals from retirement accounts. We don't count child support, gifts, Supplemental Security Income (SSI), veteran's disability payments, workers' compensation, or loan proceeds

(like from student, home equity, or bank loans).

If you entered the wrong income on your Marketplace application or if your income changes, it's important to update your application. 1092632484082404113 3

What if I move,

change jobs, get

married, or have

another change?

If you enroll in a Marketplace plan, you need to report these types of life changes within 30 days, since changes can affect your program eligibility and the amount you pay for your health plan.

How to report life changes:

1. Log into your Marketplace account

2. Select your current application

3. Select "Report a life change"

4. Or, contact the Marketplace Call Center at 1-800-***-**** Visit HealthCare.gov/reporting-changes for a full list of changes you must report. Coverage for

immigrant families

Lawfully present immigrants can apply for Marketplace coverage, even if they don't qualify for Medicaid. They may also be eligible to enroll in health coverage and get help with costs.

Individuals who aren't lawfully present can apply for Marketplace coverage for family members who may be eligible, like a lawfully present child or spouse. Individuals who aren't lawfully present may also be eligible for Medicaid to cover emergency medical treatment.

Premium tax credits If your notice says you're eligible for advance payments of the premium tax credit, it means you can get “credit” to help pay your plan premiums every month. You'll see the available credit when you choose a plan, and it can be applied when you enroll. You can choose to apply all, some, or none of the available advance payments of the premium tax credit each month. The amount of your tax credit is based on these factors:

• The number of people in your household. Your household includes the person who files the household's tax return, their spouse, and any dependents claimed on the tax return.

• Your household income for the year you want coverage. Households with income above 400% of the federal poverty level don't qualify.

• The cost of the second-lowest cost Silver Marketplace health plan in your area. This is the "benchmark" plan cost.

For more information about how to qualify for a premium tax credit, visit HealthCare.gov/lower-costs/qualifying-for-lower-costs. When do I get the

premium tax credit?

The Marketplace will send any advance payments of the premium tax credit directly to your insurance company, not to you. If you use less than the full amount of the credit, you may get the difference back at the end of the year when you file your taxes.

The final amount of your premium tax credit will be based on the actual income you report on your tax return for the coverage year. 1092632484082404113 4

Reporting premium

tax credits on

your federal tax

return

If you get advance payments of the premium tax credit to help with Marketplace health plan costs, the tax filer in your household must file a federal income tax return. When they file, the credits you used during the year --which were based on your estimated income --will be “reconciled” with the credits you're eligible for based on your actual income entered on your tax return and your other eligibility information.

• If your actual income is lower than what you reported on your application, you may be eligible for a larger premium tax credit.

• If your income is higher than what you reported on your application, you may have to pay back all or some of any excess advance payments of the premium tax credit that were made to your insurance company.

Report any changes in household size, income, and other eligibility information right away to make sure you're getting the correct amount of tax credit during the year. For more information, visit HealthCare.gov/taxes-reconciling.

What if I file a

separate tax return

from my spouse?

If you're married, you must file a joint federal income tax return with your spouse for the year you want premium tax credits. There are some exceptions, such as if you claim "head of household" status on your tax return, you're a victim of domestic violence, or you're an abandoned spouse. Call the Marketplace Call Center at 1-800-***-**** for more information.

Information for

people with

special health

care needs

If you have special health care needs, you may qualify to get coverage for more health services and pay less for care. For example, if you:

• Have a medical, mental health or substance abuse condition that limits the ability to work or go to school

• Need help with daily activities, like bathing or dressing

• Regularly get medical care, personal care, or health services at home, an adult day center, or another community setting

• Live in a long term care facility, group home, or nursing home

• Are blind

• Are terminally ill

To see if you qualify, call your state Medicaid agency at the number included in this notice. You can also update your Marketplace application with your information. Medicaid may also pay medical bills from 3 months before you apply, so ask when you call.



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