DEPARTMENT OF HEALTH AND HUMAN SERVICES

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

LONDON, KENTUCKY 40750-0001

2028351887619707626 1

Nancy Pickett Jun 01, 2021

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

F7

Marysville, MI 48040

Application Date: June 1, 2021

2021 Application ID: 398*******

Eligibility notice: You may be eligible for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP)

Nancy Pickett—If you have special health care needs (like a disability or the need for help with daily living), you may be able to get more health coverage and pay less for care, so we’re sending your information to Michigan Department of Health and Human Services to see if you qualify. You can keep any other health coverage you’re eligible for while Michigan Department of Health and Human Services reviews your information. Michigan Department of Health and Human Services will contact you. Household

member(s)

Results Next steps

Nancy Pickett • May be eligible for free or low-cost coverage through Michigan Department of Health and

Human Services. This result is based on the

monthly household income of $268.46 that

you provided on your Marketplace application.

• You'll get a final decision from the Michigan

Department of Health and Human Services.

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. 2028351887619707626 2

What should I do next?

Here’s what each person in your household needs to do to take the “Next steps” shown in this notice. 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.

If your “Results” say that you or any of your family members are or may be eligible for free or low-cost coverage through Michigan Department of Health and Human Services or Michigan MIChild, you’ll get a notice from your state agency with more information about your health benefits and how much you pay for them. If you don’t hear from them soon, call them at the phone number provided at the end of this notice. When you’re eligible for Medicaid or CHIP, you can still buy a Marketplace health plan, but you won’t get help paying for it. Medicaid and CHIP are free or low-cost programs, so if you qualify for either of them, you don’t qualify for advance payments of the premium tax credit.

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 Michigan Department of Health and Human Services or Michigan MIChild 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 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.

If someone works for a business that offers help paying for a health plan or health care expenses through a Health Reimbursement Arrangement (HRA), visit HealthCare.gov/job-based-help to learn how this may affect your eligibility for the premium tax credit.

What should I do if I think my “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 buy health coverage through the Marketplace, for premium tax credits, cost-sharing reductions, and enrollment periods. You can also appeal the plan categories available to you, if they’re limited during a Special Enrollment Period. See below for more information about appealing your eligibility for Michigan Department of Health and Human Services or Michigan MIChild. 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 2028351887619707626 3

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?

• Online: Visit HealthCare.gov/marketplace-appeals/appeal-forms and select your state. You can submit your appeal request online or download/print a form and submit it separately.

• By mail or fax: Send a completed paper form or a letter requesting an appeal. Include your name, address, and the reason for the appeal. If the appeal is for someone else (like your child), also include their name. Submit your paper form or the letter to the Marketplace: Fax: 1-877-***-****

Mail: 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:

• 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 “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.

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For more help

• Visit HealthCare.gov or call the Marketplace Call Center at 1-800-***-****. TTY users can 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 toll-free: 1-800-***-**** (TTY: 1-866-***-****) for information about Michigan Department of Health and Human Services. For more information about Michigan MIChild, contact the Michigan Department of Health and Human Services toll-free: 1-888-***-****

(TTY: 1-888-***-****).

• Get help in a language other than English. Information about how to access these services is included with this notice, and available through the Marketplace Call Center.

• Call the Marketplace Call Center to get this information in an accessible format, like large print, Braille, or audio, 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. 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. 2028351887619707626 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 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 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. For more about paying your premium, visit

HealthCare.gov/apply-and-enroll/complete-your-enrollment. 2028351887619707626 2

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, adopting a child, or being newly offered an individual coverage HRA or newly provided a QSEHRA. For some Special Enrollment Periods, you may need to submit documents to confirm your eligibility, and your plan choices may be limited. 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 may have to wait until the next Open Enrollment Period to enroll or until you have another qualifying life event.

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 re- enrollment, 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 re-enrollment time. If you have an individual coverage HRA, be sure to update your Marketplace application when the HRA plan year ends. This might occur before the Marketplace Open Enrollment period, when you’ll re-apply for Marketplace coverage.

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

categories

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. Plan choices may be limited during a Special Enrollment Period.

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 age 30 and people with hardship exemptions can buy a Catastrophic plan through the Marketplace. These plans aren’t eligible for premium tax credits. 2028351887619707626 3

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 cost-sharing reductions when you enroll in a Bronze, Silver, Gold, or Platinum plan. 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 job income, self-employment, Social Security benefits, unemployment, and withdrawals from retirement accounts. We don’t count child support, gifts, Supplemental Security Income (SSI), veteran’s payments, workers’ compensation, loan proceeds (like from student, home equity, or bank loans), or federal tax refunds and credits. If you entered the wrong income on your Marketplace application or if your income changes, it’s important to update your application. 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”

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

immigrant families

Lawfully present immigrants can apply for and enroll in Marketplace coverage, even if they don’t qualify for Medicaid. They may also 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.

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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.

• 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.

Household members with an individual coverage HRA offer qualify for premium tax credits only if the employer’s offer doesn’t meet minimum standards for affordability, and they opt out of their individual coverage HRA.

Household members with a QSEHRA should plan to use their QSEHRA to help pay for health coverage during the year. When they apply for coverage, the tax credit amount shown on the eligibility notice won't account for the amount of help they can get through their employer. For this reason, they may not want to use all of the tax credit that's shown in their eligibility notice. At tax time, the IRS will determine final eligibility for a tax credit based on how much QSEHRA the employer offered. Eligibility for a tax credit will be affected even if they didn’t use the QSEHRA. Their tax credit amount could also be affected by changes in income or other life changes during the year. If they use more tax credit than they’re eligible for, you’ll have to pay it back with your taxes.

Visit HealthCare.gov/job-based-help to learn more about how an HRA may impact eligibility for a premium tax credit.

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. 2028351887619707626 5

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 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, like 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.

January 2019

January 2019

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