December *, ****

Application ID # 468-***-****

Application date: December 4, 2022

Primary contact

Lesley Mccormick

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

Doyle, TN 38559

2023

Marketplace Eligibility Notice

Remember to update your application during the year with any changes. Results

Household not eligible for a premium tax credit because your household income is too low to qualify in your state Estimated 2023 income used to determine eligibility for financial help:

$0/year

Lesley

Mccormick

Applied for coverage. •

Eligible to enroll in a Marketplace plan until January 15, 2023. • Eligible to buy a Catastrophic plan, if available. • Likely not eligible for Medicaid or CHIP because you don't meet the criteria in your state. • ACTION: Next steps

By December 15, 2022, choose a Marketplace plan for coverage to start January 1. See Eligibility Guide, page 4. • Learn more about how you could qualify for Medicaid. See Eligibility Guide, page 7. • You can appeal your eligibility results now. See Eligibility Guide, page 8. • To learn when and how you can appeal, see Eligibility Guide, page 8. Questions about results or next steps? See the Eligibility Guide included with this notice. For more help

HealthCare.gov

Marketplace Call Center:

1-800-***-****

TTY: 1-855-***-****

LocalHelp.HealthCare.gov

(for help in your area)

TennCare (Medicaid):

855-***-****

TTY: 800-***-****

CoverKids (CHIP):

855-***-****

TTY: 800-***-****

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; 42 CFR 435.911, 435.603, 435.403, 435.406; and 42 CFR 457.348, 457.350, 457.315, 457.340. Privacy Disclosure: The Health Insurance Marketplace® protects the privacy and security of the personally identifiable information (PII) you 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 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-***-****). You can also call the Marketplace call center to get information from this notice in your language, or request a reasonable accommodation if you have a disability. You can ask for information in an accessible format, like large print, braille, or audio at no cost. 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 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 (including sexual orientation and gender identity), 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. Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services. 1

Welcome to the

MARKETPLACE ELIGIBILITY GUIDE

How to enroll in a

Marketplace plan

Compare available health plans online at HealthCare.gov by logging into your Marketplace account and opening your most recent application. Or, call the Marketplace Call Center at 1-800-***-**** to compare plans and enroll. TTY users can call 1-855-***-****. If you don’t already have a Marketplace account, you’ll need the Application ID on your Eligibility Notice. You can find an assister in your local area to help you choose a plan by visiting LocalHelp.HealthCare.gov. What if I miss a

deadline?

If you miss a Marketplace deadline to submit documents or enroll in a plan, you may not be able to enroll in a Marketplace plan until the next Open Enrollment Period (unless you qualify for a Special Enrollment Period). You may also lose any financial help you may qualify for. Open Enrollment Open Enrollment is the yearly period when people can enroll in a Marketplace plan. Outside of Open Enrollment, you may still be able to enroll in a Marketplace plan if you qualify for a Special Enrollment Period.

Special Enrollment

Period

A Special Enrollment Period means you can enroll in Marketplace health coverage outside of the yearly Open Enrollment period. You may qualify for a Special Enrollment Period if you’ve had certain life changes, like losing health coverage, moving, getting married, having a baby, or adopting a child. You may also qualify if you get a new offer from an employer for help paying for health coverage. You may need to submit documents to confirm your eligibility for some Special Enrollment Periods.

To see if you qualify for a Special Enrollment Period, you can report a life change on your application. If you qualify, your plan choices may be limited. You generally have up to 60 days following the change you’re reporting to enroll in a plan. Copayments,

coinsurance &

deductibles

Copayments, coinsurance, and deductibles are the money you pay toward the cost of your health care.

• Copayment: an amount you may pay each time you get a service, like going to the doctor or getting a prescription. It’s usually a set dollar amount, like $20.

• Coinsurance: your share of the costs of a covered health service. Coinsurance is calculated as a percent of the allowed amount for the service.

• Deductible: the amount of money you must spend each year on health care before your plan starts paying for most services. After you pay your deductible, you may still have to pay copayments or coinsurance when you get services.

Qualifying for

cost-sharing

reductions

Qualifying for “cost-sharing reductions” means you qualify for a discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. You must enroll in a plan in the Silver category to get the extra savings. Choosing a Silver Marketplace plan with extra savings may save you thousands of dollars if you have a lot of medical expenses. If you’re a member of a federally recognized American Indian tribe or Alaska Native Corporation, you can get extra savings when you enroll in any Marketplace plan. You’ll get these savings as long as everyone enrolling with you is also a member of a federally recognized tribe. How do I qualify for

cost-sharing

reductions?

You qualify to enroll in a plan with lower copayments, coinsurance, and deductibles based on:

• The household income amount you expect to report on your federal tax return

• Your eligibility for the premium tax credit

• The number of people in your household (the taxpayer and dependents listed on your federal income tax return)

• Membership in a federally recognized tribe

Bronze, Silver, Gold

& Platinum

plan categories

Health plans sold in the Marketplace are divided into 4 main health plan categories: Bronze, Silver, Gold and Platinum. Categories 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.

2

Choosing a plan

category

During Open Enrollment, you can choose a plan from any category. If you qualify for a Special Enrollment Period, you’ll see all the plan categories available to you.

• If you’re already enrolled in a Marketplace plan, your choices may be limited. For example, if you’re enrolled in a Gold plan and experience a move that qualifies you for a Special Enrollment Period, you’ll generally be able to choose plans from the Gold category only.

• You can choose a Silver plan if you’re newly eligible for cost-sharing reductions. Silver plans may also be available if you’re eligible for the premium tax credit and can enroll through a Special Enrollment Period based on estimated income.

• If you’re enrolled in a Silver plan with cost-sharing reductions and you lose those cost- sharing reductions, you can enroll in a Bronze, Silver or Gold plan. Catastrophic plans A Catastrophic plan has lower monthly premiums and high deductibles. Catastrophic plans may be an affordable way to protect yourself from worst-case scenarios, like getting seriously sick or injured, but you pay most routine medical expenses yourself. People under 30 and people with hardship exemptions can buy a Catastrophic plan through the Marketplace. These plans aren’t eligible for the premium tax credit.

Plan groupings If you apply for health coverage for more than one person in your household, the Marketplace will group your household members for plan enrollment. You’ll see these groupings when you continue to enrollment, and you can change them. You may be able to choose one plan for everyone, a separate plan for each person, or some other grouping. Adding family

members to your

plan

If you gain a new family member due to marriage, birth, adoption, foster care, or court order, you may be able to add the new family member to your current plan or enroll them in any category. If your plan’s rules don’t allow you to add new members as part of your Marketplace updates, you can enroll together in a different plan in the same category. If no other plans are available in your current plan category, your family can enroll together in a “neighboring” category. For example, if you’re currently enrolled in a Gold plan, you can generally enroll together in a new one from the Silver or Platinum categories.

You’ll automatically see all the plans available to you when you enroll. However, if you want to enroll your new dependent in their own plan of any category, you may need to “re-group” your household members when you continue to enrollment to see if other categories become available, or to enroll in a plan that’s separate from your family group. Coverage for

immigrant families

Lawfully present immigrants can apply for Marketplace coverage, even if they don’t qualify for full Medicaid benefits or for CHIP because of immigration status. Lawfully present immigrants may still be eligible to enroll in Marketplace coverage and get help with costs. Individuals who aren’t lawfully present in the U.S. can apply for Marketplace coverage on behalf of family members who may be eligible, like their lawfully present children or spouse. Individuals who aren’t lawfully present, or who don’t meet requirements for full Medicaid benefits, may be eligible for limited Medicaid coverage for emergency medical treatment, or for pregnancy-related CHIP. Applying in a

different state

You can’t enroll in a Marketplace plan in a state that’s different from where you live. Return to your application to check that your address is correct and in the state where you want coverage. If someone in your household needs coverage in a different state, they need to start a new application that’s separate from yours. For questions about Medicaid and CHIP eligibility, contact the Medicaid or CHIP agency listed on your notice. You may need to apply for Medicaid or CHIP in another state.

3

Changes can affect

your costs &

eligibility

If anything you told us on your Marketplace application changes, you should report the change as soon as possible. Report changes like these:

• A move.

• Household income changes, especially if your household income will be different than you estimated on your application.

• Household size changes, like if someone in your household marries or divorces, becomes pregnant, or has a child; or your child moves out or won’t be claimed as a dependent.

• A change in how you’ll file your federal income tax return for the year you’re getting Marketplace coverage, like if you plan to claim new dependents.

• Changes in immigration status.

• Becoming qualified for other health coverage, like through a job or Medicare.

• Getting an offer of help from a job to pay for health care costs with a Health Reimbursement Arrangement (HRA). This may also be called an individual coverage HRA or a Qualified Small Employer HRA (QSEHRA).

Visit HealthCare.gov/reporting-changes for a full list of changes to report. If you get advance payments of the premium tax credit and you don’t report a change that may affect your eligibility, you may have to pay back some or all of your premium tax credit when you file your taxes, or you may not get all the financial help you qualify for. How to report

changes on your

application

1. Log into your Marketplace account at HealthCare.gov. 2. Select your current application.

3. Select “Report a Life Change” on the left-hand menu. Or, call the Marketplace Call Center at 1-800-***-****. Need help reporting

changes?

If somebody helped you fill out your application (like an agent, broker, Navigator or Certified Application Counselor), contact them for help reporting changes or uploading required documents. Health

Reimbursement

Arrangements (HRAs)

Check the notice you get from your employer about the help they offer paying for health coverage, because your deadlines and coverage start dates might be different. For more information, visit HealthCare.gov/job-based-help.

If your employer offers an “individual coverage HRA” You can’t use both the premium tax credit and an individual coverage HRA at the same time. People offered an individual coverage HRA qualify for the tax credit only if the employer offer doesn’t meet minimum affordability standards and the person opts out of the individual coverage HRA.

If your Eligibility Notice says you’re NOT eligible for a premium tax credit, it’s a good idea to accept the individual coverage HRA offer from your employer. If your Eligibility Notice says you ARE eligible for a premium tax credit, you’ll need to opt out of the individual coverage HRA if you want to use the tax credit instead.

You’ll need to let your employer know if you enroll in a Marketplace plan, and if you plan to opt out of the individual coverage HRA. You’ll need to update your Marketplace application with HRA information each plan year.

If you have a Qualified Small Employer HRA (QSEHRA) Visit HealthCare.gov/QSEHRA to see how much tax credit you should consider using. People with a QSEHRA should plan to use their QSEHRA to help pay for health coverage during the year. However, the Marketplace doesn’t account for QSEHRA help when calculating tax credit eligibility. For this reason, people with a QSEHRA may not want to use the full amount of tax credit shown in their Eligibility Notice, or they may have to pay back some of this credit when they file taxes. The IRS will determine final tax credit eligibility at tax time based on how much QSEHRA the employer offered, even if the person didn’t use the QSEHRA. 4

More About

COVERAGE START DATES

General coverage

start dates

After you select a Marketplace plan, your coverage will be effective once you get a bill from your plan and pay your first premium.

For plans selected by December 15 during Open Enrollment, coverage starts January 1. For plans selected from December 16 through January 15, coverage starts February 1. If you enroll during a

Special Enrollment

Period

Your start date usually depends on when you select a plan. When you enroll during a Special Enrollment Period, your coverage generally starts the 1st of the next month. For example, if you select a plan on February 28, your coverage can start March 1. If the Marketplace asks you to submit documents to confirm information for your Special Enrollment Period, you can’t start using your coverage until you submit acceptable documents and get confirmation and premium payment information from the Marketplace. Special Enrollment

Periods that offer

different coverage

effective dates

Special Enrollment Periods for some situations may allow your coverage to start on a different date. Gained a dependent

• If you gained or became a dependent (due to birth, adoption, placement for adoption or foster care, child support, or other court order), your coverage can be retroactive to the day this occurred. If you want coverage to start on a date in the future, call the Marketplace Call Center at 1-800-***-****.

Loss of health coverage

• If you already lost health coverage, you can choose a plan any day of the month for coverage starting the 1st day of the next month. However, if you’re losing health coverage in the next 60 days, your new plan’s coverage can start the 1st day of the month after you lose your coverage and select a plan. For example, if your last day of coverage is January 31, you can choose a plan on January 29 for coverage that starts February 1. Employer offer to help with the cost of coverage

• If you’ll newly gain access to an individual coverage HRA or a QSEHRA, you generally need to select a plan before the day this employer’s help starts. If the employer’s help starts in the next 60 days, your new plan coverage can start the 1st day of the month following your HRA start date and your date of plan selection. If the employer’s help starts on the 1st of the month, your new plan coverage can start on that day.

Other situations

The Marketplace Call Center will work with you during your Special Enrollment Period to determine your coverage start date in these situations:

• You couldn’t enroll because of a serious medical condition or natural disaster.

• A Marketplace technical or agent’s error interfered with your ability to enroll.

• You’re newly eligible for financial help because you experienced a change in income and/or moved to a different state, and you were previously ineligible for Medicaid coverage because you lived in a state that hasn’t expanded Medicaid, and ineligible for help paying for coverage because your household income was below 100% of the Federal Poverty Level (FPL).

• You successfully appealed a Marketplace decision. Other Types of

Special Enrollment

Periods

If you qualify for a Special Enrollment Period based on estimated income for this year, you can join a Silver plan with lower copayments, coinsurance, and deductibles. You can enroll in or change plans any time, and your most recent plan choice will take effect the 1st of the next month. Note: If your income goes up, you might not qualify for this Special Enrollment Period in the future. If you qualify for a Special Enrollment Period because someone in your household is a member of a federally-recognized tribe, you can enroll in or change plans any time, and your most recent plan choice will take effect the 1st of the next month. Note that when changing plans, you may lose amounts you paid toward your old plan’s deductible. 5

More About

PREMIUM TAX CREDIT

What are advance

payments of the

premium tax credit?

The premium tax credit is a “credit” paid in advance toward your Marketplace plan premiums each month. You’ll see this credit when you choose a plan, and it’s applied toward your premium when you enroll. If you use less than the full amount you qualify for, you may get the difference back at the end of the year when you file your taxes.

When do I get the

tax credit?

The Marketplace sends advance payments of the premium tax credit directly to your insurance company, not to you. You must file a federal income tax return to report the tax credit you used. You must report this tax credit even if you don’t usually file taxes. How do I qualify

for the tax credit?

The Marketplace checks your income, household size, and other information to see if you qualify. You can only get the premium tax credit if you enroll in coverage through the Marketplace. Visit HealthCare.gov/lower-costs for information about how income affects your premium tax credit. If your results say you’re eligible for a premium tax credit, it means you don’t appear to be eligible for Medicaid or CHIP.

If your job offers health coverage or help with health care expenses through a Health Reimbursement Arrangement (HRA), you can only get the tax credit if that coverage isn’t affordable, or isn’t considered qualifying health coverage. Visit HealthCare.gov/have-job-based-coverage to learn more.

How was my tax

credit calculated?

Your premium tax credit amount is based on these factors:

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

• How much income your household expects to report on your federal income tax return for the year you want coverage. This is the amount that you put on your application, or that came from other recent information sources.

• The amount you’re expected to pay for premiums.

• The cost of the second-lowest cost Silver category Marketplace health plan in your area. This is also known as the “benchmark” cost.

The Marketplace determines your premium tax credit based on your estimated household income, but the final amount of tax credit you get will be based on your actual year-end tax filing. Why is my tax

credit amount $0?

You may be eligible for $0 premium tax credit if you’re otherwise eligible to get the tax credit, but the cost of the second-lowest cost Silver category Marketplace health plan in your area (the benchmark cost) is less than the amount you’re expected to pay for monthly plan premiums. A $0 tax credit means you won’t get a reduction in the amount you pay for your premiums. Estimating your

income

If you checked for savings when you applied, the Marketplace asked you to estimate your income. Enter any income that you include on your federal income tax return, like money from a job or self- employment. For a full list of income sources to include on your application, visit HealthCare.gov/income-and-household-information/income. When you file your tax return, the IRS will compare the information from your application to your tax return. If your income is higher than what you entered on your Marketplace application, or your household size decreases, you may have to pay back some or all of the advance payments of the premium tax credit. So, it’s important to make your best guess when estimating your income and keep this information up to date in your Marketplace application. What if I made a

mistake on my

income?

If you made a mistake when you estimated your income or your income changed, you can report a life change to update your application with the right amount. See “How to report changes on your application” on page 3 for more information. Or, call the Marketplace Call Center at 1-800-***-****. 6

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 the premium tax credit. 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. Reporting the

premium tax credit

on your tax return

If you use advance payments of the premium tax credit to reduce your health plan costs, the person who files taxes for your household must report these payments on a federal tax return by the tax filing deadline using “IRS Form 8962, Premium Tax Credit.” This is true even if you don’t usually have to file taxes. If you don’t take this step, you won’t continue to be eligible for the premium tax credit.

• You must file a tax return for each year you get the premium tax credit. Complete IRS Form 8962 using the information from “Form 1095-A, Health Insurance Marketplace Statement,” which you get from the Marketplace early each year.

• To get Form 1095-A, visit HealthCare.gov, log into your Marketplace account, and check your notices from the Marketplace. You can also call the Marketplace Call Center at 1-800-***-****.

• For more information on filing a tax return using IRS Form 8962, visit HealthCare.gov/taxes or IRS.gov/aca.

• Filing electronically can help avoid mistakes and find credits and deductions that may be available. In many cases filing electronically is free. For information about Free File and e-file, visit IRS.gov.

If you filed the tax return but didn’t include IRS Form 8962, you may need to file an amendment to your tax return (Form 1040X). To learn more, call the IRS at 1-800-***-****. TTY users can call 1-800-***-****.

Do I need to apply

for a new premium

tax credit

each year?

To make sure you stay eligible for the tax credit, keep your income and other information updated in your Marketplace application. When you completed your application, you had an option to let the Marketplace use income data (including tax return information) to help with your eligibility renewal. If you chose not to allow this, make sure to update your information each year during Open Enrollment. You can change this agreement in your Marketplace account by selecting your most recent application and choosing “Report a life change.” Step through your application, read the statement allowing the Marketplace to use income data to help with your renewal in future years, and click if you agree.

Steps to make sure

you get the right

amount of financial

help

Your household won’t be eligible for financial help with Marketplace plan costs if we don’t have complete and current information about your taxes. If your results say you don’t qualify for help with costs, take these steps so the Marketplace can check your eligibility: 1. If you told us you don’t plan to file a tax return, or you’re married but planning to file separately, update your application to see if you can get help with costs. Visit HealthCare.gov, log into your Marketplace account, and select your most recent application. Then select “Report a life change” and update your household and income information. You can also call the Marketplace Call Center.

2. If you chose not to allow the Marketplace to use information from tax returns to help renew your eligibility, you can change this for future renewals. You can update your application and click a statement to show your agreement. Call the Marketplace Call Center if you need help.

3. Did you qualify for the tax credit last year and already complete the steps above? Visit HealthCare.gov to update your application with your most current information to see if you might qualify.

7

More About

MEDICAID/CHIP

How does the

Marketplace relate

to Medicaid/CHIP?

If you checked for savings when you applied for Marketplace coverage, your application was reviewed automatically to see if you may be eligible for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP). Your state runs these programs and they may go by different names in your state.

About Medicaid &

CHIP

Medicaid and CHIP are joint federal and state programs that help with medical costs for people with limited income, families and children, pregnant women, the elderly, and people with disabilities. You may qualify for these programs based on your household size, income, and other factors, like age and special health care needs.

If you have qualifying health coverage through Medicaid or CHIP, you’ll pay little or nothing for health services and probably don’t need a Marketplace health plan. You can still purchase a Marketplace health plan, but you generally won’t qualify for advance payments of the premium tax credit or cost- sharing reductions. To learn more about when and how to end your Marketplace plan, visit HealthCare.gov/medicaid-chip/cancelling-marketplace-plan. What if I’m eligible

for Medicaid/CHIP?

If your Eligibility Notice says that someone is (or may be) eligible for Medicaid or CHIP, you’ll get another notice from your state agency telling you about these programs and any next steps, including when coverage can start.

Your Medicaid or CHIP benefits may be delayed if your state agency needs you to send documents to confirm information. If your state says you’re not eligible for Medicaid or CHIP, it will tell you how you can appeal your Medicaid or CHIP decision. You can also come back to the Marketplace to see if you can enroll in a Marketplace plan with financial help. You should “report a life change” to let the Marketplace know you were recently denied Medicaid/CHIP. What if I’m not

eligible for

Medicaid/CHIP?

If you’re found to be not eligible or “likely not eligible” for Medicaid/CHIP, your Eligibility Notice will let you know the reason why. You may still qualify for Medicaid if you have a disability or special health care needs, like if you:

• Have a medical, mental health, or substance abuse condition that limits your 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

Visit HealthCare.gov/people-with-disabilities or call your state Medicaid agency to ask about rules for your state.

See if you qualify for

Medicaid anytime

Anyone who checked for savings on their Marketplace application can ask for a full Medicaid determination at any time. To ask for a full determination: on the “Eligibility Results” screen of your Marketplace application, select the person’s name, then select “Send to Medicaid” and complete all steps. If your

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