CMS Consent

To make it easier to determine my eligibility for help paying for coverage in future years, I agree

to allow the Marketplace to use my income data, including information from tax returns, for the

next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt

out at any time.

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying

health coverage, like Medicaid, Children's Health Insurance Program (CHIP), or a job-based

health plan. I also understand that if I become eligible for other qualifying health coverage, I

must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I

don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of

health coverage for myself and/or my dependents:

I must file a federal income tax return for the 2023 tax year.

If I’m married at the end of 2023, I must file a joint income tax return with my spouse.

I also expect that:

No one else will be able to claim me as a dependent on their 2023 federal income tax return.

I’ll claim a personal exemption deduction on my 2023 federal income tax return for any

individual listed on this application as my dependent who is enrolled in coverage through this

Marketplace, and whose premium for coverage is paid in whole or in part by advance payments

of the premium tax credit.

If any of the above changes:

I understand that it may impact my ability to get the premium tax credit.

I also understand that when I file my 2023 federal income tax return, the Internal Revenue

Service (IRS) will compare the income on my tax return with the income on my application. I

understand that if the income on my tax return is lower than the amount of income on my

application, I may be eligible to get an additional premium tax credit amount. On the other hand,

if the income on my tax return is higher than the amount of income on my application, I may owe

additional federal income tax.

I know that I must tell the program I’ll be enrolled in if information I listed on this application

changes. I know I can make changes in myMarketplace account or by calling Marketplace 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.

If anyone on your 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’s found to have other qualifying coverage won’t stay

enrolled in Marketplace coverage and have to pay full cost.

I’m signing this application under penalty of perjury, 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 intentionally provide false information.

If your income is $0 (or less than the Federal Poverty Limit), you attest that your estimated

income for 2023 will be at least the Federal Poverty Limit for your state and household

requirements. If your income will be less than (or greater than) those limits, you agree to notify

us or the marketplace of any changes or updates as soon as possible. Failure to notify us of any

changes may result in your eligibility being affected.

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