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.
By clicking "agree" on our acception page:
I give my permission to Dakota Myers Build Better Benefits INC, to serve as the health
insurance agent or broker for myself and my entire household if applicable, for purposes of
enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By
consenting to this agreement, I authorize the above-mentioned Agent to view and use the
confidential information provided by me in writing, electronically, or by telephone only for the
purposes of one or more of the following: Searching for an existing Marketplace application,
Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or
other government insurance affordability programs, such as Medicaid and CHIP or advance tax
credits to help pay for Marketplace premiums, Providing ongoing account maintenance and
enrollment assistance, as necessary; or, Responding to inquiries from the Marketplace
regarding my Marketplace application. I understand that the Agent will not use or share my
personally identifiable information (PII) for any purposes other than those listed above. The
Agent will ensure that my PII is kept private and safe when collecting, storing, and using my PII
for the stated purposes above. I confirm that the information I provide for entry on my
Marketplace eligibility and enrollment application will be true to the best of my knowledge. I
understand that I do not have to share additional personal information about myself or my health
with my Agent beyond what is required on the application for eligibility and enrollment purposes.
I understand that my consent remains in effect until I revoke it, and I may revoke or modify my
consent at any time by sending notice to [email protected].
I authorize Build Better Benefits INC to access my Marketplace profile within Healthcare.gov
and make any changes necessary.Do you give us authorization to enroll you in a new $0
premium health plan if your current health plans gets cancelled or discontinued by the insurance
carrier?
Plans change every year. Do you authorize us to assess your plan, compare it to the new plans
that come out every year, and enroll you in a new plan during open enrollment if the coverage
and benefits are better?
In some cases, it may be necessary to verify your income. If income verification is required in
order to complete your enrollment, do you authorize Build Better Benefits INC to submit an
income attestation letter on your behalf with the information that you have provided?
I understand and agree that in the event I change insurance carriers, I am responsible for
promptly notifying Build Better Benefits INC, as failure to do so may result in my
coverage reverting to the originally selected plan in certain cases.