Marketplace Application & Agreements - Skyline Insurance Agency, Inc

Marketplace Application and Agreements

The Marketplace requires us to document your agreement to their terms and conditions.

Please read below and acknowledge.

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Privacy, consent, and the use of your information

Important Marketplace Emails: If the Marketplace has your email address, they’ll automatically send you important information, updates, and reminders about Marketplace enrollment. You can opt out of these communications at any time. To do this, click on the "unsubscribe" link in the footer of any Marketplace email.

Privacy and the use of your information: The Marketplace will keep your information private as required by law. Your answers on this form will only be used to determine eligibility for health coverage or help paying for coverage. The Marketplace will check your answers using the information in their databases and the databases of other federal agencies. If the information doesn't match, the Marketplace may ask you to send them proof. The Marketplace won't ask any questions about your medical history. Household members who don't want coverage won't be asked questions about citizenship or immigration status.

As part of the application process, the Marketplace may need to retrieve your information from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security (DHS), and/or a consumer reporting agency. They need this information to check your eligibility for coverage and help paying for coverage if you want it and to give you the best service possible.The Marketplace may also check your information at a later time to make sure your information is up to date. The Marketplace will notify you if they find something has changed.

By continuing, you (the consumer) grant Matthias Allred, Skyline Insurance Agency, and HealthSherpa (our enrollment software) permission to access your Marketplace application.

To continue, you must agree and check each of the following statements:

I agree to have my information used and retrieved from data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from data sources.(Required)

Yes

You must agree to all terms to continue.

I understand that I'm required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage.(Required)

Yes

You must agree to all terms to continue.

Agreements

Please read the attestations below and select a response for each statement.

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.(Required)

I Agree

I Disagree

How long would you like your eligibility to be renewed? If you opt out of this now, it may impact your ability to get help paying for coverage when you renew in the future.(Required)

Tax attestation

Please read the attestations below and select a response for each statement.

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.(Required)

Yes

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 2024 tax year. If I’m married at the end of 2024, I must file a joint income tax return with my spouse.(Required)

Yes

Answering no means you will have to pay full price for your plan.

I also expect that: No one else will be able to claim me as a dependent on their 2024 federal income tax return. I’ll claim a personal exemption deduction on my 2024 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.(Required)

Yes

Answering no means you will have to pay full price for your plan.

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 2024 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.(Required)

Yes

Answering no means you will have to pay full price for your plan.

Tax attestation

Please read the attestations below and select a response for each statement.

I know that I must tell the program I’ll be enrolled in within 30 days if information I listed on this application changes. I know I can make changes in my Marketplace account or by calling the 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.(Required)

Agree

Disagree

Selecting this option may impact your eligibility for programs and savings. Learn more.

If anyone on your application is enrolled in Marketplace coverage and is also found to have Medicare coverage, the Marketplace will automatically end their Marketplace plan coverage. They will get a notice before Marketplace terminates their coverage in case they need to keep it or make changes. During all the months of overlapping coverage, they're responsible for paying the full cost for the Marketplace plan premium and covered services.(Required)

Agree

Disagree

Agree(Required)

Disagree(Required)

I don't give the Marketplace permission to end Marketplace coverage for anyone on my application who's enrolled in both Marketplace and Medicare coverage. I understand that they will have a marketplace health plan without financial help and pay the full cost for their share of the Marketplace plan premium and covered services, if eligible.

Eligibility Results & Application Accuracy

Please read the attestations below and select a response for each statement.

I acknowledge I have reviewed, or will review, my Eligibility Results Notice, for accuracy. Any inaccuracies have been reported to my agent. A copy can be found online at https://health.skylineinsuranceagency.com(Required)

Yes

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.(Required)

Agree

Disagree

Selecting this option may impact your eligibility for programs and savings. Learn more.

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