Marketplace Authorization & Consent Form

If I have coverage outside the Marketplace - 

If anyone on your application is enrolled in Marketplace Coverage and is later determined to have other qualifying health coverage (Medicaid, Medicare, etc) the Marketplace will automatically terminate their coverage. It is important to note, CMS can require you to repay any subsidy you have received during the year.

Updating your Marketplace Information - 

If your personal information changes throughout the year, you may make changes to your Marketplace account online or by calling the Marketplace Call Center at (800) 318-2596 (TTY: (855) 889-4325). I can also call Kelli Keith to help me. Changes to my information could affect eligibility, subsidy amounts, and premiums for member(s) of my household.

Factual Information - 

The information you provide must be factual and accurate. You may be subject to penalties under Federal law for intentionally providing false information on your application.