Tip for Federal Marketplace Application

Have your most recent tax return handy — income determines your premium tax credit

Tip for Federal Marketplace Application

Report income changes promptly to avoid owing money at tax time

Tip for Federal Marketplace Application

If your income is below 150% FPL, check if you qualify for Medicaid instead

Medicaidhard

HealthCare.gov Marketplace Application

Federal Marketplace Application · CMS / Federal Marketplace

Federal marketplace application that also screens for Medicaid/CHIP eligibility and refers to state agencies when the applicant qualifies.

Form Details

Total fields: 90
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Filled by: patient
Frequency: annual

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Where to Submit This Form

🌐

HealthCare.gov (recommended)

https://www.healthcare.gov/apply-and-enroll/

Create an account and complete the application online. Available 24/7.

🌐

Call the Marketplace Call Center

1-800-318-2596 (TTY: 1-855-889-4325). Available 24/7.

🏢

Get help from a certified Navigator or broker

https://localhelp.healthcare.gov/

Free in-person assistance is available.

📬

Mail paper application

Health Insurance Marketplace Department of Health and Human Services 465 Industrial Blvd London, KY 40750-0001

Filing Deadline

Open Enrollment: typically November 1 - January 15. Special Enrollment Period: 60 days from a qualifying life event (job loss, marriage, birth, move, etc.).

Required Attachments

📎 Social Security Numbers for all household members applying for coverage
📎 Immigration document information (for lawfully present non-citizens)
📎 Employer and income information (pay stubs, W-2, tax return)
📎 Policy numbers for any current health coverage
📎 Information about job-related health coverage available to you

Processing Time

Eligibility determination is typically instant for online applications. You can select and enroll in a plan immediately after being determined eligible.

What Happens Next

You will receive an eligibility determination showing your premium tax credit amount. Select a plan and pay the first month's premium to activate coverage.

Tips for This Form

✓ Have your most recent tax return handy — income determines your premium tax credit
✓ Report income changes promptly to avoid owing money at tax time
✓ If your income is below 150% FPL, check if you qualify for Medicaid instead
✓ Coverage begins the 1st of the month after plan selection during Open Enrollment

More Medicaid Forms

Medicaid Application

State-specific · State Medicaid Agencies / CMS via HealthCare.gov

Unified application for Medicaid, CHIP, and Marketplace coverage under ACA. Uses MAGI for financial eligibility. Available online, by mail, phone, or in person.

Emergency Medicaid Application

State-specific (e.g., Form 520) · State Medicaid Agencies

Application for Emergency Medical Assistance for individuals meeting all Medicaid requirements except citizenship/immigration status. Must have received emergency services.

Presumptive Eligibility Determination

State-specific PE form · State Medicaid Agencies / Qualified Entities

Temporary Medicaid coverage granted by qualified entities (hospitals, clinics) based on preliminary income assessment. Covers services until full application is processed.

Medicaid Renewal / Redetermination

State-specific (e.g., CA MC 210 RV) · State Medicaid Agencies

Annual renewal verifying continued Medicaid eligibility. Includes income, expenses, and household composition. Failure to complete results in disenrollment.

Medicaid Spend-Down Documentation

State-specific · State Medicaid Agencies

Documents medical expenses applied toward meeting the spend-down amount. Once the difference between income and the medically needy income level is met, Medicaid covers remaining expenses.

QMB / Medicare Savings Program Application

State-specific MSP/QMB form · State Medicaid Agencies

Application for Medicare Savings Programs (QMB, SLMB, QI) that help pay Medicare premiums, deductibles, and copays for low-income Medicare beneficiaries.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the CMS / Federal Marketplace or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.