DEPARTMENT OF HEALTH AND HUMAN SERVICES

465 INDUSTRIAL BOULEVARD

LONDON, KENTUCKY 40750-0001

Dorie woodward Dec 13, 2020

411 north main st
Apt A
Hersey, MI 49639

Application Date: December 13, 2020

2021 Application ID: 3774306220

Eligibility notice: Important information about health coverage for your household

Household Results Next steps

member(s)
Dorie woodward • Eligible to buy a 2021 Marketplace plan. • Choose a plan and pay your first month's
• Eligible for advance payments of the premium premium.
tax credit to help pay for a Marketplace plan. • You must choose a Silver plan to get cost-
You can use up to this much of the tax credit: sharing reductions, which provide extra savings
• $550.00 each month, which is $6,600.00 on out-of-pocket costs.
for the year, for your tax household.
• This is based on the yearly household income
of $36,585.53—the amount that you put on
your application, or that came from other
recent information sources.
• Can choose a Silver plan with lower
copayments, coinsurance, and deductibles
(cost-sharing reductions).

If your “Results” say you’re eligible for advance payments of the premium tax credit or cost-sharing
reductions, it means that you don’t appear to be eligible for Medicaid based on your application information.
However, you could still be eligible for Medicaid if you have a disability or special health care needs that you
didn’t report on your application. To learn more, visit HealthCare.gov/people-with-disabilities or call your
state Medicaid agency to ask about rules for your state.

Why don’t I qualify for other programs?

1905943077660142101 1
Dorie woodward—You don't qualify for Medicaid because your monthly household income ($3,048.80) is too
high.

Micheal Woodward—You don't qualify for Medicaid or CHIP because you don’t meet the current criteria in
your state.

What should I do next?

Here’s what each person in your household needs to do to take the “Next steps” shown in this notice. If your
“Next steps” tell you to send more information, follow instructions for sending it. If you don’t, you could lose
what you qualify for now because your information doesn’t match the data we have, or we can’t verify all of
the information in your application.

Enroll in coverage
Dorie woodward—Enroll in coverage by December 15, 2020.

Online: You can enroll through HealthCare.gov. You’ll need to create a Marketplace account if you don’t
already have one. Go to HealthCare.gov, click “Log In” in the top right, then click “Create One.” When you log
in the first time, you’ll need the Application ID at the top of this notice. Visit HealthCare.gov/create-account to
learn more about creating an account.
By phone: Compare plans and enroll over the phone. Call the Marketplace Call Center for help.
• If you don’t already have a Marketplace account, you’ll need the Application ID that’s printed on this
notice.
• Open Enrollment for the Marketplace ends on December 15, so you must enroll in a plan and pay the
first month’s bill (the “premium”) by then.
• If you miss the deadline, you may not be able to enroll in a health insurance plan through the
Marketplace until the next Open Enrollment Period, unless you qualify for a Special Enrollment Period.
• For more information, visit Healthcare.gov/apply-and-enroll/how-to-apply.

When will Marketplace coverage begin?

If you’re eligible to buy a Marketplace plan, your plan’s coverage will start January 1.

What if information from my application changes during the year?

If you have life changes and the information you gave us when you applied is no longer correct, you need to
let us know within 30 days of the change. Changes may affect your eligibility for:
• Premium tax credits
• Cost-sharing reductions that lower your copayments, coinsurance, and deductibles
• Coverage through Michigan Department of Health and Human Services or Michigan MIChild

You’re allowed to switch plans after you report certain changes, but your plan choice may be limited.

1905943077660142101 2
If you enroll in a Marketplace plan and later become eligible for other qualifying coverage, like Medicaid, CHIP,
Medicare, or coverage through a job, you won’t be eligible for advance payments of the premium tax credit,
although you can keep your Marketplace plan and pay the full premium. If you become eligible for other
qualifying coverage, you must contact the Marketplace to end your advance payments of the premium tax
credit and let the Marketplace know if you also want to end your health plan. If you don’t stop the advance
payments of your premium tax credit to your health insurance company, you may need to pay back the
payments paid on your behalf.

If someone works for a business that offers help paying for a health plan or health care expenses through a
Health Reimbursement Arrangement (HRA), visit HealthCare.gov/job-based-help to learn how this may affect
your eligibility for the premium tax credit.

What should I do if I think my “Results” are wrong?

If you think we made a mistake, you can appeal a final determination of eligibility to the Marketplace Appeals
Center. This includes your eligibility to buy health coverage through the Marketplace, for premium tax credits,
cost-sharing reductions, and enrollment periods. You can also appeal the plan categories available to you, if
they’re limited during a Special Enrollment Period. See below for more information about appealing your
eligibility for Michigan Department of Health and Human Services or Michigan MIChild. Please note that:
• If you need health services right away and a delay could seriously jeopardize your health, you can ask
for a fast (expedited) appeal using the Appeal Request form or by sending a fax or a letter to the
address below.
• You can represent yourself or appoint a representative to help you with your appeal. This person can be
a friend, relative, lawyer, or someone else.
• You can ask to keep your eligibility during your appeal. If you were previously eligible for Marketplace
coverage or financial assistance and your eligibility is changed, you can appeal this change. In this case,
you may be able to keep your previous eligibility during your appeal.
• The outcome of an appeal could change the eligibility of other members of your household even if they
don’t ask for an appeal.

How much time do I have to request an appeal?

Generally, you have 90 days from the date of your eligibility notice to request an appeal. However, if this
notice says that someone needs to submit documents, then you must follow instructions for sending them.
Until you submit documents and your issue is resolved, your eligibility notice isn’t a final determination of
eligibility and it can’t be appealed.

How do I request an appeal?

• Online: Visit HealthCare.gov/marketplace-appeals/appeal-forms and select your state. You can submit
your appeal request online or download/print a form and submit it separately.
• By mail or fax: Send a completed paper form or a letter requesting an appeal. Include your name,
address, and the reason for the appeal. If the appeal is for someone else (like your child), also include
their name. Submit your paper form or the letter to the Marketplace:
Fax: 1-877-369-0130
Mail: Health Insurance Marketplace

1905943077660142101 3
 ATTN: Appeals
465 Industrial Blvd.
London, KY 40750-0061

Appealing your eligibility for Medicaid or CHIP

If this notice says that you may be eligible for Medicaid or CHIP, or that your state is reviewing your eligibility
for Medicaid or CHIP, your state Medicaid or CHIP agency will send a notice to let you know if you qualify for
these free or low-cost programs.

If your state determines that you’re not eligible for Medicaid or CHIP:
• Your state will tell you how to ask for a Medicaid fair hearing through the state fair hearing process.
• You may also be able to resubmit your Marketplace application for health coverage through the
Marketplace and help with costs. If you then disagree with your updated “Results,” you can request an
appeal through the Marketplace Appeals Center.

For more information about your Medicaid or CHIP eligibility, including your right to appeal if your state
determines you’re not eligible for Medicaid or CHIP, contact your state Medicaid or CHIP agency at the phone
number included at the end of this notice.

More about getting Medicaid or CHIP

If your “Results” tell you that you’re eligible to buy a Marketplace plan, we don’t think you qualify for
Michigan Department of Health and Human Services. Some people may still qualify for Michigan Department
of Health and Human Services, but only Michigan Department of Health and Human Services can make the
final decision.

You might want to ask Michigan Department of Health and Human Services to continue your application if
you:
• Need a lot of medical services or have medical bills
• Have a family income close to the Michigan Department of Health and Human Services income limit, or
you don’t agree with the income amount that was used to determine your eligibility
• Have a disability
You can keep your coverage described in this notice while Michigan Department of Health and Human
Services reviews your application.

Here’s how to continue your application for Michigan Department of Health and Human Services or Michigan
MIChild:
• Visit HealthCare.gov, log into your Marketplace account and select your most recent application, then
select “Eligibility & Appeals.” You can also log into your Marketplace account and select your most
current application, then go through your application until you reach the “Eligibility Results” screen.
Check the box for a “Full Medicaid Determination” and complete all steps.
• Call the Marketplace Call Center and request that Michigan Department of Health and Human Services
continue to review your Michigan Department of Health and Human Services application.
It’s recommended that you continue your application for Medicaid, even if you aren’t sure that you’re eligible.
Because your Medicaid eligibility must ultimately be determined by the Michigan Department of Health and

1905943077660142101 4
Human Services—and not the Marketplace—you can only request an appeal once that final determination is
made by Michigan Department of Health and Human Services.

For more help

• Visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call
1-855-889-4325. You can also make an appointment with an assister who can help you. Information is
available at LocalHelp.HealthCare.gov.
• Contact your state’s Medicaid agency toll-free: 1-800-642-3195 (TTY: 1-866-501-5656) for information
about Michigan Department of Health and Human Services. For more information about Michigan
MIChild, contact the Michigan Department of Health and Human Services toll-free: 1-888-988-6300
(TTY: 1-888-263-5897).
• Get help in a language other than English. Information about how to access these services is included
with this notice, and available through the Marketplace Call Center.
• Call the Marketplace Call Center to get this information in an accessible format, like large print, Braille,
or audio, at no cost to you.

For information including more about advance payments of the premium tax credit, lower out-of-pocket costs,
and Medicaid eligibility, visit HealthCare.gov.

Sincerely,

Health Insurance Marketplace

Department of Health and Human Services
465 Industrial Boulevard
London, Kentucky 40750-0001

The determinations or assessments in this letter were made based upon 45 CFR 155.305, 155.410, 155.420-430 and 42 CFR 435.603, 435.403,
435.406 and 435.911.

Privacy Disclosure: The Health Insurance Marketplace protects the privacy and security of the personally identifiable information (PII) that you have
provided (see HealthCare.gov/privacy/). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45 CFR
part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace. The
Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on
your application. If you have questions about this data, contact the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1207.

Nondiscrimination: The Health Insurance Marketplace doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis
of race, color, national origin, disability, sex, or age. If you think you’ve been discriminated against or treated unfairly for any of these reasons, you
can file a complaint with the Department of Health and Human Services, Office for Civil Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697),
visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S. Department of Health and Human Services/ 200
Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.

1905943077660142101 5
January 2019
January 2019