FROM COVERAGE

TO CARE Health Insurance

ENROLLMENT

TOOLKIT

Helping Consumers Choose

 the Health Plan 

That’s Right for Them
Quick 

Start 

Guide 

to This 

Toolkit

FROM 

COveRage 

tO CaRe

Discussion 

guides for 

Community 

Partners

MS4260 Talking Points NEW_CS5_dw.indd 1 6/9/14 12:56 PM

Every year, consumers can 

enroll in health insurance 

coverage (coverage) or 

change their health insurance 

plan (plan). People may 

be overwhelmed by their 

choices. They may not know 

how to choose the plan 

that meets their needs or 

how to use their coverage 

to get the care they need.

This Toolkit is for 

community partners, 

assisters, and other people 

who help consumers enroll 

in coverage or change their 

plan. Sections start with a 

few questions consumers 

might have. There are 

key messages for you to 

emphasize at the top of 

each page. At the end of 

the section there are links to 

more resources for you and 

consumers on each topic.

You may be helping someone 

get covered for the first time, 

helping them re-enroll, or 

explaining coverage options 

so consumers can enroll on 

their own. You can use the 

information and resources here 

and in the From Coverage 

to Care Roadmap to Better 

Care and a Healthier You

to help consumers get the 

coverage that’s right for them 

and help them move From 

Coverage to Care. 

The Roadmap and other 

From Coverage to Care (C2C) 

resources are available at:

go.cms.gov/c2c.

 LET’S BEGIN

Personalize It.

To make the most of your time with 

consumers, look for ways to personalize 

this information to each person. Before you 

begin, ask if consumers have questions. 

Their answers will help you navigate this 

Toolkit to meet their needs. 
TABLE OF CONTENTS ENROLLMENT

TOOLKIT

Why consumers should sign up for health coverage (page 2)

• Benefits of coverage

• Affordability

• Minimal essential coverage

What consumers should know before enrolling in a plan (page 8)

• What services are covered

• Costs of coverage

• How to get help paying for coverage

• Re-enrollment reminders

What consumers should know when picking a plan (page 19)

• Plan categories (Bronze, Silver, Gold, Platinum)

• Provider networks

• Prescription drugs & formularies

• Dental & vision coverage

What consumers should do after they get coverage (page 29)

• Completing enrollment

• How to know what’s covered

• Picking or changing providers

• Ongoing treatment & prescription drugs

What consumers with special circumstances should know 

about enrolling in coverage (page 34)

• American Indians & Alaska Natives

• Limited English proficiency

• Immigrants

• Resources for other populations
1

2

WHY CONSUMERS 

SHOULD SIGN UP FOR 

HEALTH COVERAGE 

If the consumer you’re working with isn’t 

sure why he or she should get coverage, 

talk about the points below, and make it 

personal. For example, you could ask if 

there was a time when they thought they 

should go to a doctor but didn’t, or if 

this happened to a family member. Was 

it because they couldn’t afford the visit? 

Were they afraid of finding a problem and 

how much it would cost to treat it? Let 

consumers know that having coverage 

means they can get the care they need, 

and that there is a limit to the amount 

they will have to pay towards the cost of 

their care. Tell them that together you can 

find a plan that meets their health care 

needs and budget. 

When we say “coverage”... we mean 

a legal entitlement consumers have to 

payment or reimbursement for their 

health care costs. It is generally offered 

through:

Health Insurance Company

Group health plan offered in 

connection with employment

OR

A government program like 

Medicare, Medicaid, or the 

Children’s Health Insurance Program 

(CHIP)

ARE THERE QUESTIONS ABOUT ...

BENEFITS

OF COVERAGE?

GO TO

 3

AFFORDABILITY?

GO TO

 4

MINIMUM

ESSENTIAL

COVERAGE? 

GO TO

 5
 

•

 

1. Coverage Is Security. 

Even if they’re uninsured, most consumers use 

health care when they are sick. This may involve 

waiting until a health condition is unbearable, then 

going to an emergency department or clinic for 

care. Explain that coverage can relieve some of 

the stress about using health care by providing 

a set of health care services they know will be 

covered, including mental health and substance 

use disorder services (known as Essential Health 

Benefits, explained more on page 9). 

Having coverage can also help relieve the stress 

of not knowing how much health care will cost if 

you get sick and get a high bill. With coverage, 

consumers know the portion of health care costs 

they’re responsible for, and what their plan will pay. 

They also get access to free or low cost preventive 

care, which can keep people healthy and help them 

avoid more expensive medical problems in the 

future. 

PERSONALIZE THE 

CONVERSATIONS FOR ...

Someone with a chronic condition (like 

diabetes, hypertension, depression, 

or cancer): Ask consumers to think about 

their health and their family’s health. For 

example, high blood pressure, diabetes 

or heart disease may run in their family. 

Explain that they can use their coverage to 

find out if they have a condition, then get 

treatment to manage it if they do. You could 

provide an example of the cost of a vial 

of a prescription drug like insulin. Without 

insurance, it could cost them $300 but with 

coverage they would only pay a copayment 

– like $10 or $20. 

To explain more about how total costs are 

different from what they’ll pay when they’re 

covered, refer to the Cost Tables in the 

From Coverage to Care Roadmap. There 

is an example Cost Table for “Costs of Type 

2 Diabetes” on page 15.

• A young adult: Young adults are 

sometimes called “young invincibles” 

because they think they can’t get sick or 

injured. They might not see the value of 

coverage right away. Ask consumers if 

they’ve been to the emergency department 

recently – and if they know how much the 

visit cost. You can explain to them that 

without coverage, treating a broken arm can 

cost nearly $7,700.

They may be thinking about starting a 

family. If so, let them know that having a 

baby can cost thousands of dollars. You 

can use the “Costs of Having a Baby” Cost 

Table in the Roadmap (on page 15) to show 

them an example of how having coverage 

could affect how much they’ll pay. 

Remind young consumers that they have 

options. They may be able to stay on their 

parents’ plan until they’re 26, get covered 

through their school’s health plan, or enroll 

in Medicaid or a Marketplace plan with 

financial help. Having coverage will protect 

them from large health care costs if they get 

sick. Plus, using coverage for preventive 

services can reduce their health care costs 

over time by keeping them healthy. 

Share information about preventive services 

and screenings that may be covered 

without cost-sharing. There’s a link to the 

Roadmap and other resources to help you 

work with young adults at the end of this 

section on page 7.

3
2. Coverage May Be More Affordable Than You Think.

Eighty-five percent of individuals who 

selected a Marketplace plan last year 

qualified for financial help to lower their 

out-of-pocket costs. But many people didn’t 

apply for coverage because they thought they 

couldn’t afford it. Remind consumers that 

they will only find out whether they qualify for 

help paying for coverage if they apply to the 

Marketplace or their state Medicaid agency. 

Consumers can select “See plans & prices” 

on HealthCare.gov and enter some basic 

information to get an estimate of their costs to 

use as a guide. If you can, show consumers 

an estimate of their costs by window shopping 

on the site with them, but let them know their 

costs and the exact amount of financial help 

they’ll get is only available once they apply. 

Applying is free and it may save the consumer 

out-of-pocket costs.

Section 2 has more information on how to 

see plans and prices on HealthCare.gov

and there’s a cheat sheet on page 13 so you 

can quickly tell whether a consumer might 

qualify for help based on their income. Remind 

consumers these are only estimates and the 

Marketplace and state Medicaid agencies will 

make final determinations when they apply for 

health coverage. 

 

SEE PLANS & PRICES AT: 

https://www.healthcare.gov/see-plans/

80% Or 8 out of 10 Consumers

can get coverage for $100or less

per month after any applicable tax credits in 2015.

4
3. Know What Counts As Minimum Essential Coverage. 

Minimum Essential Coverage 

Applicable individuals must maintain Minimum 

Essential Coverage each month. In prior tax years, 

consumers without coverage had to pay the Individual 

Shared Responsibility Payment – a fee for going 

without coverage for part or all of the year. Beginning 

Janauary 1, 2019, the fee has been reduced to $0, but 

individuals must still maintain coverage.

What Counts as Minimum Essential Coverage? 

Qualified health plans in the Marketplace meet this 

standard. So do TRICARE, the Veteran’s health care 

program, Medicare Part A, Medicaid, coverage for 

Peace Corps Volunteers, and job-based coverage. 

Minimum Essential Coverage doesn’t include coverage 

that only provides limited benefits. For example, 

coverage for just vision or dental care, and Medicaid 

just for certain benefits like family planning, workers’ 

compensation or disability, don’t meet this standard.

For more information or to find out what coverage 

qualifies, visit: https://www.healthcare.gov/feesexemptions/plans-that-count-as-coverage/

5

Some consumers are exempt from this 

requirement if any of these apply to them: 

• Uninsured for less than 3 months of 

the year

• Lowest-priced coverage available would 

cost more than 8% of their household 

income

• Don't have to file a tax return 

because their income is too low 

• Member of a federally recognized 

tribe or eligible for services through 

an Indian Health Services provider

• Member of a recognized health care 

sharing ministry

• Member of a recognized religious 

sect with religious objections to 

insurance, including Social Security 

and Medicare

• Incarcerated (either detained or 

jailed), and not being held pending 

disposition of charges

• Not lawfully present in the U.S.

• Qualify for a hardship exemption

Encourage consumers to apply for 

coverage even if they believe they are 

exempt. Once they see that they can get 

affordable coverage, they may decide 

they want the peace of mind and access 

to affordable health care services that 

they get when they’re covered. There 

are more resources at the end of this 

section on page 7 to help you explain 

what qualifies for an exemption and how 

consumers can apply.
4. Your Coverage Pays For Preventive Care That Can Keep You Healthy. 

ONCE CONSUMERS HAVE COVERAGE, 

THEY CAN TALK WITH A PROVIDER 

ABOUT HOW TO USE IT TO STAY 

HEALTHY.

Consumers may have had a provider 

recommend vaccines, screenings, or tests to 

them or a family member, but they may not 

have known why they needed it, or the value 

of knowing the results. Explain that screenings 

and test results help providers monitor patients’ 

health and make sure they’re on the right track. 

And most preventive services, like screenings, 

tests and vaccines, are available at no cost to 

the enrollee (no copayments or deductibles). 

Explain to consumers that if they’re diagnosed 

with a health condition or illness, catching it 

early could be life-saving. Many serious health 

conditions can be treated or managed. 

Consumers may have also heard statistics, like: 

1 in 8 women will develop breast cancer in their 

lifetime, or 1/3 of all people have heart disease. 

People with a family history of a certain illness 

or health condition may have heard that they’re 

more likely to get sick. They may even think that 

they can’t avoid it, and may be afraid to see 

a provider. Talk about how consumers can be 

proactive and get regular health care to prevent 

illness or to catch it early.

Quit Smoking

Eat Healthy

 

Exercise & Lose Weight

Do Consumers Need Help Enrolling?

Call the Marketplace Call Center:

• 1-800-318-2596

• TTY: 1-855-889-4325

• Available 24 hours a day, 7 days a week

in more than 150 languages

Find local in-person help, visit: 

https://localhelp.healthcare.gov/

6
RESOURCES 

From Coverage to Care resources 

(Partner/Consumer) 

go.cms.gov/c2c

Manage Your Health Care Costs 

(Partner/Consumer)

https://www.cms.gov/About-CMS/AgencyInformation/OMH/Downloads/C2C-ManageYour-Healthcare-Costs-508.pdf

Incomes that qualify for lower costs

(Partner/Consumer)

https://www.healthcare.gov/lower-costs/

qualifying-for-lower-costs/

How to estimate income for the 

Marketplace (Partner/Consumer) 

https://www.healthcare.gov/income-andhousehold-information/how-to-report/

How health coverage affects your 

taxes (Partner/Consumer)

https://marketplace.cms.gov/outreach-andeducation/health-coverage-affects-taxes.pdf 

Where and how to get an exemption 

(Partner/Consumer) 

https://www.irs.gov/affordable-care-act/

individuals-and-families/aca-individualshared-responsibility-provision-exemptions

Qualifying for a hardship exemption 

(Partner/Consumer) 

https://www.healthcare.gov/healthcoverage-exemptions/hardshipexemptions/

Questions & answers on the 

Individual Shared Responsibility 

Payment and exemptions

(Partner/Consumer) 

https://www.irs.gov/affordable-careact/individuals-and-families/questionsand-answers-on-the-individual-sharedresponsibility-provision

Health coverage for young adults 

(Partner/Consumer)

https://www.healthcare.gov/young-adults/ 

Myhealthfinder web app for 

personalized preventive care 

recommendations (Consumer)

healthfinder.gov/myhealthfinder/

Mental health and substance use 

disorder services treatment locator 

and resources (Consumer)

http://www.mentalhealth.gov/

7
2

WHAT CONSUMERS 

SHOULD KNOW BEFORE 

ENROLLING IN A PLAN 

People enrolling in health coverage 

for the first time may not understand 

common health insurance coverage 

terms. Misconceptions and knowledge 

gaps can make shopping for coverage 

difficult. Use this section and the 

From Coverage to Care Roadmap, 

Step 2 to discuss key coverage terms 

and consumers’ concerns about costs.

Emphasize the four topics below, and get 

the Roadmap at: go.cms.gov/c2c

ARE THERE QUESTIONS ABOUT ...

WHAT SERVICES

 ARE COVERED?

8

GO TO

9

COSTS OF 

COVERAGE?

GO TO

10

HOW TO GET HELP

PAYING FOR 

COVERAGE?

GO TO

13

RE-ENROLLMENT 

REMINDERS?

GO TO

17
1. 

1. All Marketplace Plans Must Cover Doctor

Visits, Preventive Services, Prescription Drugs, Mental Health Care, 

Hopitalization, And More. 

Consumers may be hesitant to enroll in 

coverage because they are unclear on 

what is covered and afraid to pick the 

wrong plan. They may have had a bad 

experience in the past, been denied 

coverage, had their coverage cancelled, 

or thought a treatment was covered 

when it wasn’t, which may contribute to 

their hesitation. Reassure consumers 

that although each plan is different, 

Marketplace plans must meet certain 

minimum standards, including covering 

the ten Essential Health Benefits listed 

to the right. Plans also cover many 

preventive services like screenings and 

vaccines without out-of-pocket costs 

to the consumer, like copayments, 

coinsurance, or deductibles.

Talk to consumers about which services 

they may need. Ask if there are other 

things that they don’t see listed in the 

box to the right. Write them down and 

refer back to the list when comparing 

available plans.

WHAT ARE ESSENTIAL HEALTH BENEFITS?

A set of health care service categories 

that Marketplace plans must be covered 

by plans sold through the Marketplace.

1

2

3

4

5

6

7

8

9

10

9

Outpatient care is care a person gets without 

being admitted to the hospital as an inpatient

Emergency services

Treatment in the hospital for inpatient care

Care before and after a baby is born

Mental health and substance use disorder 

services

Prescription drugs

Services and devices to help you a person 

recover if they’re injured or have a disability 

or chronic condition, or that help you gain 

function (called habilitative and rehabilitative 

services)

Lab tests and services

Preventive services including counseling, 

screenings, and vaccines to keep people 

healthy and manage a chronic disease

Pediatric Services - services tailored to the 

needs of children to ensure they grow up and 

develop properly, including dental and vision 

care for kids
2. Once You Understand Key Terms, You Can Compare Costs For Plans.

ONE IN THREE CONSUMERS DON'T UNDERSTAND 

WHAT A PREMIUM IS.

Consumers may not understand common 

health care terms, including deductible, 

premium, copayments, and coinsurance.

Below are some key pieces of information to 

point out: 

Premiums are payments generally made 

every month to maintain coverage. Explain 

that consumers will pay their premium to their 

insurance plan, regardless of whether they use 

any health care services. Remind them that 

it’s important to pay their premiums in order to 

keep their coverage. 

Copayment (or Copay) is the 

fixed amount a consumer pays for a covered 

health care service or supply. Copayments 

are usually a set amount, for example $15 for 

primary care visits and $35 for specialty care 

visits. Point out the copayment amounts for 

each service. With some types of coverage 

(like Medicaid) there may not be a copayment. 

Mention that copayments could differ based 

on the type of care or service they receive 

(for example, primary care, specialist, 

emergency department, and brand-name and 

generic prescription drugs may have different 

copayments). 

Go to Section 3 for more information about 

talking with consumers about the costs of 

prescription drug coverage. 

Coinsurance is the consumer’s share of 

the costs of a covered health care service. 

It’s different from a copayment because it 

is a percent of the total allowed amount for 

the service, not a set dollar amount. For 

example: if the cost of a visit to a specialist 

is $180, and the consumer is responsible for 

paying 20% coinsurance, he or she would 

pay $36.

Deductible is the dollar amount consumers 

have to pay for health care services before 

their plan will start paying for their care. The 

deductible may not apply to all health care 

services. For example, in all Marketplace 

plans, coverage for preventive services is 

not subject to the deductible. Other plans 

may not have a deductible for primary 

care or prescription drugs. Different plans 

may have different deductibles for specific 

services, so consumers should know the 

deductibles before they pick a plan. Let 

them know their insurance company will 

keep track of how much they’ve paid toward 

their deductible, but they should keep track 

as well.

SAMPLE: WHAT YOU PAY WITH COINSURANCE

$180 x .20 = $36

Specialist cost x 20% coinsurance = Patient cost

10
1.2. Once You Understand Key Terms, You Can Compare Costs For 

Plans (Continued).

Out-of-pocket limit is the maximum 

amount consumers will have to pay for 

covered health care services for the year. 

One of the benefits of having coverage 

is that consumers are protected from 

paying very high costs because of the 

out-of-pocket limit. Once they reach 

this limit, their plan will pay for 100% of 

the rest of the covered health care they 

need. Each plan sets its own out-ofpocket limit, but it can’t be more than 

$7,900 for an individual (or $15,800 for 

2 or more people) in 2019. This may still 

be unaffordable for some consumers. 

Remind consumers they may qualify to 

get a cost-sharing reduction that lowers 

their maximum out-of-pocket expenses 

even more. There’s more information 

about how to apply in this section.

Have consumers go to www.healthcare.

gov/see-plans/ and answer a few 

basic questions. They will see a display 

like this one for the available plans 

with estimated costs and some of 

the financial help they may get. Write 

down the costs for the plans they’re 

considering, then select a few on the 

website and print. 

11
Talk about the different costs to get a 

sense of the consumer’s preferences. 

Some people may prefer to pay a 

smaller amount each month, even if their 

copayments when they get care are a 

little higher. Consumers can filter plans 

by plan category, premiums, or out-ofpocket costs to find one that meets their 

needs. For example, if a low premium is 

the most important thing, consumers can 

see plans sorted from lowest premium 

prices to the highest. 

Discuss monthly budget or spending 

and which options are affordable. If 

consumers aren’t sure which plan to 

enroll in, encourage them to take the 

information home and to talk with trusted 

family and friends, if needed, about 

which plan meets their health care needs 

and budget. Remind consumers that the 

information in the “window shopping” 

feature may not reflect their specific 

costs or savings – it will only provide an 

estimate of the premium tax credit, but 

not other help. Consumers need to apply 

to know exactly what their costs and 

financial assistance will be. 

TALK TO CONSUMERS ABOUT THEIR 

MONTHLY BUDGET AND WHICH 

COVERAGE OPTIONS ARE AFFORDABLE. 

Application for Health Coverage & Help Paying Costs 

(Short Form)

 Apply faster online at HealthCare.gov 

 Use this application 

to see what coverage 

you qualify for

• Affordable private health insurance plans that offer comprehensive coverage to 

help you stay well.

• A tax credit that can immediately help pay your premiums for health coverage.

• Free or low-cost coverage from Medicaid or the Children’s Health Insurance 

Program (CHIP).

 Who can use this 

application?

Single adults who:

• Aren’t offered health coverage from their employer

• Don’t have any dependents and can’t be claimed as a dependent on someone 

else’s tax return

NOTE: If any of the following apply, you need to fill out a different form to make 

sure you get the most benefits possible:

• You’re married or have dependent children.

• You were in the foster care system, and you’re under age 26.

• You have items that can be deducted from your income. If your only deduction 

is student loan interest, you can use this form.

• You’re American Indian or Alaska Native.

 What you may 

need to apply

• Your Social Security number (or document number if you’re an eligible 

immigrant)

• Employer and income information (for example, from paystubs, W-2 forms, or 

wage and tax statements)

 Why do we ask for 

this information?

We ask about income and other information to let you know what coverage you 

qualify for and if you can get any help paying for it.

We’ll keep all the information you provide private and secure, as required 

by law. To view the Privacy Act Statement, go to HealthCare.gov.

 What happens 

next?

Send your complete, signed application to the address on page 3. If you don’t 

have all the information we ask for, sign and submit your application 

anyway. We’ll follow up with you within 1–2 weeks and you may receive a

call from the Marketplace if we need more information. You’ll get an eligibility 

determination letter in the mail after your application is processed. Filling out this 

application doesn’t mean you have to buy health coverage.

 Get help with this 

application

• Online: HealthCare.gov.

• Phone: Call the Marketplace Call Center at 1-800-318-2596. TTY users should 

call 1-855-889-4325.

• In person: There may be counselors in your area who can help. Visit 

HealthCare.gov, or call the Marketplace Call Center at 1-800-318-2596 for more 

information.

• En Español: Llame a nuestro centro de ayuda gratis al 1-800-318-2596.

• Other languages: If you need help in a language other than English, call 

1-800-318-2596 and tell the customer service representative the language you 

need. We’ll get you help at no cost to you.

You have the right to get the information in this product in an alternate format. 

You also have the right to file a complaint if you feel you’ve been discriminated 

against. Visit www.cms.gov/about-cms/agency-Information/aboutwebsite/

cmsnondiscriminationnotice.html, or call the Marketplace Call Center at 

1-800-318-2596 for more information. TTY users should call 1-855-889-4325.

09/2017

Form Approved

OMB No. 0938-1213 

PRA Disclosure Statement: 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 0938-1191. The time required to complete this information collection is estimated to average 15 minutes per 

response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments 

concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop 

C4-26-05, Baltimore, Maryland 21244-1850.

(You must be 18 or older to submit this application. If you have an Authorized Representative, that person may submit the application for you 

as long as you sign Appendix C.) 

1. First name

Middle name

 Last name Suffix

Home address (Leave blank if you don’t have one.)

3. Apartment or suite number 2. 

4. City 5. State 6. ZIP code

7. County, parish, or township

8. Mailing address (if different from home address)

9. Apartment or suite number

10. City 11. State 12. ZIP code

13. County, parish, or township

15. 14. Daytime phone number

Evening phone number

 

 

16. Do you want to get information about this application by email? ....................................................................................................... Yes No

Email address:

17. What’s your preferred spoken language? What’s your preferred written language? 

18. Date of birth (mm/dd/yyyy) 19. Sex

Male Female

20. Social Security Number (SSN) 

We need a Social Security number (SSN) if you want health coverage and have an SSN or can get one. We use SSNs to check income and 

other information to see who’s eligible for help paying for health coverage. If you need help getting an SSN, visit socialsecurity.gov, or call 

Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 

STEP 1: Tell us about yourself. 

Please print in capital letters using black or dark blue ink only. 

Fill in the circles ( ) like this .

21. Are you a U.S. citizen or U.S. national? ............................................................................................................................................................................... Yes No

22. Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.) 

YES. If yes, complete a and b. NO. If no, continue to question 23.

a. Alien number:

b. Certificate number:

After you complete a and b, 

SKIP to question 24. 

23. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? YES. Enter document type and ID number. See instructions.

Immigration document type

Status type (optional)

Write your name as it appears on your immigration document.

Alien or I-94 number

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

24. Are you pregnant? ..................................................................................... Yes No a. If yes, how many babies are expected during this pregnancy? 

25. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc.) or live in a medical facility or nursing home? ...................................................................................................................................................... Yes No

Optional:

(Fill in all that 

apply.)

26. If Hispanic/Latino, ethnicity: Mexican Mexican American Chicano/a Puerto Rican Cuban Other

27. Race: White Black or African American American Indian or Alaska Native Filipino Japanese Korean Asian Indian Chinese

Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other 

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a 

language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325. 

 

Page 1 of 4

(You must be 18 or older to submit this application. If you have an Authorized Representative, that person may submit the application for you 

as long as you sign Appendix C.) 

1. First name

Middle name

 Last name Suffix

Home address (Leave blank if you don’t have one.)

3. Apartment or suite number 2. 

4. City 5. State 6. ZIP code

7. County, parish, or township

8. Mailing address (if different from home address)

9. Apartment or suite number

10. City 11. State 12. ZIP code

13. County, parish, or township

15. 14. Daytime phone number

Evening phone number

 

 

16. Do you want to get information about this application by email? ....................................................................................................... Yes No

Email address:

17. What’s your preferred spoken language? What’s your preferred written language? 

18. Date of birth (mm/dd/yyyy) 19. Sex

Male Female

20. Social Security Number (SSN) 

We need a Social Security number (SSN) if you want health coverage and have an SSN or can get one. We use SSNs to check income and 

other information to see who’s eligible for help paying for health coverage. If you need help getting an SSN, visit socialsecurity.gov, or call 

Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. 

STEP 1: Tell us about yourself. 

Please print in capital letters using black or dark blue ink only. 

Fill in the circles ( ) like this .

21. Are you a U.S. citizen or U.S. national? ............................................................................................................................................................................... Yes No

22. Are you a naturalized or derived citizen? (This usually means you were born outside the U.S.) 

YES. If yes, complete a and b. NO. If no, continue to question 23.

a. Alien number:

b. Certificate number:

After you complete a and b, 

SKIP to question 24. 

23. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? YES. Enter document type and ID number. See instructions.

Immigration document type

Status type (optional)

Write your name as it appears on your immigration document.

Alien or I-94 number

Card number or passport number

SEVIS ID or expiration date (optional)

Other (category code or country of issuance)

24. Are you pregnant? ..................................................................................... Yes No a. If yes, how many babies are expected during this pregnancy? 

25. Do you have a physical, mental, or emotional health condition that causes limitations in activities (like bathing, dressing, daily

chores, etc.) or live in a medical facility or nursing home? ...................................................................................................................................................... Yes No

Optional:

(Fill in all that 

apply.)

26. If Hispanic/Latino, ethnicity: Mexican Mexican American Chicano/a Puerto Rican Cuban Other

27. Race: White Black or African American American Indian or Alaska Native Filipino Japanese Korean Asian Indian Chinese

Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander Other 

NEED HELP WITH YOUR APPLICATION? Visit HealthCare.gov, or call us at 1-800-318-2596. Para obtener una copia de este formulario en Español, llame 1-800-318-2596. If you need help in a 

language other than English, call 1-800-318-2596 and tell the customer service representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-855-889-4325. 

 

Page 1 of 4

12
If your state is expanding Medicaid: You may qualify for Medicaid coverage if your yearly income is below...If your state is isn't 3. Financial Assistance May Be Available, 

But You Must Apply To Learn What You Qualify For.

Many people don’t think they can afford coverage, and don’t realize that financial assistance may be 

available. Talk to consumers about tax credits, cost-sharing reductions, Medicaid and the Children’s 

Health Insurance Program (CHIP), and protections for American Indian and Alaska Natives and 

members of federally recognized tribes and ANCSA shareholders. Let people know that help is 

available for eligible people and families with lower household incomes. See below for a cheat sheet 

from HealthCare.gov to match up their income to the federal poverty level (FPL). The amounts 

below are 2019 numbers and used for calculating eligibility for Medicaid and the Children's Health 

Insurance Program (CHIP). 2018 numbers are used to calculate eligibility for savings on private 

insurance plans for 2019.

PRIVATE MARKETPLACE

HEALTH PLANS

Number of people in household... 1 2 3 4 5 6

You may qualify for lower premiums 

for Marketplace insurance if your yearly 

income is between...

$12,140 - 

$48,560

$16,460 - 

$65,840 

$20,780 - 

$83,120

$25,100 - 

$100,400 

$29,420 - 

$117,680 

$33,740 - 

$134,960

You may qualify for lower premiums 

AND lower out-of-pocket costs for 

Marketplace insurance if your yearly 

income is between...

$12,140 - 

$30,350 

$16,460 - 

$41,150 

$20,780 - 

$51,950 

$25,100 - 

$62,750 

$29,420 - 

$73,550

$33,740-

$84,350

PREMIUM TAX

CREDIT-ELIGIBLE:

This is 100% - 400% 

FPL in 2018

MEDICAID COVERAGE

Number of people in household... 1 2 3 4 5 6

If your state is expanding Medicaid: 

You may qualify for Medicaid 

coverage if your yearly income is 

below...

$16,753 $22,715 $28,676 $34,638 $40,600 $46,561

If your state isn't expanding 

Medicaid: You may not qualify for 

any Marketplace savings programs if 

your yearly income is below....

$12,140 $16,460 $20,780 $25,100 $29,420 $33,740

MEDICAID

ELIGIBLE:

This is 108%

FPL in 2018

COST SHARING

ELIGIBLE:

This is 100% - 250% 

FPL in 2018

This is 100% 

FPL in 2018

13
2018 FPL Alaska 2018 FPL Hawaii 2018 FPL

1 $12,140 $15,180 13,960

2 $16,460 $20,580 $18,930

3 $20,780 $25,980 $23,900

4 $25,100 $31,380 $28,870

5 $29,420 $36,780 $33,840

6 $33,740 $42,180 $38,810

7 $38,060 $47,580 $43,780

8 $42,380 $52,980 $48,750

14

NOTE: INCOMES THAT 

QUALIFY FOR LOWER 

COSTS ARE HIGHER IN 

ALASKA & HAWAII.

Types of Financial Assistance

Premium tax credit is for people with household incomes between 

100% - 400% FPL who are not eligible for certain other coverage. 

Lower incomes are eligible for a larger credit. The credit reduces 

monthly premium payments. Consumers can apply the credit before 

they pay their premium so they pay less per month, or when they file 

taxes to get money back at the end of the year. 

Cost-sharing reductions provide additional financial assistance for 

eligible consumers with incomes between 100% - 250% FPL who 

also qualify for premium tax credits. Let consumers know that this 

reduction lowers the amount they will have to pay for out-of-pocket for 

deductibles, coinsurance, and copayments, but they must enroll in a 

specific category of plan (Silver, and we’ll talk about the categories in 

Section 3). 

American Indians and Alaska Natives (AI/AN) and members of federally 

recognized tribes and ANCSA shareholders have special protections 

and cost-sharing. Section 5 has more information. 
3. Financial Assistance May Be Available, 

But You Must Apply To Learn What You Qualify For (Continued).

Premium tax credits: Talk to consumers 

about how coverage will affect their income 

taxes when they file their federal income 

tax returns. People may not realize they 

could get a premium tax credit, even if they 

earn more than $40,000 a year. Advance 

payments of the premium tax credit can 

lower monthly premium costs. If they 

qualify for a tax credit, consumers can 

decide how much of the credit to apply 

to their premium each month up to their 

maximum credit amount. They can apply 

the credit when their coverage starts and 

pay less per month or claim the credit 

when they file their taxes. 

Let consumers know they must file their 

federal taxes to get this subsidy, whether 

they apply it up front as advance payment 

of the premium tax credit or when they 

file their taxes. When the individual files 

their annual federal income tax return, the 

amount of premium tax credit they received 

during the year will be reconciled with 

their eligibility for the premium tax credit 

based on their actual household income 

for the year. If the individual received 

excess premium tax credit than what they 

are eligible for, they may have to repay the 

excess amount.

Cost-sharing reductions: In addition to 

the premium tax credit, eligible consumers 

enrolling in Marketplace plans with 

incomes whose household income is 

between 100% - 250% 

of FLP and who don’t 

qualify for Medicaid 

can get cost-sharing 

reductions if they enroll 

in a Silver plan. This 

subsidy is different from the premium tax 

credit in these ways: it is only for Silver 

plans, it reduces the consumer’s out-ofpocket costs when they use health care 

services, and it applies to their deductibles, 

copayments and coinsurance.

• Without the cost-sharing subsidy, 

a consumer’s total out-of-pocket 

maximum can be no higher than 

$7,900 for an individual and $15,480 

for 2 or more people. 

• With the cost-sharing subsidy, a 

consumer’s out-of-pocket maximum 

can be no higher than $2,600 for 

an individual or $5,200 for a family 

depending on where their if the 

consumer’s household income falls 

between 100% - 200% FPL and the 

consumer enrolls in a silver plan. If 

the consumer’s household income 

falls between 200% - 250% FPL, 

with the cost-sharing subsidy, the 

consumer’s out-of-pocket maximum 

can be no higher than $6,300 for an 

individual or $12,600 for a family if 

the consumer enrolls in a silver plan.

A plan can change how it combines 

its charges for copayments, 

coinsurance, and deductibles, but 

consumers will never pay more 

than these out-of-pocket maximum 

amounts for covered health care 

services. If you’re serving consumers 

who are members of a federally 

recognized tribe, are ANCSA 

shareholders, or are American Indian 

or Alaska Native, let them know they 

could be eligible for additional costsharing reductions. Go to Section 5

for more information. 

15
Paying for coverage and care may seem 

expensive, but having coverage actually makes 

using health care more affordable. Explain that 

coverage can be like having a coupon – plans 

negotiate a lower payment rate with health 

care providers who participate with their plan 

so consumers pay a reduced rate for services. 

Coverage is also like having a gift card – when 

consumers use their coverage, their plan 

generally pays part of the covered services, so 

consumers’ payments (or out-of-pocket costs) 

are lower. If consumers are uninsured they might 

be billed a higher amount for the same services 

and have to pay the full cost of their care.

Medicaid and the Children’s Health 

Insurance Program (CHIP)

Medicaid and CHIP provide 

comprehensive benefits for people at 

no cost or low cost so talk with eligible 

consumers about enrolling. In states 

that have expanded eligibility, more 

adults qualify than ever before – but 

children and adults may qualify even if 

your state has not expanded eligibility. 

People also may not know they can 

enroll any time of the year if they qualify. 

Let them know that if they’re eligible 

for Medicaid but choose to enroll in a 

Marketplace or other private plan, they 

can’t get the premium tax credits and 

cost-sharing reductions.

16

If your state chose not to expand its Medicaid 

program and consumers are not eligible for 

Medicaid, adults below 100% FPL may not have 

access to cost-sharing reductions or premium 

tax credits. Medicaid expansion is a state choice 

and some states did not increase the eligibility 

threshold. If you are working with low-income 

consumers who are not eligible for Medicaid, 

they also may not be able to afford Marketplace 

coverage. Be sensitive to their circumstances 

and let them know they can’t get federal 

help paying for coverage for a Marketplace 

plan. If possible, connect them to any local 

or state resources that might help cover 

the costs of their care. Additionally, notify 

these individuals that they may qualify for 

a hardship exemption. Go to Section 1

for more information on exemptions and 

use resources on page 7 to help eligible 

consumers apply. 

Job-Based Coverage & 

Financial Assistance

In general, if an employer offers a 

consumer a plan that’s affordable and 

meets the minimum value standard for 

plans in the Marketplace, the consumer 

won’t qualify for financial help if they 

purchase Marketplace coverage – even 

if they meet the income threshold. If the 

employer plan doesn’t meet these two 

standards, consumers can qualify for 

premium tax credits in the Marketplace.

• The health plan has to be 

affordable: cost of coverage for 

one person is less than 9.5% 

of the individual’s household 

income. 

• The health plan has to meet 

minimum value standards. 

Most job-based coverage will meet 

the minimum standards. If a consumer 

thinks their coverage doesn’t qualify, 

have them bring the Employer 

Coverage Tool to their employer to 

fill out. You can help them apply for a 

determination to see whether they’re 

eligible for help paying for coverage. 

Employer Coverage Tool: https://www.

healthcare.gov/downloads/employercoverage-tool.pdf
Compare 

Health

Plans!!!!

2018 Health Plan

2019 Health Insurance 

Options

4. If You’re Already Enrolled In A Marketplace

Plan, Review Current Plan Options To Make Sure Your Coverage Still Meets 

Your Needs And Update Your Information. 

17

Encourage consumers to log in to 

HealthCare.gov to review and update their 

income and report life changes, including 

information about changes like a birth, 

adoption, marriage, divorce, or change of 

address. This information will be used to 

determine eligibility for premium tax credits 

and cost-sharing reductions. 

Reporting changes will help consumers 

avoid getting a smaller refund or owing 

money they didn’t expect to owe on their 

federal tax return. If you’re working with 

consumers who are claiming the premium tax 

credit for 2018, you may want to remind them 

that they must file a federal tax return in order 

to get it. If they are married, they generally 

must file taxes jointly with their spouse. 

When consumers file their annual federal 

income taxes, the IRS will match up the 

information they report with the premium tax 

credit they received. The IRS may adjust the 

amounts consumers owe or are due if:

• The amount of advance payments of the 

premium tax credit that consumer got 

is less than the premium tax credit due. 

Consumers will receive the difference 

as a refund.

OR

• A consumer’s advance payment of the 

premium tax credit for the year is more 

than the amount of the premium tax 

credit due. Consumers will have to 

repay the excess with their tax return, 

subject to statutory repayment limits.

Health plans will be different this year. 

Let consumers know that every year health 

insurance plans may change benefits and 

how they cover certain services, prescription 

drugs, or include particular providers in their 

networks. Teach them how to review their 

coverage this year – and every year. Let them 

know they could find a more affordable plan, 

or one with better choices and value, if they 

go back to the Marketplace and look at their 

options during open enrollment.
RESOURCES

Helping consumers compare and 

select a plan (Partner)

https://marketplace.cms.gov/technicalassistance-resources/plan-compare-andplan-selection-help.html

Essential Health Benefits covered in 

the Marketplace (Consumer)

https://www.healthcare.gov/blog/10-

health-care-benefits-covered-in-the-healthinsurance-marketplace/

How to estimate your income for the 

Marketplace (Consumer) 

https://www.healthcare.gov/income-andhousehold-information/

Basics about the Premium Tax Credit 

(Consumer)

http://www.irs.gov/uac/The-Premium-TaxCredit 

Qualifying for Marketplace costsharing reductions (Consumer)

https://www.healthcare.gov/lower-costs/

save-on-out-of-pocket-costs/

Find and compare plans in your area 

(Consumer)

https://www.healthcare.gov/see-plans/

HealthCare.gov employer-provided 

coverage tool (Consumer)

https://www.healthcare.gov/downloads/

employer-coverage-tool.pdf

MEDICAID & CHIP

To find out information about specific 

State Medicaid programs (Partner)

https://www.medicaid.gov/medicaid/bystate/by-state.html 

Information on Medicaid programs 

(Partner/Consumer)

http://www.medicaid.gov/ 

Information on Children’s Health 

Insurance Programs 

(Partner/Consumer)

http://www.insurekidsnow.gov/

18
3

19

WHAT CONSUMERS 

SHOULD KNOW BEFORE 

ENROLLING IN A PLAN 

ARE THERE QUESTIONS ABOUT ...

PLAN 

CATEGORIES?

GO TO

20

PROVIDER 

NETWORKS?

GO TO

22

PRESCRIPTION 

DRUGS & 

FORMULARIES?

GO TO

25

DENTAL & VISION 

COVERAGE?

GO TO

27

Once consumers have a basic understanding 

of health coverage and cost-sharing, they’re 

ready to find the health plan that best meets 

their health care needs and budget. Explain 

that different plans and provider networks 

have different costs and benefits. For example: 

some plans may have very low premiums, but 

limited provider and hospital networks and 

high out-of-pocket costs. Other plans may 

have higher premiums but a bigger selection of 

providers and hospital facilities, and lower outof-pocket costs like deductibles, copayments, 

and coinsurance. 

This section has discussion-starters and 

diagrams to help you explain the benefits 

of different plans. If you haven’t already, 

ask which things are most important to 

each individual you’re helping so you can 

personalize your assistance. 
1. Choosing Your Plan Category Generally 

Means Balancing Monthly Premium Costs With Costs When You Get 

Health Care Services. 

Plans sold in the Marketplace are divided into 

four different categories: Bronze, Silver, Gold, 

and Platinum. The main difference between 

metals, or plan categories, is the proportion of a 

consumer’s health care costs that their plan will 

pay. Another difference will be how much costsharing the consumer will be responsible for. In 

general, there is a trade-off between premiums 

and costs at the time of care: lower premiums 

usually come with higher out-of-pocket 

costs. Make sure consumers understand this. 

Consumers should also be aware that no matter 

which category they choose, all plans cover the 10 

Essential Health Benefits discussed in Section 2. 

Let consumers know that the plan categories only 

apply to certain health insurance plans, and not 

Medicaid, CHIP, or other coverage types. 

Consumers under 30 (and certain individuals 

who qualify for an exemption from the individual 

shared responsibility fee) may want to consider 

a Catastrophic plan. These plans have low 

premiums and require consumers to meet a high 

deductible before their coverage starts, except 

for coverage for certain preventive services and a 

limited number of primary care visits (three 

visits, generally). Consumers who do not 

plan on using much health care during 

the year and who only want protection 

against very high costs in case of a serious 

accident or illness may want to consider 

this type of plan. 

As with all Marketplace plans, the 

maximum amount consumers with a 

Catastrophic plan will pay during a policy 

year is $7,350 for an individual plan 

and $14,700 for a family plan in 2018. 

After that, the plan covers 100% of the 

cost of the covered Essential Health 

Benefits. Without any coverage, a serious 

accident or illness could cost a consumer 

thousands of dollars in health care bills. Let 

consumers know that premium tax credits 

can’t be used to discount premiums on 

Catastrophic plans.

BRONZE SILVER GOLD PLATINUM

20
1. Choosing Your Plan Category Generally 

Means Balancing Monthly Premium Costs With Costs When You Get Health 

Care Services (Continued).

Cost-sharing reductions are available for 

Silver Plans if you are eligible.

BRONZE SILVER GOLD PLATINUM

What You Pay Each Month (Premium*) $ $$ $$$ $$$$

What You Pay When You Go For Care

(Out of Pocket Costs, including Deductible, 

Copays & Coinsurancce)

$$$$ $$$ $$ $

Percent of Total Average Costs of Care 

Your Plan Will Cover (Actuarial Value)

60% Your Plan

40% You

70% Your Plan

30% You

80% Your Plan

20% You

90% Your Plan

10% You

Might Be Good For You If You...

don't plan to 

need a lot of 

health care 

serives for the 

year.

need to balance 

your monthly 

premium with 

your out of 

pocket costs.

want to keep 

your out of 

pocket costs low, 

but can afford a 

higher monthly 

premium.

plan to use a lot 

of health care 

services.

The actuarial value of your plan is the percentage of total 

average costs for covered benefits that a plan will cover. For 

example, if a plan has an actual value of 70%, on average, 

you would be responsible for 30% of the costs of all covered 

benefits. However, you could be responsible for a higher or 

lower percentage of the total cost of covered services for the 

year, depending on your actual health care needs and the terms 

of your insurance policy.

* Note: These numbers are not real and give an idea of different premium costs. Check the plans in your area for 

exact costs. You may find a lower premium on a higher metal level plan.

21
2. Aside From Choosing A Plan Category, Decide What Type of 

Provider Network Helps You Balance the Providers You Can See 

With How Much You’ll Pay For A Visit.

A plan’s provider network is the list of 

providers, facilities, and suppliers a health 

insurer or plan has contracted with to provide 

health care services. The From Coverage 

to Care Roadmap, Step 2 introduces the 

provider network concept to consumers. 

Explain that plans negotiate lower rates 

for consumers with providers who are “innetwork” for a plan. These providers can be 

called “preferred providers” or “participating 

providers.” So, in-network providers will 

usually cost consumers less than out-ofnetwork providers. With some plans, out-ofnetwork care will not be covered, meaning the 

consumer will pay the full cost. 

Each consumer has different priorities, so as 

you talk about provider network types, discuss 

whether they would be willing to pay more 

to have a larger pool of providers. Some 

plans keep premiums low by contracting 

with a smaller, “tighter” network of providers. 

Emphasize the key differences between 

networks, like: 

• Costs of care inside and outside the 

network

• Size of the network

• Specialists in the network

Use HealthCare.gov’s “window shopping” 

feature and the Summary of Benefits and 

Coverage to show differences between 

provider networks. Point out how plans vary 

in provider networks and how services are 

covered by out-of-network/non-participating 

providers versus in-network/participating 

providers. As you compare Marketplace plans 

on HealthCare.gov, consumers can look at 

each plan’s provider directory and search for 

a specific provider or hospital they want to 

continue using. You may want to emphasize 

that for HMOs and EPOs, the plan may not 

pay anything for out of network services, 

but with PPOs and POS networks the plan 

will generally provide some coverage.

Refer to the definitions below and talk about 

each type of network. Have consumers look 

at a specific plan’s Summary of Benefits and 

Coverage to understand how that plan covers 

in-network versus out-of-network services. 

There are links at the end of this section on 

page 28 to a sample Summary of Benefits 

and Coverage and other resources to help 

you talk with consumers about provider 

network types. 

PLAN B

PLAN A

22
HMO

EPO

POS

PPO

Types of Provider

Networks

23

An HMO, or Health 

Maintenance Organization, is 

a type of health insurance plan that 

usually limits coverage to care from 

doctors who work for or contract 

with the HMO. It generally won't 

cover out-of-network care except in 

an emergency.

A POS, or Point of Service 

Plan, is a type of plan in which 

you pay less if you use doctors, 

hospitals, and other health care 

providers that belong to the plan’s 

network. POS plans also require 

you to get a referral from your 

primary care doctor in order to see 

a specialist.

A PPO, or Preferred 

Provider Organization, 

is a type of health plan that 

contracts with medical 

providers, such as hospitals 

and doctors, to create a 

network of participating 

providers. You pay less if you 

use providers that belong 

to the plan’s network. You 

can use doctors, hospitals, 

and providers outside of the 

network for an additional cost.

An EPO, or Exclusive 

Provider Organization, 

is a managed care plan 

where services are covered 

only if you go to doctors, 

specialists, or hospitals in the 

plan’s network except in an 

emergency.
3. Check For Your Providers Before Enrolling. 

Ask if the consumer has a provider they would 

like to continue seeing. If a consumer wants to 

keep his or her provider, show how to check to 

see if the provider is “in-network” for the plan 

under consideration. You can use the provider 

directories linked on HealthCare.gov, or show 

consumers how to look up their provider by name 

on a particular plan’s website. However, since 

providers can change the plans they contract 

with at any time, encourage consumers to call 

their provider's office directly to confirm their 

participation in a plan’s network before enrolling 

and, if possible, before seeking care. 

If the provider they’re looking for isn’t in one 

plan’s network, a consumer may want to select 

a different plan to continue seeing the same 

provider. They can also look at the providers who 

are “in-network” and see if there are other options 

that meet their needs. 

ENCOURAGE CONSUMERS TO 

CALL THEIR PROVIDER'S OFFICE 

TO CONFIRM THEIR PLAN 

PARTICIPATION. 

Consumers may not be familiar with mental 

health parity, or they may want to know 

if mental health services are covered in a 

particular plan. Explain that there's a law that 

generally prevents health plans from limiting 

access to mental health and substance use 

disorder services any more than they restrict 

access to medical and surgical services. 

If consumers want to locate a treatment 

provider, suggest they use the provider 

locator on MentalHealth.gov. As with their 

primary care provider, remind consumers to 

check whether the provider they're thinking 

about is in their network before they get care.

24
4. Know What Prescription Drugs Are Covered And What They’ll Cost.

CHECK A PLAN'S FORMULARY FOR 

EXPENSIVE PRESCRIPTION DRUGS. 

A plan’s formulary is a list of prescription 

drugs that are covered by a plan. Ask 

consumers if they’re currently taking any 

prescription drugs. Consumers, especially those 

with a chronic condition, need to understand 

how much they’ll pay. Help consumers see how 

much their drugs will cost by showing them how 

to find and read a plan’s formulary. Consumers 

with Medicaid and CHIP generally have to pay 

some money for prescription drugs, but it’s not a 

lot. Marketplace plans’ formularies are posted on 

HealthCare.gov and consumers can see lists of 

covered drugs as they compare plans. 

Some drugs cost more than others. Formularies 

are usually divided into categories, or tiers. They 

tell you how much drugs in each category cost 

for the health plan and for the consumer. The tiers 

are usually called: 

• Generics (often the lowest

cost for consumers) 

• Preferred brands 

• Non-preferred brands 

• Specialty drugs (often the

highest cost) 

If a consumer takes an expensive 

prescription drug or fills several 

prescriptions, they should check the 

plan’s formulary for these particular 

prescription drugs to see if they’re 

covered. Some people may want to 

choose a Gold or Platinum plan because 

although the monthly premium may 

cost more, if their prescription drugs or 

treatments are covered their care would 

cost less over the year. 

For example, if a consumer is prescribed 

a drug to manage their cholesterol, the 

cost would depend on: 1) how the plan 

classifies that drug in its formulary, and 

2) what level of coverage the plan provides 

for each type of drug. Also explain to 

the consumer that they can talk to their 

provider about switching from a particular 

brand to the generic brand for the same 

drug, which may cost less. Use the table 

below as an example of how a plan might 

cover different prescription drugs in its 

formulary. 

SAMPLE CONSUMER COST TABLE

Bronze vs. Gold Plan for 30 day supply of a prescription drug

BRONZE GOLD

Generic

Drugs $20 copay $10 copay

Preferred Brand 

Drugs $45 copay $35 copay

Non-Oreffered 

Brand or 

Generic Drugs

$75 copay $70 copay

Specialty

Drugs

40%

coinsurance

30%

coinsurance

25
Some drugs have special rules. Most health 

plan formularies have rules, or restrictions, on 

certain prescription drugs. These rules can 

include: 

• Requiring prior authorization

• Limiting the amount of a drug a person

can get over a certain period of time

• Requiring a consumer to use a cheaper

drug that has been proven effective

before covering the more expensive

drug if the first option doesn’t work

(also known as “step therapy”)

Talk to consumers about any restrictions 

in the formularies for the plans they’re 

considering since this could impact their care. 

Reassure consumers that they can work with 

their provider and their plan to get the care 

they need. 

Re-enrolling? Remind consumers that 

health plans update their formularies 

regularly and can change which drugs 

are covered, add new generic drugs, or 

change their costs. If there are changes 

that could affect their care, consumers 

may want to consider switching plans 

or talking with their provider about 

changing to another covered prescription 

drug instead.

26

Prescription drugs still too expensive?

Even with coverage, consumers may still be 

concerned about the cost of their prescription 

drugs. National and local patient assistance 

groups such as the Partnership for Prescription 

Assistance may be able to help qualifying 

patients get their prescription drugs for very low 

or no cost. 

Go to sites like this one for help: 

https://www.pparx.org/
5. Not All Plans Cover Dental And Vision Care.

Individuals and families who are new to 

coverage may assume that enrolling in a 

Marketplace plan will give them coverage 

for dental or vision care automatically. Ask 

consumers if they want dental or vision 

coverage. All Marketplace plans are 

required to cover pediatric dental care 

for consumers who are 18 and under, and 

pediatric vision care. This is not true for 

adults. Insurers do not have to offer adult 

dental coverage. If adult dental or vision 

coverage is important to them, check the 

Summary of Benefits and Coverage for a 

particular plan to see if it’s included. If it is, 

let consumers know they’ll pay one monthly 

premium for everything – the premium 

shown for the plan on HealthCare.gov

includes both health and dental coverage. 

If the plan they’re considering doesn’t 

cover adult dental or if they want different 

dental coverage, consumers can compare 

the stand-alone dental plans that may be 

available using the “window shopping” 

feature of HealthCare.gov. If they choose 

a separate dental plan, consumers will pay 

a separate, additional premium. If dental 

plans aren’t available, or if consumers would 

like to enroll in other coverage like a standalone vision plan that is not offered in the 

Marketplace, talk about how to find a standalone plan in your state, including contacting 

your state’s Department of Insurance or a 

local agent or broker. 

27

INSURERS ARE NOT REQUIRED TO OFFER 

ADULTS DENTAL AND VISION BENEFITS. BE 

SURE TO SHOP AROUND IF YOU WANT THIS 

TYPE OF COVERAGE.
RESOURCES

Get ready to apply for or renew your 

Health Insurance Marketplace coverage 

(Consumer)

https://marketplace.cms.gov/outreach-andeducation/apply-for-or-renew-coverage.pdf

Explaining a Summary of Benefits and 

Coverage (Partner) 

https://marketplace.cms.gov/technicalassistance-resources/summary-of-benefitsfast-facts.pdf

FAQs on coverage for young invincibles 

(Consumer)

https://www.healthcare.gov/young-adults 

Marketplace coverage and metal levels 

(Consumer)

https://www.healthcare.gov/choose-a-plan/

plans-categories/

How to find information on health care 

providers (Consumer)

https://www.healthcare.gov/choose-a-plan/

find-provider-information/

Health insurance coverage of mental 

health and substance use disorder 

services (Partner/Consumer)

https://www.mentalhealth.gov/get-help/healthinsurance

28
4

WHAT CONSUMERS 

SHOULD DO AFTER THEY 

GET COVERAGE 

After enrolling, many consumers may 

be unsure what they should do next. Let 

consumers know that getting coverage 

is the first step in their journey to better 

health. Use the From Coverage to Care 

Roadmap and the messages in this 

section to help consumers understand 

how to use their coverage to live a long 

and healthy life. 

ARE THERE QUESTIONS ABOUT ...

COMPLETING

ENROLLMENT?

29

GO TO

30

HOW TO 

KNOW WHAT’S 

COVERED?

GO TO

31

PICKING OR 

CHANGING 

PROVIDERS?

GO TO

31

ONGOING 

TREATMENT OR

PRESCRIPTION 

DRUGS?

GO TO

32
1. Confirm You’re Covered.

After consumers complete the enrollment process, they should receive information from 

their plan about benefits and paying their premiums. Let consumers know there are ways to 

confirm they’re covered if they don’t hear from their plan or they aren’t sure they’ve finished 

the enrollment process. They can: 

• Log in to their account on HealthCare.gov and click on their application. Consumers

will see a summary on the “My Applications & Coverage” page where they can find

more details about their enrollment and plan benefits.

• Call the Customer Service Center of their new plan, using the listing and

instructions on HealthCare.gov. Consumers can confirm whether they’re enrolled and

whether they’ve paid their first month’s premium. Go to: https://www.healthcare.gov/

apply-and-enroll/complete-your-enrollment/.

• If they are still having trouble, call the Marketplace Call Center at 1-800-318-2596

(TTY: 1-855-889-4325).

2. Pay Your Monthly Premium To Keep Your Coverage.

Consumers who are new to health 

coverage may not realize they have to 

pay their premiums every month. Tell 

them they need to do this even if they 

don’t use any services in the month. Let 

people know that once they are enrolled, 

they must pay their first premium directly 

to the insurance company – not to the 

Marketplace. They should follow any 

instructions from their insurer about 

how and when to make their premium 

payment. Consumers who don’t 

pay their premiums risk losing their 

coverage and having to pay for 100 

percent of the cost of their health 

care. It may also mean they have to pay 

the fee for not having coverage. Remind 

consumers that staying covered is as 

important as getting covered. 

2000345 Pay Your 

Premiums!

30
 

3. Review Plan Materials And Learn About Your Benefits. 

YOU'RE COVERED. NOW GET THE CARE YOU NEED. 

Suggest to consumers that they review their 

plan materials and coverage documents and 

store them in a safe place right after they enroll. 

They’ll get the most out of their coverage if they 

know what’s covered and what their costs will 

be. If they have questions, encourage them to 

call their health plan (or state Medicaid or CHIP 

office, if they are eligible for those programs) 

for answers. 

4. Talk With A Provider About How To Improve Your Health 

And Well-Being. 

Health Insurance Files 

31

While the consumer was enrolling in coverage, 

you probably talked about whether he or she 

already has a provider. If they don’t, explain that 

having a regular provider is an important first 

step to getting the primary care and preventive 

services they need. Some consumers may have 

been assigned to a provider by their plan. If they 

want to change, show them how to contact their 

plan to do so.

You’ve picked a provider, now schedule an 

appointment. As soon as coverage begins, 

consumers can see a provider to learn about 

their health needs, and start working with them 

toward better health. 

The Roadmap, Steps 4, 5, and 6 help you talk 

with consumers about finding a provider, and 

how to schedule and prepare for their first 

appointment. 

The Roadmap, Step 7 helps you guide the 

consumer to find the provider that’s right for 

them. 

Know where to go for care. Consumers 

who are new to coverage may have used the 

emergency department for care in the past. 

Remind them that they should only use the 

emergency department when they have a lifethreatening illness or injury. Encourage them 

to use their primary care provider for other 

situations. 

The Roadmap, Step 3 helps you talk about 

where to go for care and the differences 

between primary care and the emergency 

department. 
 5. Keep Getting The Prescription Drugs And Treatment You Need. 

You probably talked about consumers’ ongoing treatment or prescription drugs earlier in the 

enrollment process. Remind individuals that they’ll need to take action to keep getting care while 

their coverage changes. If a consumer needs ongoing treatment for a chronic condition or needs to 

fill a prescription regularly, urge them to talk with their provider immediately to see what needs to be 

done under their new plan. Let the consumer know that if their new plan has restrictions on certain 

prescription drugs or services, sometimes these can be waived if their provider and plan work 

together. If their treatment is denied they always have the right to appeal that decision. Talk about 

where to look for their plan’s appeals process, and remind them that their provider can help them 

appeal a decision. There are links to more information about the appeals process at the end of this 

section on page 33.

6. Keep Your Information Current On HealthCare.gov.

32

The information consumers enter into their 

Marketplace application on HealthCare.gov

(for example, family size and household 

income level) is used to calculate their 

premium tax credit. Remind consumers 

about the importance of keeping 

their information current so they 

receive the right amount of financial 

assistance and don’t end up owing 

money when they file their taxes. 

Encourage them to update their 

information on HealthCare.gov when 

there is a change within 30 days of 

the change. In addition to keeping 

their records accurate, consumers 

may become eligible for a Special 

Enrollment Period if they have a 

major life event like a birth, adoption, 

marriage, or job loss, and they may 

want to choose a new plan that meets 

their changing health care needs.
RESOURCES

Confirming enrollment in coverage 

(Partner/Consumer)

https://www.healthcare.gov/apply-andenroll/complete-your-enrollment/

Contact the Marketplace 

(Partner/Consumer)

https://www.healthcare.gov/contact-us/

From Coverage to Care resources 

(Partner/Consumer) 

go.cms.gov/c2c 

Helping a consumer with appealing a 

plan’s decision not to cover 

(Partner)

http://marketplace.cms.gov/technicalassistance-resources/internal-claims-and

appeals.pdf

Options for coverage outside of Open 

Enrollment (Partner/Consumer)

https://www.healthcare.gov/coverageoutside-open-enrollment/your-options/

Qualifying for a Special Enrollment 

Period (Consumer)

https://www.healthcare.gov/coverageoutside-open-enrollment/specialenrollment-period/

33
 

5

WHAT CONSUMERS WITH 

SPECIAL CIRCUMSTANCES 

SHOULD KNOW ABOUT 

THEIR COVERAGE OPTIONS

Some consumers have special 

circumstances that affect their coverage 

options and enrollment. Three of these 

groups are discussed in this section, and 

there are resources on page 40 to help 

you work with these and other special 

populations. You may want to partner 

with others in your community to share 

resources, best-practices and tips to 

meet your consumers’ needs.

ARE THERE QUESTIONS ABOUT ...

AMERICAN 

INDIANS &

ALASKA NATIVES?

GO TO

35

34

LIMITED ENGLISH 

PROFICIENCY?

GO TO

37

IMMIGRANTS? GO TO

38
1. American Indians And Alaska Natives (Ai/An) 

May Have New Coverage Benefits And Protections. 

Some benefits are available to members of federally recognized tribes or Alaska Native Claims 

Settlement Act (ANCSA) Corporation shareholders. Others are available to people of Indian descent 

or who are otherwise eligible for services from the Indian Health Service, a tribal program, or an 

urban Indian health program. 

Based on their eligibility, talk to American Indian and Alaska Native consumers about limited and 

zero cost-sharing plans and Medicaid. Help them compare plans by window shopping at “See Plans 

& Prices” on HealthCare.gov to find one that works for them. Remind consumers they will have to 

pay their premiums if they enroll in a Marketplace plan. You should also help them check to see if 

they're eligible for premium tax credits (discussed in Section 2).

Financial Assistance for American Indians and Alaska Natives

35

Members of federally recognized Indian tribes and ANCSA Corporation shareholders (regional or 

village) may qualify for zero or limited cost-sharing plans or cost-sharing reductions based on their 

income. Let consumers know that they can enroll in a Marketplace plan any time during the year, not 

just during the yearly Open Enrollment period. 

• Household income in 2018 is below $75,300 for a family of 4 ($94,140 in Alaska): can enroll in 

a zero cost-sharing plan. Let them know they have no out-of-pocket costs like copayments, 

deductibles, or coinsurance. 

• Household income in 2018 is above $75,300 for a family of 4 ($94,140 in Alaska): Can enroll in a 

limited cost-sharing plan. Let people know they won’t have to pay out-of-pocket costs when 

they get services from an Indian health care provider – or from another provider, if they have a 

referral from an Indian health care provider. 

American Indians or Alaska Natives, and others eligible for services from the Indian Health Service, 

tribal program, or urban Indian Health program have additional opportunities for coverage: 

• May qualify for Medicaid or CHIP: Let consumers know they have special cost and eligibility 

rules for Medicaid and CHIP that make it easier to qualify for these programs. 

• Don’t pay out-of-pocket costs for Indian health programs: regardless of their income, consumers 

won’t have any out of pocket costs for items or services provided by the Indian Health Service, 

tribal programs, or urban Indian programs, including Contract Health Services. 

• Don’t pay the penalty: Consumers who do not enroll in coverage won’t have to pay the fee that 

most other people without health insurance must pay, but do have to apply for an exemption. 

For more information about coverage for American Indian and Alaska Natives, go to: 

https://www.healthcare.gov/american-indians-alaska-natives/
Where do you go for care? Consumers 

who’ve been using tribal health care 

services may not know which other 

providers will take their new coverage. 

American Indian and Alaska Natives can 

use an Indian health care provider as a 

primary care provider or choose to use 

a provider in their new plan’s network. 

If they get health care from an Indian 

health provider already, let them know 

that they can continue to see that Indian 

health provider and many others after 

they enroll in Marketplace coverage. 

They may also qualify for coverage with 

low or zero cost-sharing. If they don’t 

have a provider, show them how to find 

one using the plan’s provider directory 

posted on HealthCare.gov or the health 

plan’s website, if they have one. Let 

consumers know that getting covered 

will give them more options when they 

need health care. 

Enroll in coverage or apply for an 

exemption. Many American Indians and 

Alaska Natives get health care at various 

types of Indian health care providers, 

including Indian Health Services, tribal 

programs, and urban Indian programs 

(called ITUs). Although they have access 

to health care services, explain that this 

health care is not considered insurance 

for purposes of the individual shared 

responsibility requirement. Let them 

know that they still need to enroll in 

minimum essential coverage or apply 

for an exemption to avoid having to pay 

the individual shared responsibility fee. 

You can use the Tribal version of the 

Roadmap and resources at the end 

of this section on page 40 to help you 

work with tribal populations. You’ll find 

more information about help with costs, 

how American Indian and Alaska Native 

consumers can get an exemption, what 

documents are required, and how to 

access care. 

HEALTH CARE SERVICES YOU GET AT 

IHS, URBAN INDIAN PROGRAMS, OR 

TRIBAL PROGRAMS DON'T COUNT 

AS MINIMUM ESSENTIAL COVERAGE.

36
 

2. Help Is Available If You Speak A Language Other Than English.

If you’re helping someone who speaks a language other than English, there are resources in the 

box below for help that may be available in his or her preferred language. Some of these resources 

include interpreters, call center support, and print and web resources like a Uniform Glossary and 

Marketplace application guides. You can also use the “local help” feature on HealthCare.gov to 

find in-person support in your community. 

Get In-Language Assistance

You can use these resources together, or consumers can access these services on 

their own. 

The Marketplace Call Center has representatives available in English and Spanishspeaking representatives, and interpretation and translation services in 150 languages. 

These services are free. 

For help in a language other than English, call 1-800-318-2596.

Some In-person “assisters,” like navigators, Certified Application Counselors, and 

others partner offer services in languages other than English. Consumers can get a list 

of local organizations with contact information, office hours, and types of help offered 

including non-English language support. Visit https://localhelp.healthcare.gov/ and 

type in a city and state or ZIP Code.

Online resources are available in many languages, with more being developed. You 

can find Marketplace application guides in 27 languages. For more information visit: 

https://www.healthcare.gov/language-resource/.

En Español: https://www.cuidadodesalud.gov/es/

membantu ayuda pomoc saadni

aide aiuto

giúp đỡ 

Yardım

hjelp

Hilfe Help

37
3. Many Immigrants Can Enroll In Marketplace 

Plans, Medicaid, Or CHIP, And May Be Eligible For Financial Assistance.

Non-U.S. citizens or members of their family 

may have questions about whether they can 

enroll in coverage and get help with costs. 

They may also wonder what documentation 

they need. 

People with the following immigration 

status qualify for Marketplace coverage:

• Lawful Permanent Resident (LPR or 

Green Card Holder)

• Asylees

• Refugees

• Cuban and Haitian entrants

• Paroled to the U.S. for at least 1 year

• Conditional entrant granted before 1980

• Battered non-citizens, spouses, children 

or parents

• Victims of trafficking or and their 

spouses, children, siblings or parents

• Granted withholding of deportation

• American Indian born in Canada 

• Humanitarian statuses or 

circumstances (including Temporary 

Protected Status, Special Juvenile 

Status, asylum applicants, Convention 

Against Torture, victims of trafficking)

• Valid non-immigrant visas

• Legal status conferred by other laws 

(temporary resident status, LIFE Act, 

Family Unity individuals)

See a full list of eligible immigration statuses 

eligible to use the Marketplace here: 

https://www.healthcare.gov/immigrants/

immigration-status/

In general, Medicaid and CHIP require 

lawfully present immigrants to become 

lawful permanent residents, and to wait five 

years before they can enroll in coverage. 

During this five-year waiting period eligible 

individuals may be able to get coverage to 

treat an emergency medical condition. Lawful 

permanent residents who haven’t completed 

the five-year waiting period can enroll in 

a Marketplace plan and may be eligible 

for premium tax credits and cost-sharing 

reductions during that time. Some states don’t 

have the five-year waiting period for children 

and pregnant women. Use the resource below 

to see if your state is one of them.

DO THEY HAVE TO WAIT 5 YEARS? 

Check whether your state allows children and/

or pregnant women to enroll in Medicaid and 

CHIP with no five-year waiting period. Go to:

https://www.insurekidsnow.gov/coverage/

index.html

38
FOR A COMPLETE LIST OF DOCUMENTATION IMMIGRANTS

 CAN USE WHEN ENROLLING IN COVERAGE:

https://www.healthcare.gov/help/immigration-document-types/

Immigrants who aren’t lawfully present aren’t 

eligible to enroll for coverage through the 

Marketplace, get premium tax credits or costsharing reductions, or enroll in non-emergency 

Medicaid or CHIP. They can file a Marketplace 

application for their lawfully present children or 

family members. Family members who aren’t 

applying for coverage for themselves will not 

have to give information about their immigration 

status, so they can help anyone in their family 

apply. 

You may need documentation when you apply 

and enroll. The documents individuals need to 

enroll in Marketplace coverage will depend on 

their immigration status. Here are some of the 

documents immigrants may need: 

• Permanent Resident Card, “Green Card” 

(I-551)

• Reentry Permit (I-327)

• Refugee Travel Document (I-571)

• Employment Authorization Card (I-766)

• Machine Readable Immigrant Visa (with 

temporary I-551 language)

• Temporary I-551 Stamp (on passport or 

I-94/I-94A)

• Arrival/Departure Record (I-94/I-94A)

• Arrival/Departure Record in foreign 

passport (I-94)

• Foreign Passport

• Certificate of Eligibility for Nonimmigrant 

Student Status (I-20)

• Certificate of Eligibility for Exchange 

Visitor Status (DS2019)

• Notice of Action (I-797)

• Document indicating membership in 

a federally recognized Indian tribe or 

American Indian born in Canada

• Certification from U.S. Department 

of Health and Human Services (HHS) 

Office of Refugee Resettlement 

(ORR)

• Office of Refugee Resettlement 

(ORR) eligibility letter (if under 18)

• Document indicating withholding of 

removal

• Administrative order staying removal 

issued by the Department of 

Homeland Security (DHS)

• Alien number (also called alien 

registration number or USCIS 

number) or 1-94 number

39
RESOURCES

AMERICAN INDIANS AND ALASKA NATIVES

From Coverage to Care Roadmap – Tribal Version (Partner/Consumer)

go.cms.gov/c2c

Tip sheet for Assisters working with AI/ANs (Partner) 

https://marketplace.cms.gov/technical-assistance-resources/working-with-aian.pdf

Details on special Marketplace protections and benefits for AI/ANs 

(Consumer) 

https://www.healthcare.gov/tribal

How to apply for an exemption (Consumer) 

https://www.healthcare.gov/health-coverage-exemptions/forms-how-to-apply/ 

Information for tribal leaders and tribal health programs, National Indian 

Health Outreach and Education (NIHOE) (Partner/Consumer)

http://tribalhealthcare.org/

LIMITED ENGLISH PROFICIENCY

Glossary of health care terms for consumers with limited English 

proficiency (Partner/Consumer)

https://marketplace.cms.gov/technical-assistance-resources/plan-compare-and-planselection-help.html

Translated resources from Marketplace (Partner) 

https://marketplace.cms.gov/outreach-and-education/other-languages.html 

Videos in English and other languages for outreach and enrollment to 

diverse populations (Partner/Consumer) 

https://www.youtube.com/playlist?list=PLBXgZMI_zqfRXt44Uk6YeMW0Npmbemc2h

Uniform Glossaries in other languages (Partner/Consumer)

https://marketplace.cms.gov/outreach-and-education/tools-and-toolkits.html

40
Marketplace Call Center instructions in other languages (Consumer)

https://marketplace.cms.gov/outreach-and-education/getting-help-in-a-language-otherthan-english.pdf. 

Find local enrollment help in other languages (Consumer)

https://localhelp.healthcare.gov/

HealthCare.gov resources in other languages (Consumer) 

https://www.healthcare.gov/language-resource/

Spanish version of HealthCare.gov (Consumer)

https://www.cuidadodesalud.gov/es/

Help filing a complaint in other languages (Consumer)

http://www.hhs.gov/ocr/office/file/languageaccess.html

IMMIGRANTS

Overview of immigrant eligibility for affordable health coverage (Partner)

https://marketplace.cms.gov/technical-assistance-resources/immigrants-refugees-needto-know.pdf

Information on immigration status and the Marketplace (Consumer)

https://www.healthcare.gov/immigrants/immigration-status

41
OTHER VULNERABLE POPULATIONS 

Helping special populations enroll (Partner)

https://marketplace.cms.gov/outreach-and-education/special-populations.html

Understanding health coverage needs of people with disabilities (Partner)

http://www.nationaldisabilitynavigator.org/wp-content/uploads/presentations/

NDNRC_CMS_Nov-21-14.pdf

Coverage options for people with disabilities (Consumer)

https://www.healthcare.gov/people-with-disabilities/ 

Overview of assisting people with disabilities in the Marketplace (Partner)

https://marketplace.cms.gov/technical-assistance-resources/assisting-people-withdisabilities.pdf

Tools for working with consumers with HIV/AIDS (Partner/Consumer)

https://careacttarget.org/category/audience/consumers-and-community 

Enrollment assistance for lesbian, gay, bisexual, and 

transgender communities (Partner)

https://store.samhsa.gov/product/PEP14-LGBTACAENROLL 

Health care toolkit for faith and community-based organizations (Partner)

https://www.hhs.gov/about/agencies/iea/partnerships/community-resources/index.html

RESOURCES (Continued)

42
NOTES 

43
NOTES 

44
45
go.cms.gov/c2c

CMS Product No. 11909

Revised October 2018