Revised for plan year 2024. Updated 4/29/2024

The Centers for Medicare & Medicaid Services (CMS) requires health insurance agents, brokers, and web-brokers to document and ensure that the consumer or their authorized representative has reviewed and verified the accuracy of eligibility application information prior to submission.

You understand that:

Renewal of Coverage

1. You have the option to authorize the Marketplace to use updated income data, including details from tax returns, for a period of up to five (5) years. This makes it easier to determine your eligibility for future coverage assistance. You can choose to opt out at any time.

Premium Tax Credit

2. Your monthly insurance premium of your Marketplace plan can be lowered through the use of premium tax credits. Your estimated income and household information listed on your Marketplace application will determine your tax credit.
3. You have the option to use all, a portion, or none of your tax credit in advance to lower your monthly insurance premium.

Tax Attestations

4. Having other qualifying health coverage (including Medicaid, Children’s Health Insurance Program (CHIP), or an insurance plan from your employer) may disqualify you from receiving a premium tax credit.
5. It is your responsibility to inform the Marketplace about your eligibility for other qualifying health coverage to avoid premium tax credit repayment issues.
6. You acknowledge that the premium tax credit will be applied to reduce the cost of your health insurance premiums for you and/or your dependents.
7. Filing a federal income tax return for 2024, including a joint tax return if married, is required.
8. You cannot be claimed as a dependent on anyone else’s 2024 federal income tax return other than your own.
9. You can claim a personal exemption deduction for each dependent enrolled in Marketplace coverage who has their premium partially or fully paid by advance payments of the tax credit.
10. You understand that any changes to the information provided may affect your eligibility for the premium tax credit, as well as the eligibility for your household member(s).
11. The IRS will cross-reference the income reported on your 2024 federal income tax return with the information provided on your application.
12.  You will receive Form 1095-A, Health Insurance Marketplace Statement, in the mail no later than mid-February of the following year. This Form 1095-A will come from the Marketplace and contains Marketplace plan information relating to you and/or anyone in your household who had coverage in
    2024. You will need to bring this form with you and give it to your tax preparer when you file your 2024 federal income taxes.
13. In order to “reconcile” your advanced premium tax credit usage and the tax credit amount you actually qualify for based on your final yearly income, you will need to use the information from Form 1095-A to file Form 8962, Premium Tax Credit, with your 2024 federal income taxes.
14. Discrepancies between your advance premium tax credit usage and your final yearly income may result in the potential need to repay the difference or receive a refundable credit when you file your 2024 federal income taxes, depending on if you used more or less premium tax credits than you qualified for, respectfully.

Additional Attestations

   15. The Marketplace will automatically end your Marketplace coverage if you or anyone listed on your application is later found to have other qualifying                      health coverage (like Medicare, Medicaid, or CHIP).

   16.  If the information you provided on the application changes, you must notify the Marketplace within 30 days to update your application. You can contact              the agent below to report any changes. You can also visit HealthCare.gov or call 1-800-318-2596 to report any changes.

    17.  You confirm that the information you provided on your Marketplace application is true to the best of your knowledge.

By signing below, you acknowledge that:

• The information you provided for your application has been reviewed and confirmed to be accurate,
• You understand the information provided in the “Renewal of Coverage,” “Premium Tax Credit,” “Tax Attestations,” and “Additional Attestations” sections, and
• The agent explained the attestations at the end of the eligibility application.

By signing below, you authorize the agent to submit your reviewed and confirmed application to the Marketplace.

All of the agents listed below are licensed insurance agent/brokers authorized to sell life and health insurance in the state of Texas.

Use of Electronic Signatures: Each party agrees that this Review form and any associated documents may be electronically signed, and that any electronic signatures appearing on this Review form or associated documents are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.