2020 ACA Enrollment WO Cover (PDF)

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2020 INDIVIDUAL HEALTH COVERAGE ENROLLMENT FORM

OFFICE USE ONLY - DO NOT WRITE IN THIS BOX

Please complete all fields to avoid a delay in processing your application.
Primary Applicant:

SSN:

DOB:

Street Address:

Zip:

City:

County of Residence:

Contact Phone:

Email:

Employer:

W2 or 1099 (circle one)

Work Phone:

Employer Offer Group Health? Y / N (circle one)

Tobacco? Y / N (circle one)

Anticipated 2020 Income*:

Tell us about all the members of your household. If applying for coverage, SSN must be provided.
SSN:

Spouse:

DOB:

Employer Offer Group Health? Y/ N (circle one)

Tobacco? Y / N (circle one)

Dependent 1:
Sex: F / M (circle one)

Tobacco? Y / N (circle one)

Applying?: Y / N (circle one)
SSN:

DOB:
Tobacco? Y / N (circle one)

Anticipated 2020 Income:

Applying?: Y / N (circle one)
SSN:

DOB:
Tobacco? Y / N (circle one)

Anticipated 2020 Income:

Dependent 4:
Sex: F / M (circle one)

SSN:

Anticipated 2020 Income:

Dependent 3:
Sex: F / M (circle one)

Anticipated 2020 Income*:

DOB:

Dependent 2:
Sex: F / M (circle one)

Applying?: Y / N (circle one)

Applying?: Y / N (circle one)
SSN:

DOB:
Tobacco? Y / N (circle one)

Anticipated 2020 Income:

TOTAL 2020 TAX HOUSEHOLD SIZE:

Applying?: Y / N (circle one)

TOTAL 2020 HOUSEHOLD INCOME:

Who did you have coverage with in 2019 (circle one)

BCBS /Ambetter/ Cigna/ Did not Have

Preference of Carrier (We will still show you all options) (circle one)

BCBS / AMBetter / Cigna / Bright Health

ATTESTATION: I certify that the information provided above is accurate to the best of my knowledge. IF THE HEALTH INSURANCE IS
MARKETPLACE IS DETERMINED TO BE THE BEST OPTON FOR HEALTH COVERAGE: I further certify that my stated 2020 Income and Household
Size is MY ESTIMATE that is used to determine whether or not I qualify for financial assistance with the Health Insurance Marketplace.
ClearBenefits LLC is in no way liable for mistakes that are made with my Income and Household Size Estimate. I further understand
that I can (and should) report changes to my income or household during the year and that ClearBenefits LLC is in no way liable for
tax penalties or subsidy chargebacks that I may receive as the result of my participation in the Health Insurance Marketplace. I
hereby appoint ClearBenefits LLC as my legal representative for the sole purpose of creating my Marketplace Account and
submitting my Application with my electronic signature to the Health Insurance Marketplace on my behalf.
Primary Applicant Signature:

Date:

Email or Fax your completed form to:
ClearBenefits LLC
clearbenefits1@gmail.com
Phone: 919-493-4272
Fax: 919-493-4930
*Modified Adjusted Gross Income that you anticipate reporting on your 2020 Tax Return – See back…..

Modified Adjusted Gross Income under the Affordable Care Act
UC Berkeley Center for Labor Research and Education July 1, 2014
Under the Affordable Care Act, eligibility for income-based Medicaid1 and subsidized health insurance through the





















































































































































of MAGI under the Internal Revenue Code2 and federal Medicaid regulations3 is shown below. For most individuals who apply
for health coverage under the Affordable Care Act, MAGI is equal to Adjusted Gross Income. This document summarizes
relevant federal regulations; it is not personalized tax or legal advice. Consult the Health Insurance Marketplace for your
state, your local Medicaid agency, or a legal or tax advisor for assistance in determining your MAGI.

Modified Adjusted Gross Income (MAGI) =
Include:

Adjusted Gross
Income (AGI)
Line 4 on a Form
1040EZ

Line 37 on a Form
1040

Note: Check the IRS
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Deduct:
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Certain self-employed expenses5
Student loan interest deduction

Taxable amount of pension, annuity or IRA
distributions and Social Security benefits4
Business income, farm income, capital gain,
other gains (or loss)

§

Educator expenses

§

IRA deduction (traditional IRAs)

§

Moving expenses

§

Unemployment compensation

§

Penalty on early withdrawal of savings

§

Ordinary dividends

§

Health savings account deduction

§

Alimony received

§

Alimony paid

§

Rental real estate, royalties, partnerships, Scorporations, trusts, etc.

§

Domestic production activities deduction

§

§

Taxable refunds, credits, or offsets of state and
local income taxes

Certain business expenses of reservists,
performing artists, and fee-basis government
officials

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Other income

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Line 21 on a Form
1040A



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-tax contributions, such as those for child care, commuting, employer-sponsored health insurance,



flexible spending accounts and retirement plans such as 401(k) and403(b), are not included in AGI but are not listed above because they are already
subtracted out of W-2 wages and salaries.

Add back
certain
income

+

For Medicaid
eligibility

Exclude from
income

§

Non-taxable Social Security benefits4 (Line 20a minus 20b on a Form 1040)

§

Tax-exempt interest (Line on 8b on a Form 1040)

§

Foreign earned income & housing expenses for Americans living abroad (Form 2555)

§

Scholarships, awards, or fellowship grants used for education purposes and not for living
expenses

§

Certain American Indian and Alaska Native income derived from distributions, payments,
ownership interests, real property usage rights, and student financial assistance

§

An amount received as a lump sum is counted as income only in the month received

Endnotes
1. Medicaid eligibility is generally based on MAGI for parents and childless adults under age 65, children and pregnant women, but not for individuals eligible on
the basis of being aged, blind, or disabled.
2. 26 CFR 1.36B-1(e)(2)
3. 42 CFR 435.603(e)
4.
h should be excluded.
Deductible part of selfcoverage
in the individual Marketplace and claim the premium tax credit on your tax return, the amount of the premium reimbursed by the credit may not also be
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