Ao rece vescrce Mere sepumuamrormaummonnunseevers 465 INDUS TROAL BOUL E WARD {emo TUE Se ONL Arme% POO) Tota cONasING «1 AT 406 NELOLAS PRANKS, B —— —_—:, plore tN tat toto typ to apg tf 13/2015, Application date: 12/4/2014 po) — Important: Respond within 60 days to keep your Marketplace health coverage: We received the application you submitted for health coverage through the Health Insurance: Marketplace. As 2 part af your application, you attested that the information you provided was accurate. We're following up because, as stated on your eligibility notice we previously sent 10 you, we Reed more information from you so you can keep your coverage through the Marketplace, The following individuals in your household need to vend the Marketplace proof that they are a U.S. citizen, U.S. national, or have an eligible immigration status. NIKOLAS FRANIS and PIERCE FRANKS, Submit the requested documents using the enclosed instructions and bar code page. Including the bar code page helps us process your paperwork faster so you can keep your coverage through the Marketplace. if you aren't lawfully present in the U.S., you can’t get coverage through the Marketplace and you don’t quality for help paying your health coverage costs. If you got an advance premium tax credit and used 10 to lower your monthly premise, but weren't qualified, you may have to pay back the advance Premium tax credit that the Marketplace paid to your health pian.What should | do next? 1. Look at the attached tat of documents and make 8 copy of any documents you have trom the ist. It's possibte that you may have to provide more than one document based on what documents you have. 2. Upload» copy of the documents to your My Account on HealthCare.gow. This is the fastest way to get your documents processed. If you can’t upload « document to HealthCare pov, you can mail the documents to the address below a5 proof that the inceviduals listed above are either US. citizens, U.S. nationals, or tawtully present in the U.S. Ht you mail documents, be sure to mail a COPY, and heep the originals for your records. Where to send your documents Send a copy of the documents to: Heath insurance Marketplace Attn: Supporting Documentation 465 Industrial Biv. London, KY 40750 ‘Sicerety, Heath insurance Marketplace Department of Health and Human Services 465 industrial Boulevard London, Kentucky 40750-0003 Privacy Otsctosure: The Hesith inustance Martetplace protects the prteacy and securky of the personally kbeetitiie \eformation (*00 that you hove growled (see hipa //wanw healthcare gow/prvacy/). Then notice wnt gerverated by the Marketplace Based on 45 CFR 155.230 and 63 CFM part 155, subpart D. The Ml uned to create tha notice was collected on ‘he aapication yau fied ovt and trom aches daca sources through the electronic eighty verfication process ised to get in eiagibeiny Soverrrémation for erwofirant mn » qualifies health plan through the Marbecpiace ped for briwrarwe affordatiity rogram. For more information about the eivecy ane Yecury of your PIL vat PhesthCare gow ‘The Marherptoce may have used data frov a coraumer reporting agency to help Oevermirw etigibtiny for the ietyicuats on your application If vou Rave questions shout this data, please comtact the Murtatglace at 1.800-318.2596 (ITY: 2455-4075), you have questions: Go to HeathCare gou/mnatatplace. Cr. call 1-BOD- 318-2508. FTV users wneud cal 1-855-409-4125. ‘The calls eee. You can aise fre out how to talk to someone it person, online oF through the help tineIMPORTANT! : Mail this page in the same envelope with your documents. This page helps the Marketplace match your documents to the correct application. = Remember to send the Marketplace the following: 1 A cag of cocaine peng aunty sane in eats sage Inigo sek Mf you hee questions. Goto HealthCare pre/rmarkenplace Or, call t 800-338 2596, TTY wer showhd cal 1-455-889-4375. The calls ree. You Cae sive find out how to tat to sowseone in person, onikew or through the help fine.DOCUMENTS NEEDED TO PROVE ELIGIBLE IMMIGRATION STATUS, CITILENSHIP OR STATUS AS A NATIONAL you want to heep your coverage through the Marketstace, you need to tend additional documents. You ‘need to vend us proof that you're either 2 citinen of national, oF that you are lawfully present in the U.S. Prease beep your original document and send ut copy. ‘Send us your most recent immigration document that shows your current imenigration status so that we can decide f you're still eligible in your state. You should have one cf the following documents: Permanent Raudient Card, “Gowen Cad” (551) Rewvtry Perase (1-327) Pechuge Trove! Coeumers (1-572) Levghoyment Aatrevitation Card (2 M66) Machane Reseabie bramigrant ¥i.a [with termporary 1581 Langeage) Temporary 551 Stamp [on pausport or 4/1 94A) Arrteat/Departare Record (} 54/44) ‘Arrveal/Departare Record. foreyy pauxpart (164) Foreagn Posse Certitcate of ERptety for Nonimmigrant Stuckest Status (20) Certificate of tgibitty for Exchange Wishor Status (052019) Notice of Action (+797) Document indicating membersip in a federsty recogrised Indian tribe or American inéian born in Canta Certification trom U.S. Oepartmert of Heath and Humsn Services [HHS] Otte of Rahagee Reuwrttiement (OR) Oftace of Rebugre Revemierrnnt (O#M) etsy better (if under 38) ‘Gerttication trom W'S. HHS ORR Document nccaning methncdding of removal Acearaatvg cer ving terme nud by Yh Ogeroment ef Homeland Seurty W yor have questions: Go to HealthCare gowlmarbetphace. Or. call 1-800-318-2596. TTY waers should cal 1-855-283-4525. The calls free. You can ato find ovt how 60 ck 8e someone in person. ordine oF Chron the help hrs.Abvecn freuronce Marespioce DEPARTMENT OF HEALTH AND HUMAN SERVICES 465 MORISTRIAL BOULEVARD LONDON, KENTUCKY 49730-0001 cald Yd — sage : ae Ya - NAB PLAC TOT COON FAT 48 —_, Med lhl tenet ia/2018 Application date: 12/4/2014 ———- —— Important. Respond within 60 days to keep your Marketplace health coverage We received the application you suberutted for heaith coverage through the Heath Insurance Marketpiace As a part of your application, you attested that the information you provided was accurate, We're following up Because, a stated on your eligibility notice we previously sent to you, we ‘need more information from you x0 you can keep your coverage through the Marketplace. The toiowing individuals in your household need to send the Marketplace proo! that they are a US. citizen, US. national, oF have an eligible iemigration status. OKOUAS FRANKS and PIERCE FRANKS ‘Submit the requested documents using the enclosed instructions and bar code page. Including the bar code page helps us process your paperwork faster so you can Keep your coverage through the Marketplace. I you aren't lawfully present im the U.S. you can't get coverage through the Marketplace and you don't quality for help paying your health coverage cents. I! you got an advance premium tax credit and wed it to lower your monthly premium, but weren't qualified, you may have to pay back the advance Prema tax credit that the Marketplace paid to your health plan.Al vecn ve rcrce Meetioce 465 Industrast Boulevard ‘Apr 02, 2015 ‘AMIOT-M POCO T-20@n geOLECR TAT 408 oalbant ten hetir tee anette lll Aepication Date Ageil 2, 2015 _—, important: fligibitity for or help paying for heath coverage is Changing tor you or someone in your household. (Dear Nicolas Franks © ‘You're petting this notice because the Marketplace auked you oF someone on your application for documents to verify your application information, but we either dkin’t receive documents of recetved documents that idn’t resolve the data matching issue. ‘This notice expitrins the changes that enpact your family and what to do next, Who is alfected? + Foorce Franks - We requested documentation provirg that you're eligible to enroll in a heath plan through vhe Mucket place, and sufficient documentation wasn't provided. You don’t qualify for 2 heakh Kien trough the earbetplace, 0 your coveraas end any tax credit oF cost-sharing reductions you may _ have been receiving wif nnd. You’ ‘the option to Continae your coverage outside of the 7 Warkerplace, but you woe't be able to receive a tax credit oF cost-sharing reductions, We encourage you to comtact your Issuer directly if you wish to continue coverage outside the Marketplace. - What should 1 do next? _—_® Rerce Franits » You don't qualty for a health plan through the Marketplace and are no torger enrolled nave qunstnons. Goto HealthCare gevimarketgtince. Or, caf 1-800-3ERI5%6, FIV users vhowké Call 1ASS-ARDAI2S. The call fethne, Ye cir abo fend cue herw 9 tale to samen in person, enifine or Shreaagh the hep ne marimguinectes tesim the Marketptace health plan. You have the option to continue your coverage outside of the Marketplace, but you won't be able to receive a tax cred or cost-sharing reductions. We encourage you to contact the health plan directly to continve coverage ovtside the Marketplace and to pay the few preeriaen, Everyone ete on the application who is eligible 10 be enroited in a health pian through the Marketplace is still enrolied in the same health plan * For anyone who qualifies tor a tax credit, the tax eredit amount has changed 10 $12.00 per month. If you are enotied in 2 heaith plan through the Marketplace. this change will be effective on the fest day Cf the mext month, Those who are stil eligible and wish to continue caverage should contact the pian to find out the new premium ammount. * Your premium senount may be different because the Marketplace has adjusted how much of the tax ‘credit Is applied to your monthly costs (the premium") to $156.0 per menth. Comact your plan to fine ‘cut your new premium amount. What should I do if thik avy eligibility results are wrong? ‘You wll receive a final eligibility determination notice containing information about how you may appeal If You think this decision is wrong. ‘Where can I find more information? Visit at HealthCare gov, or, call the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325). for more information about , contact the at To®-Free:1-888-318-8890 (TTY: 711), For more information about , contact ‘the at Toll-Free: ‘B18-8890 (TTY: 711), Health Insurance: Londen, Kentucky 40750-0001 ‘The determinations or astessments in this latter were made based upon 45 CFR 155.305, 155.315, 155.320, 195.410, 155.415, 155.420-480 and 42 CFR 435,603, 435.403, 435.406 and 435.911. The Marketplace may hove used data from a consumer reporting agency to help determine eligibility for the Wpnunave questions: Gono HeatnCare gow/marketptace. Ov, cil 1.800318. 2990. TTY user should S5ANF4I7S The call In free You can ase find ca how totale to sorerose 1 person. 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