Hello ApplicantFormController!

It will be helpful for you to have your Marketplace enrollment information or completed application handy before you begin. You’ll need information from one of these sources to complete the HealthConnect application.

Is HealthConnect currently paying your health insurance premium?

YesNo

Step 1. Information about you

Name

First

Middle initial

Last

Suffix

Date of birth

Home address

City

State

Zip

County

Mailing address same as home

Mailing address

City

State

Zip

How much money do you make a year (your annual household income)?

This should be the same number as found on line 7 of your IRS tax form 1040.

How many people are in your household?

You must write the same number that you wrote on your application for Health Insurance Marketplace coverage.

Does anyone covered by this policy use tobacco?

HealthConnect will not pay the tobacco surcharge (extra fee) if you or anyone in your household uses tobacco.

YesNo

Step 2. Your contact information

Step 3. Information about your health insurance

Step 4. Information about your health insurance premium subsidy

Has HealthConnect helped you pay for health insurance at any time?

YesNo

Look at your Health Insurance Marketplace application. Find the Premium Tax Credit section. How much of the health insurance tax credit are you eligible for?

Did you select the “Advance Payment” option for your Advance Premium Tax Credit?

You must select the “Advance Payment” option in the Health Insurance Marketplace to be eligible for financial help from HealthConnect.

YesNo

Look at your Health Insurance Marketplace application. How much is your monthly insurance premium?

What month did/will your insurance coverage begin?

Step 5. Read and sign application

You must check ALL of the boxes to submit your application.

All the information I wrote on this application is true. I give permission to United Way and my insurance company to talk about the information on my application to decide if I am eligible for HealthConnect.

I understand that I have to pay the monthly tobacco surcharge (extra fee) if I or a family member in my house smokes or uses tobacco.

I understand that if I am approved for financial help from HealthConnect, United Way will pay my health insurance premium (monthly payment) directly to my insurer starting the month I am approved and ending in December 2022, as long as I remain eligible. If I have already paid the premium for the month I am approved, HealthConnect assistance will begin the following month.

I understand that the HealthConnect program will not pay or reimburse me for any health insurance premium payments I made before my application was approved.

If I have two insurance plans at the same time, I understand HealthConnect will not pay any tax penalties that result.

I understand that HealthConnect pays for my 2022 health insurance premium only and that any medical expenses that are not covered by that insurance are my responsibility.

I understand that HealthConnect assistance may not be used to cover outstanding debts from prior coverage.

I give permission and consent to be contacted in the future by Great Rivers United Way as it relates to my experience with the HealthConnect program.

2022 HealthConnect form

Step 1. Information about you

Step 2. Your contact information

Step 3. Information about your health insurance

Step 4. Information about your health insurance premium subsidy

Step 5. Read and sign application