Medical Insurance Application Forms
The following applications and appendices should be used to apply for health coverage and help paying costs through Maryland Health Connection when you are unable to access and fill out an online application. Please review to find the one that applies to you and your situation. Each application has an introductory page that provides helpful information to get started. Please also look at the appendices to see if any of them apply to you.
If you choose you can print the application, fill it out and send it to the address noted. Or you can save the file to your desktop and type your information into the fields using your computer. Once you have completed the form online, then print it off and mail it to the address noted.
Please call our free phone line at any time you need help in the process at 1-855-642-8572 or 1-855-642-8573 for assistance if you are hard of hearing or deaf.
Applications for Exemptions
Starting in 2014, most people will be required to have health insurance and if you choose not to have health coverage you will have to pay a fee when you file your taxes. Some people are “exempt” from the requirement to have coverage and do not have to pay a fee even if they remain uninsured. For example, you may be exempt if you cannot afford coverage, are facing a hardship, have a religious objection to buying insurance, are an American Indian or Alaska Native, or are incarcerated. Depending on the reason for requesting an exemption, you will need to apply for an exemption when you file your federal taxes or by submitting an application to the federal Department of Health and Human Services (HHS). The federal government will decide who is exempt from the coverage requirement. You can see if you may be eligible for an exemption and how and when to request the exemption using the applications provided here.
Certain groups do not need to file an exemption application and are still exempt from the coverage requirement: You do not need to file an exemption application if: 1) you have a gap in coverage of less than three months during the plan year; 2) you are not legally present in the US; and/or 3) your income is low enough that you do not have to file taxes, even if you file a return in order to get a refund of money withheld from your paycheck (but you can file the affordability exemption if you are unsure if you meet the filing threshold). If you file taxes, these coverage gaps can be noted on your plan year tax filing.
Eligibility for catastrophic coverage due to a hardship or affordability exemption: If you receive an exemption due to hardship or affordability, you may purchase catastrophic coverage through Maryland Health Connection regardless of your age. If you do not receive an exemption due to hardship or affordability, only individuals under 30 years old are permitted to enroll in catastrophic coverage.
|Religious Conscience||If you get this exemption, you can keep it for future years without submitting another application unless you turn 21 or leave your religious sect.||Use this application if you and/or anyone in your tax household is a member of an approved religious sect or division which is described in section 1402(g)(1) of the Internal Revenue Code, and an adherent of established tenets or teachings of such sect or division, including conscientious opposition to acceptance of the benefits of any private or public insurance which makes payments in the event of death, disability, old-age, or retirement or makes payments toward the cost of, or provides services for, medical care (including Medicare and Social Security.)||Download »|
|Membership in health care sharing ministry||Use this application only if you’re requesting an exemption for months of membership in a health care sharing ministry for 2014. If you want to request this exemption for 2014 after the end of 2014, you’ll need to claim it on your federal income tax return.||A health care sharing ministry is an organization whose members share a common set of ethical and religious beliefs and share medical expenses among themselves in accordance with these beliefs.||Download »|
|Incarceration||Use this application only if you’re requesting an exemption for months of incarceration in 2014. If you want to request this exemption for 2014 after the end of 2014, you’ll need to claim it on your federal income tax return.||Use this application if you and/or anyone in your tax household was incarcerated (detained or jailed), other than being held pending disposition of charges.||Download »|
|Tribal: American Indians or Alaska Natives||If you get this exemption, you can keep it for future years without submitting another application if your membership or eligibility for services from an Indian health care provider remains unchanged.||Use this application if you and/or anyone in your tax household is:||Download »|
|Hardship||Use this application if you and/or anyone in your tax household is:||Download »|
|Affordability||Use this application to ask for an exemption for months in the future. If you want this exemption for a whole calendar year, you need to request it before the year starts. You can also claim an exemption on your federal income tax return if you’re unable to afford coverage.||Use this application if you and/or anyone in your tax household is:||Download »|