Application Forms

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.

Exemption Type
Additional Information
Eligibility
Application Download
Religious ConscienceIf 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 ministryUse 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 »
IncarcerationUse 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 NativesIf 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:

  1. A member of an Indian tribe.

  2. Another individual who’s eligible for health services through the Indian Health Service, tribes and tribal organizations, or urban Indian organizations.
Download »
HardshipUse this application if you and/or anyone in your tax household is:
  1. Homeless.

  2. Evicted in the past 6 months or were facing eviction or foreclosure.

  3. Received a shut-off notice from a utility company.

  4. Recently experienced domestic violence.

  5. Recently experienced the death of a close family member.

  6. Experienced a fire, flood, or other natural or human-caused disaster that caused substantial damage to your property.

  7. Filed for bankruptcy in the last 6 months.

  8. Had medical expenses you couldn’t pay in the last 24 months.

  9. Experienced unexpected increases in necessary expenses due to caring for an ill, disabled, or aging family member.

  10. Expect to claim a child as a tax dependent who’s been denied coverage in Medicaid and MCHP, and another person is required by court order to give medical support to the child. In this case, you do not have the pay the penalty for the child.

  11. As a result of an eligibility appeals decision, you’re eligible for 1) enrollment in a qualified health plan (QHP), 2) lower costs on your monthly premiums, or 3) cost-sharing reductions for a time period when you weren’t enrolled in a QHP.

  12. Your individual insurance plan was cancelled and you believe other marketplace plans are unaffordable.

  13. You experienced another hardship in obtaining health insurance.
Download »
AffordabilityUse 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:

  1. Lacks of affordable coverage based on projected income.

    1. If a consumer is eligible for health coverage offered by his/her employer, a job-based health plan is considered “affordable” if the employee’s share of premiums for the lowest cost self-only coverage that meets the minimum value standard is less than 9.5% of their family’s income.

  2. Required to file an income tax return for the calendar year because his/her gross income was below the filing threshold but who: 1) filed, 2) claimed a dependent with a filing requirement, and as a result, 3) had household income exceeding the applicable tax return filing threshold described in section 5000A(e)(2) of the Internal Revenue Code.

  3. Ineligible for Medicaid based on a state's decision not to expand.
Download »