Privacy Notice Statement

Certified Application Counselors and Registered Brokers are authorized to collect personal information and any supporting documentation, including social security numbers, under the Patient Protection and Affordable Care Act (Public Law No. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Public Law No. 111-152), and the Social Security Act.
The Certified Application Counselor or Registered Broker needs the information provided about you and the other individuals requesting coverage to help CMS determine eligibility for: (1) enrollment in a qualified health plan through the Federal Health Insurance Marketplace, (2) insurance affordability programs (such as Medicaid, CHIP, advanced payment of the premium tax credits, and cost sharing reductions), and (3) certifications of exemption from the individual responsibility requirement. As part of that process, CMS will verify the information provided to the Marketplace, communicate with you or your authorized representative, and eventually provide the information to the health plan you select so that they can enroll any eligible individuals in a qualified health plan or insurance affordability program. CMS will also use the information provided as part of the ongoing operation of the Marketplace, including activities such as verifying continued eligibility for all programs, processing appeals, reporting on and managing the insurance affordability programs for eligible individuals, performing oversight and quality control activities, combating fraud, and responding to any concerns about the security or confidentiality of the information.
While providing the requested information (including social security numbers) is voluntary, failing to provide it may delay or prevent your ability to obtain health coverage through the Marketplace, advanced payment of the premium tax credits, cost sharing reductions, or an exemption from the shared responsibility payment. If you don’t have an exemption from the shared responsibility payment and you don’t maintain qualifying health coverage for three months or longer during the year, you may be subject to a penalty. If you don’t provide correct information on this form or knowingly and willfully provide false or fraudulent information, you may be subject to a penalty and other law enforcement action.
In order to verify and process applications, determine eligibility, and operate the Marketplace, the Certified Application Counselor or Registered Broker will need to share selected information that that they receive, including to:
  1. Federal agencies, (such as the Centers for Medicare and Medicaid Services, Internal Revenue Service, Social Security Administration and Department of Homeland Security), state agencies (such as the Louisiana Department of Health and Hospitals) or local government agencies. CMS may use the information you provide in computer matching programs with any of these groups to make eligibility determinations, to verify continued eligibility for enrollment in a qualified health plan or Federal benefit programs, or to process appeals of eligibility determinations. Information provided by applicants won’t be used for immigration enforcement purposes;
  2. Verification sources including consumer reporting agencies;
  3. Employers identified on applications for eligibility determinations;
  4. Applicants/enrollees, and authorized representatives of applicants/enrollees;
  5. Agents, Brokers, and issuers of Qualified Health Plans, as applicable, who are certified by CMS who assist applicants/enrollees;
  6. CMS contractors engaged to perform a function for the Marketplace; and
  7. Anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013).
You can learn more about how CMS handles your information at: