ClockExpirationNotice 2

DEPARTMENT OF HEALTH AND HUMAN SERVICES
465 INDUSTRIAL BOULEVARD

LONDON, KENTUCKY 40750-0001
Jacqueline Ricci Jul 06, 2023

177 Quail Ridge Drive
Kyle, TX 78640
Application Date: March 23, 2023

Application ID: 4618207577
Dear Jacqueline Ricci:
You're getting this notice because the Health Insurance Marketplace® asked for additional documents to verify
your application information. We have now updated your application status.
This notice explains the changes that impact your family and describes any additional action(s) you may need
to take.
Who is affected?
• Louis Ricci - We requested documentation to prove you didn't have access to or weren't enrolled in
other health coverage, and sufficient documentation wasn't provided. As a result, you don't qualify for
a tax credit or cost-sharing reductions. If you're enrolled in a health plan through the Marketplace,
your coverage will continue, so contact your plan to find out your new premium or cost sharing
amounts.
If you're a member of a federally-recognized Indian tribe or shareholder of an Alaska Native

Corporation, your cost-sharing may have changed. But, you still qualify for the special cost-sharing
protections that are available to all members of federally-recognized Indian tribes and shareholders of
Alaska Native Corporations, regardless of income. Contact your plan to confirm your cost-sharing
amount.
1688650657770 1
What should I do next?
• For anyone who qualifies for a tax credit, the tax credit amount has changed to $910.00 per month. If
you are enrolled in a health plan through the Marketplace, this change will be effective on August 1,
2023. Those who are still eligible and wish to continue coverage should contact the plan to find out the
new premium amount.
• Your premium amount may be different because the Marketplace has adjusted how much of the tax
credit is applied to your monthly costs (the "premium") to $910.00 per month. Contact your plan to
find out your new premium amount.
• For anyone who qualifies for cost-sharing reductions, the Marketplace may have adjusted the amount
of your cost-sharing reductions. You may now owe different copayment, coinsurance and deductible
amounts. If you are enrolled in a health plan through the Marketplace, this change will be effective on
August 1, 2023. Those who are still eligible and wish to continue coverage should contact the plan to
find out more about your change in costs.
• For anyone who was receiving a tax credit or cost-sharing reductions, we have determined that you no
longer qualify for the tax credit or cost-sharing reductions. If you are enrolled in a health plan through
the Marketplace, this change will be effective on August 1, 2023. Those who are still eligible and wish
to continue coverage should contact the plan to find out the new premium amount.
What should I do if I think my eligibility results are wrong?
You will receive a final eligibility determination notice containing information about how you may appeal if
you think this decision is wrong.
For more help
• Visit HealthCare.gov or call the Marketplace Call Center at 1-800-318-2596. TTY users can call
1-855-889-4325. You can also make an appointment with an assister who can help you. Information is
available at LocalHelp.HealthCare.gov.
• Get help in a language other than English. Information about how to access these services is included
with this notice, and through the Marketplace Call Center.
• Call the Marketplace Call Center to get this information in an accessible format, like large print, braille,
or audio, at no cost to you.
Sincerely,
Health Insurance Marketplace

Department of Health and Human Services
1688650657770 2
465 Industrial Boulevard
London, Kentucky 40750-0001
The determinations or assessments in this letter were made based upon 45 CFR 155.305, 155.315, 155.320, 155.410, 155.415, 155.420, 155.430
and 42 CFR 435.603, 435.403, 435.406 and 435.911.
Privacy Disclosure: The Health Insurance Marketplace® protects the privacy and security of the personally identifiable information (PII) that you
have provided (see HealthCare.gov/privacy). This notice was generated by the Marketplace based on 45 CFR 155.230 and other provisions of 45
CFR part 155, subpart D. The PII used to create this notice was collected from information you provided to the Health Insurance Marketplace®. The
Marketplace may have used data from other federal or state agencies or a consumer reporting agency to determine eligibility for the individuals on
your application. If you have questions about this data, contact the Marketplace at 1-800-318-2596 (TTY: 1-855-889-4325).
You can also call the Marketplace call center to get information from this notice in your language, or request a reasonable accommodation if you
have a disability. You can ask for information in an accessible format, like large print, braille, or audio at no cost.
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB
control number. The valid OMB control number for this information collection is 0938-1207.
Nondiscrimination: The Health Insurance Marketplace® doesn’t exclude, deny benefits to, or otherwise discriminate against any person on the basis
of race, color, national origin, disability, sex (including sexual orientation and gender identity), or age. If you think you’ve been discriminated
against or treated unfairly for any of these reasons, you can file a complaint with the Department of Health and Human Services, Office for Civil
Rights by calling 1-800-368-1019 (TTY: 1-800-537-7697), visiting hhs.gov/ocr/civilrights/complaints, or writing to the Office for Civil Rights/ U.S.
Department of Health and Human Services/ 200 Independence Avenue, SW/ Room 509F, HHH Building/ Washington, D.C. 20201.
Health Insurance Marketplace® is a registered service mark of the U.S. Department of Health & Human Services.
1688650657770 3
January 2022
Health Insurance Marketplace® is a registered service mark of the
U.S. Department of Health & Human Services. January 2022

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

465 INDUSTRIAL BOULEVARD

Jacqueline Ricci Jul 06, 2023

Application Date: March 23, 2023

Dear Jacqueline Ricci:

If you're a member of a federally-recognized Indian tribe or shareholder of an Alaska Native

What should I do if I think my eligibility results are wrong?

For more help

Health Insurance Marketplace

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