DC Health Link
You hereby authorize Stride Health, Inc. to act as your Broker of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on the DC Health Link. By submitting your application, you agree to the DC Health Link Terms of Use and Privacy and Security. You also acknowledge and agree to the following:
###Your Information
We will keep your information private and will not share it with anyone unless you allow it or it is required by law. Your answers will only be used to decide whether you are eligible for Medicaid Managed Care or to purchase private health insurance with or without financial assistance. Information about your health will not be used to deny you insurance or determine how much you pay.
You can complete an application for health insurance including Medicaid for your children or other family members even if you do not qualify. If you are applying for benefits for other members of your family, you will need to give us information about where you live and your income, but we will not ask you any questions about your citizenship or immigration status and you will not have to give us a Social Security Number.
Important: As part of the application process, we will be checking the information you give us with information from other government agencies like IRS, Social Security Administration, and the Department of Homeland Security. If the information you provide does not match the information we get from these agencies, we may ask you to send us proof. Remember, if you are not applying for benefits for yourself, we will not ask you about your citizenship or immigration status and will not check your information with the Department of Homeland Security.
###Privacy Act Statement
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 authorizes DC Health Link to collect the information on your application and any necessary supporting documentation, including social security numbers, to determine whether you and the listed people on your application are eligible for health coverage or help paying for health coverage. We need the information you told us on your application about yourself and the other people listed on your application to determine eligibility for: (1) enrollment in a qualified health plan through DC Health Link, (2) insurance affordability programs (such as Medicaid, 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, we will electronically verify the information you told us on your application; communicate with you or your authorized representative, if you choose to have one; 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. We will also use the information in the future to conduct activities such as verifying your continued eligibility for health coverage or help paying for health coverage, processing appeals, reporting on and managing the insurance affordability programs for eligible individuals, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information.
While providing the information we ask you on the application (including social security numbers) is voluntary, failing to provide the information may delay or prevent you from obtaining health coverage or help paying for health coverage through the DC Health coverage. You should also know that 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 tax 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 determine if you and the people on your application are eligible for health coverage or help paying for health coverage, and to operate DC Health Link, we will electronically check the information you told us on your application with the information in other electronic data sources. We will need to share your information with other District and Federal government agencies, such as the Internal Revenue Service (IRS), the Social Security Administration (SSA), and the Department of Homeland Security (DHS);
Other electronic data sources, including consumer reporting agencies;
Employers identified on applications for eligibility determinations;
Applicants/enrollees, and the authorized representatives of applicants/enrollees;
Agents, Brokers, and issuers of Qualified Health Plans, as applicable, who are certified by DC Health Link who assist applicants/enrollees;
Contractors we engage to help run DC Health Link; and
Anyone else as required by law.
This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e)(4)).
###Privacy and Security###
The District of Columbia is committed to protecting the privacy of all visitors to any of our websites through the following practices.
###Collection and Use of Online Information### When you visit our website, certain data, such as your computer's unique Internet protocol (IP) address, will be automatically collected and sent to the servers that support our website system to help us provide better service and a more effective website. In addition, as part of these efforts, sections of this site may place a small text file (typically only a few bytes) on your hard drive to allow us to identify your computer. We will not attempt to read any additional information on your hard drive, and we do not combine collected information with other personal information to determine your identity or your email address.
In order to visit certain areas of this site, or to use certain services, you may be asked to provide personal information, such as your name, address, or gender. If you are making a payment, we may ask for your credit card number and billing address. If you decline to provide requested information, our ability to serve you may be limited. But you will still be able to visit the site and take advantage of the wealth of information it offers.
###Secure Transmissions###
Please be assured that this site is equipped with security measures to protect the information you provide us. We encrypt credit card numbers and other data that must remain secure to meet legal requirements.
###Protection of Personal Information### Your individual identifying information will not be shared, sold, or transferred to any third party without your prior consent, or unless it is required by law. It is available to District web development employees only for the purpose of maintaining the DC.Gov web portal and improving the site visitor experience.
DC Health Link is operated by the DC Health Benefit Exchange Authority (the "Authority"). This privacy and security policy describes the Authority's approach to information that is obtained from you via this website ("Site"). For information about our policy with respect to the collection, use, disclosure and maintenance of personally identifiable information ("Personally Identifiable Information" or "PII") in connection with the Authority's health benefit exchange ("Exchange") operations generally, see our Privacy and Security Policy for Exchange Operations.
At the DC Health Benefit Exchange Authority ("Authority"), consumer privacy is important to us. We respect your right to privacy and will protect the information we maintain about you in the ongoing operation of the health benefit exchange ("Exchange") in accordance with applicable laws, regulations and standards for security and privacy. As a reflection of our commitment to protecting your information, the Authority has adopted these privacy and security policies, which govern our creation, collection, use, disclosure and maintenance of personally identifiable information ("Personally Identifiable Information" or "PII") in connection with Exchange operations (the "Privacy and Security Policies for Exchange Operations").
The Privacy Act of 1974 is a United States federal law that governs the collection, maintenance, use, and dissemination of Personally Identifiable Information (PII) about individuals that is maintained in systems of records by government agencies. Individuals who apply for health insurance via DC Health Link receive notice of the Privacy Act Statement prior to submitting their application for health insurance coverage.
###Other Sites### The District of Columbia's privacy policy extends to District government websites only. If you access another organization's website through the www.dc.gov website, you should read that organization's privacy policy to determine its website practices.
###Application Agreement### I understand that I must report any changes that might affect my eligibility or the eligibility of a household member for health insurance. I can report changes by going online and logging into “My Account”, by calling DC Health Link's Customer Care Center toll-free at 1-855-532-5465, or by submitting information via mail or in-person at one of the Department of Human Services’ Service Centers.
I'm the person whose name appears in the signature line below. I understand that I’m submitting an application for health insurance and that information I provided will be used to decide eligibility for each member of my application group.
I've reviewed the information in this application, and I attest under penalty of perjury, that it’s accurate and complete to the best of my knowledge. I understand if I’m not truthful, there may be a penalty, including retroactive termination of my coverage and an obligation to repay all medical claims previously covered by the health insurance company.
###I Agree###
###Terms and Conditions### I chose this plan based upon written information provided by the insurer and nobody has my permission to change the terms of the offer or to agree to changes to it.
I know that some plan benefits have limitations or maximums.
I know that some personal information may be collected from other sources, such as District of Columbia or federal databases that can verify information I provided.
All of the information I provided on this application is true and complete to the best of my knowledge.
I know that the plan contract will have in it the details of our agreement, including procedures, exclusions and limitations. No benefit comparison, summary or other description of the plan should be considered more correct than the contract in describing the details of the plan's services.
I know that this application is part of the agreement or policy issued by the insurer. When I sign below, it means I agree to the terms and conditions of that agreement or policy.
WARNING: It's a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines.