You hereby authorize Stride Health, Inc. to act as your Agent 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 MNsure. By submitting your application, you agree to the MNsure Terms and Privacy, Privacy Warnings and Coverage Rights and Responsibilities. You also acknowledge and agree that:
Creating an account is the first step to determine eligibility for benefits and to choosing a plan, and MNsure must verify your identity during the account creation process.
The purpose and intended use of collecting the requested data
In order to verify your identity, MNsure collects private data, including your name, address, Social Security number, and birthdate. MNsure does not collect, maintain or use genetic information. Your social security number is used to tell you apart from other people. MNsure shares identity information with the Federal Data Services Hub and Experian, an external identity verification provider, in order to retrieve information necessary to perform identity verification. You will be prompted to answer identity verification questions based on your credit history and federal sources. An inquiry will be made against your consumer report and will not affect your credit score. MNsure does not retain the credit report questions and answers that you are prompted to answer. The inquiry for “CMS Proofing Services” will be removed from your Experian consumer report after 25 months. For information on this service, please see http://www.experian.com/help/.
Whether legally required
You are not legally required to provide this data, and you may refuse to provide the data. However, we may not be able to create your account without it.
Known consequences for supplying or refusing to provide the data
If you provide the data, you are doing so in accordance with our Privacy Policy and Rules of Behavior. If you knowingly provide false information, you may be subject to investigation and possibly face criminal or civil penalties. Refusal to provide data means we may be unable to verify your identity in order to create an online account.
Identities of persons or entities authorized by state or federal law to receive the data
Designated employees within MNsure may use this data to provide customer service or assistance in identity verification. Designated employees within MNsure may also access this data to perform quality and technical assurance, conduct audits, and investigate fraud. MNsure also shares identity information with dedicated staff in federal agencies in order to retrieve information necessary to perform eligibility verifications. An inquiry will be made against data held by federal agencies including the Department of Homeland Security to verify citizenship and immigration status, the Social Security Administration to verify incarceration status, and other federal insurance sources to verify minimum essential coverage. Others who may have access include: designated DHS employees working on behalf of MNsure, representatives of the Legislative Auditor, MN.IT information technology staff, enforcement agencies with statutory authority, and persons authorized by court order.
Records Retention
Certain identity information collected and shared with the Federal Data Services Hub and Experian (an external identity verification provider), including credit report questions and answers that you are prompted to answer, are not retained by MNsure. MNsure’s complete record retention schedule is available here. After the appropriate time period, MNsure will destroy the data in a manner than prevents their contents from being determined, including the shredding of paper files and permanently removing electronic data so as to prevent the possibility of recovery. This system is the property of the State of Minnesota and is subject to the Minnesota Government Data Practices Act. By using this system, you are representing yourself as an authorized user, and as such, you agree to use the system for authorized purposes only and in compliance with state and federal law and the MNsure TERMS AND CONDITIONS
###Privacy Warning### The purpose and intended use of collecting the requested data
In order to verify your eligibility for Medicaid, Minnesota Care, cost-sharing reductions, and advanced payment of premium tax credits, MNsure collects private data, including household size, Social Security number, immigration information and income, and verifies this information against state and federal sources. MNsure will also collect information to confirm that you reside in Minnesota, are lawfully present in the United States, and are not incarcerated. MNsure is required to collect the information in order to determine eligibility for Medicaid, cost-sharing reductions and advanced payment of premium tax credits. MNsure does not collect, maintain or use genetic information.
MNsure collects your social security number to tell you apart from other people, to prevent duplication of state and federal benefits, and to verify income, resources or other information that may affect your eligibility and benefits. You do not have to provide a Social Security number for persons in your home who are not applying for coverage or if you have religious objections. If you are permanently living in the U.S. without permission or approval from the U.S. Citizenship and Immigration Services, you do not need to provide your Social Security number, but you may not be eligible to enroll in benefits or plans offered on MNsure.
Immigration information is used to see if you are eligible to get coverage. Pub. Law 111-148, Section 1312(f)(3). You do not have to give us immigration information about yourself if you are helping someone else apply or about anyone in your household who is not applying for coverage. For Medicaid, you do not have to provide immigration information if you are applying for emergency medical care only or are a pregnant woman living in the U.S.
Whether legally required You are not legally required to provide this data, and you may refuse to provide the data. Income information is necessary in order to make an eligibility determination for Medicaid, Minnesota Care, cost-sharing reductions, and advanced payment of premium tax credits. If you elect to purchase a plan without seeking financial assistance, you do not have to provide income information.
Known consequences for supplying or refusing to provide the data If you provide the data, you are doing so in accordance with our Privacy Policy and Rules of Behavior. Our Privacy Policy requires that if you are providing information on behalf of another individual in your household, you must have consent to provide and view information on all the people who you have listed on the application and agree to safeguard their information. If you knowingly provide false information, you may be subject to investigation and possibly face criminal or civil penalties. Refusal to provide data or answers in response to questions means we may be unable to determine whether you are eligible for income assistance, subsidies, or other benefits. You may proceed with purchasing a qualified health plan without supplying the requested income information, provided you meet identity verification and other requirements as necessary under state or federal law.
Identities of persons or entities authorized by state or federal law to receive the data Designated employees within MNsure may use this data to provide customer service or eligibility and enrollment functions. Designated employees within MNsure may also access this data to conduct quality and technical assistance, and investigate fraud. For information you provide for income assistance programs, the Department of Human Services is also authorized to view and use the information you provide pursuant to Minn.Stat. § 13.46.
MNsure will also share identity information with the Federal Data Services Hub in order to retrieve information necessary to perform eligibility verifications. An inquiry will be made against data held by federal agencies including the Department of Homeland Security to verify citizenship and immigration status, the Internal Revenue Service to verify federal tax information, the Social Security Administration to verify income and incarceration status, Centers for Medicaid and Medicare Services to verify health insurance tax credits, and other federal insurance sources to verify minimum essential coverage. An inquiry will also be made against data held by state agencies including the Department of Human Services and the Department of Employment and Economic Development. Others who may have access include representatives of the Legislative Auditor, MN.IT information technology staff, enforcement agencies with statutory authority, and persons authorized by court order.
Records Retention Information provided in an application for coverage through MNsure is subject to the False Claims Act and may be retained for up to ten years. MNsure follows the general records retention schedules for state agencies and for the Department of Human Services, and maintains data in accordance with state and federal law. After the appropriate time period, MNsure will destroy the data in in a manner that prevents their contents from being determined, including the shredding of paper files and permanently removing electronic data so as to prevent the possibility of recovery. MNsure’s complete record retention schedule is available in the Terms and Privacy link in the footer of this page. I agree that I have read and understand my rights and responsibilities described in the warning. I understand that if I do not want to provide income information, I can apply for insurance coverage without income assistance or tax credits by signing out and using the "Apply for health coverage WITHOUT financial help" link.
Renewing Coverage Each year, MNsure matches data to verify and renew eligibility for help paying for health coverage. MNsure needs consent to use information from tax returns to verify and renew your financial assistance for coverage. If you do not give consent to use this data, your financial assistance cannot be verified during the year and renewed. You can change your consent at any time. I agree to the use of tax return information to verify and renew my eligibility for help paying for health coverage.
Application Agreement
I received and reviewed the Notice of Rights and Responsibilities and Notice of Privacy Practices.
I know that I must report changes to the information listed on this application.
I declare under the penalties of perjury that this application has been examined by me and to the best of my knowledge is a true and correct statement of every material point. I understand that a person convicted of perjury may be sentenced to imprisonment of not more than five years or to payment of a fine of not more than $10,000, or both. I understand that there may be other penalties for not telling the truth.
###Additional Agreements for Medical Assistance and MinnesotaCare:###
If anyone on this application is eligible for Medical Assistance or MinnesotaCare, I consent to the release of medical records as described in the Consent for Sharing of My Information section of the Notice of Rights and Responsibilities.
If anyone on this application is eligible for Medical Assistance, I give the Medical Assistance agency our rights to pursue and get any money from other health insurance, legal settlements, or other third parties.
If anyone on this application is eligible for Medical Assistance, I have read and understand that the state may claim repayment for the cost of medical care, or the cost of the premiums paid for care, from [my estate or my spouse’s estate](https://www.mnsure.org/current-customers/rights/rights-public.jsp#liens claims).
If anyone on this application is eligible for Medical Assistance or MinnesotaCare, I understand that my information, and information about me shared from third parties, will be shared for fraud prevention investigations as stated in the Notice of Privacy Practices and the Notice of Rights and Responsibilities.
If I am a parent that is eligible for Medical Assistance, I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support will harm me or my children, I can tell the agency, and I may not have to cooperate. I give to the Medical Assistance agency the rights to medical support paid for my children.