Premium Support Program


Premium Support Program

Supported by CHRISTUS St. Michael Health System

*This is not an application for health insurance. Premium Support helps you pay the premium for health insurance that you buy from the Health Insurance Marketplace.

Step 1: INFORMATION ABOUT YOU

First
Middle Initial
Last
Suffix
Street Address
City
State
ZIP
County
Street Address
City
State
ZIP
County
How much money do you make a year (annual income)? You must write the same amount as you wrote on your Health Insurance Marketplace application.
You must write the same number as you wrote on your Health Insurance Marketplace application.
If you or a family member in your house use tobacco, you will pay a separate charge (more money) for health insurance. Premium Support will not pay the tobacco surcharge (separate charge). You must pay the extra charge in advance.

STEP 2: YOUR CONTACT INFORMATION

Ark-Tex Council of Governments will send a letter to your home/mailing address to tell you if you are eligible for financial help from Premium Support. Would you like the Ark-Tex Council of Governments to contact you another way?

STEP 3: INFORMATION ABOUT YOUR HEALTH INSURANCE

Before you bought insurance at the Health Insurance Marketplace, what insurance did you have?

STEP 4: INFORMATION ABOUT YOUR HEALTH INSURANCE PREMIUM SUBSIDY

STEP 5: READ AND SIGN THE APPLICATION

You must CHECK next to all of the sentences to submit your application.
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