Georgia Access

PO Box 12264
Birmingham, AL 35202
www.georgiaaccess.gov

Mackenzie Henderson
408 Minchew Rd
Douglas, GA 31533

Account number: 100-065-986

Date: December 02, 2024

Re: Your Eligibility Results from Georgia Access

ApplicationID: 11389162025
Application Date: 12/02/2024

Dear Mackenzie Henderson,

We received your Georgia Access health insurance coverage application on December 02,
2024. This letter has the results of your application and lists any follow-up steps that you
may need to take.

The Summary of your Application Results shown below indicates which health insurance
coverage programs each household member is eligible for based on the information
provided on your application. Please review the following information to understand the next
steps you need to take to enroll, including any documents you may need to submit to confirm
your eligibility.

Summary of your Application Results:

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 Household
Results
member(s)

Eligible to enroll in a health plan through Georgia Access

Eligible for financial assistance to lower premium costs, called
Advance Premium Tax Credits (APTCs).
Mackenzie Eligible for financial assistance to lower out-of-pocket costs, called
Henderson Cost Sharing Reductions (CSRs). Can choose a silver plan with
lower copayments, coinsurance, and deductibles. This silver plan
limit does not apply to the members of federally recognized tribes.
Applicant is eligible to buy a Catastrophic Plan

If you requested financial assistance on your Georgia Access application and were not
assessed as potentially eligible for Georgia Medicaid or PeachCare for Kids® then you can
ask for a full Medicaid determination at any time. To ask for a full determination, please click
"Request Full Medicaid Determination" within your application.

Household members eligible to enroll in health and/or dental insurance coverage

through Georgia Access

Based on the information provided on your application, the following household members are
eligible to enroll in health and/or dental insurance coverage through Georgia Access. Please
review the following table to understand any next steps you need to take to enroll, along with
any documents you may need to submit to confirm your eligibility. If you are already enrolled
and do not need to submit any documents, no further action is required.

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 Household
Results Next steps
member(s)

Your Advance
Premium Tax
Credits
(APTCs)
amount is
$286.30 each
month, which is
$3,435.60 for
the year, for
your tax
household.
All eligible
members This is based
on the yearly
household
income of
$23,400.00 -
the amount that
you put on your
application, or
that came from
other recent
information
sources

Eligible to enroll
Choose a plan and pay your first month's
in health
bill or premium by 01/15/2025.
insurance
coverage You must choose a Silver plan to get
through Georgia Cost Sharing Reductions (CSRs), which
Mackenzie Access. provide extra savings on out-of-pocket
Henderson costs. Choosing a Silver plan instead of a
This result is
Bronze plan may save you thousands of
based on the
dollars if you use a lot of medical
household
services. This silver plan limit does not
income you
apply to the members of federally
provided on
recognized tribes.
your application.

If any household members are eligible for financial subsidies or become eligible at any time
in the future, it is important to note the importance of reconciling APTC received on your tax

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years for all years members of the household will or have received APTC. Failure to
reconcile APTC received on your tax return for the applicable year could result in the denial
of financial assistance in the future. Please visit IRS.gov and search for "Form 8962" if you
would like more information about reconciling current or prior APTCs. You may also call the
Georgia Access Contact Center at 888-687-1503.

What should I do next?

Now that you are eligible for coverage through Georgia Access, it is time to enroll in a health
insurance plan by 01/15/2025, or for coverage beginning January 1, 2025, make sure to
enroll by December 16, 2024. For coverage beginning February 1, 2025, make sure to enroll
by January 15, 2025.

Follow the steps below to enroll in a plan. Again, if you are already enrolled, you do not need
to take any action at this time.

Our records indicate you already have an account with the Georgia Access portal.

For help updating your application and to enroll in a health insurance plan, please visit the
Georgia Access portal at https://enroll.georgiaaccess.gov/hix or call the Georgia Access
Contact Center at 888-687-1503 for additional assistance.

Log in at https://enroll.georgiaaccess.gov/hix to enroll, view or change your plan.

If you would like to choose a different certified Georgia Access enrollment partner to work
with, you can view the full list at GeorgiaAccess.gov.

Select the right health insurance coverage for your health needs and budget.
Pay the first month's premium to start your coverage.
Complete any outstanding tasks listed under "Next Steps" in the table above for each
household member, which could include requests for documentation.
See the "What documents should I submit?" section of this notice for a list of
documents you can submit and how to submit them.

How do I update my application or change plans?

If you have life changes and the information you gave us when you applied is no longer
correct, you need to let us know within 60 of the change. Changes may affect your eligibility
for:

Advance Premium Tax Credits (APTCs)

Cost Sharing Reductions (CSRs) that lower your copayments, coinsurance, and
deductibles
Coverage through Georgia Medicaid or PeachCare for Kids®.

Here are some examples of changes you should report:

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 Change in income
Birth, adoption, or court-ordered dependent
Change in lawful presence, incarceration, or American Indian/Alaskan Native status
Loss of minimum essential coverage
Marriage
Moved into the state
Death of a household member

You can update your application and change your plan through your Georgia Access portal
account. You can also get assistance or answers to your questions by contacting the
Georgia Access Contact Center at 888-687-1503.

Access your account at https://enroll.georgiaaccess.gov/hix.

If you enroll in a health insurance plan through Georgia Access and later become eligible for
other qualifying coverage, like Georgia Medicaid, PeachCare for Kids®, Medicare, or
coverage through a job, you will not be eligible for Advance Premium Tax Credits (APTCs),
although you can keep your plan and pay the full premium. If you become eligible for other
qualifying coverage, you must report this change to end your APTCs and let us know if you
also want to end your health insurance plan. If you do not stop the APTCs to your health
insurance company, we will update your application to remove the APTCs from your health
insurance plan. You will receive a notice of this decision.

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

If you think there is an error with your results, the first step is to confirm that all the
information on your application is correct and up to date.

You can view and make edits to your application through your certified Georgia Access
enrollment partner or the Georgia Access portal.

If do not have a certified Georgia Access enrollment partner and you would like to choose
one to work with, you can view the full list at GeorgiaAccess.gov.

How do I request an appeal?

If your application information is correct and you believe the State made an error in your
eligibility results you may file an appeal. You have 90 days from the date of this eligibility
notice to file an appeal. Appeals may be filed by mail or electronically through your certified
Georgia Access enrollment partner or the Georgia Access portal.

Complete the Georgia Accessconsumer appeal request form available at GeorgiaAccess.

gov and upload the document through your Georgia Access portal account.

OR

Mail a copy of the Georgia Access consumer appeal request form to the address below.

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 Make sure to write your name and Application ID, which would be included in this
notice, on your form.
Send a copy of the Georgia Access consumer appeal request form to:

ATTN: Appeals
Georgia Access Contact Center
PO Box 12264
Birmingham, AL 35202

Appealing your eligibility for Georgia Medicaid or PeachCare for Kids®

If this notice says that you may be eligible for Georgia Medicaid or PeachCare for Kids®, the
Georgia Division of Family and Children Services (DFCS) will send a notice to let you know if
you qualify for these free or low-cost programs. If DFCS determines that you are not eligible
for Georgia Medicaid or PeachCare for Kids®, that notice will tell you how to ask for a
Georgia Medicaid or PeachCare for Kids® fair hearing through the Georgia fair hearing
process.

More about getting Georgia Medicaid or PeachCare for Kids®

If your eligibility results tell you that you are eligible to buy a health insurance plan, we do not
think you qualify for Georgia Medicaid or PeachCare for Kids®. Some people may still qualify
for Georgia Medicaid or PeachCare for Kids®, but only DFCS can make the final decision.

You may want to ask DFCS to continue your application if you:

Need a lot of medical services or have unpaid medical bills

Have a family income close to Georgia Medicaid or PeachCare for Kids® income limit,
or you do not agree with the income amount that was used to determine your eligibility
Have a disability
Had a pregnancy that ended within the last 12 months, and you were not covered by
Georgia Medicaid or PeachCare for Kids®

You can keep your coverage described in this notice while DFCS reviews your application.

For more information about your Georgia Medicaid or PeachCare for Kids® eligibility,
including your right to appeal if DFCS determines you are not eligible for Georgia Medicaid
or PeachCare for Kids®, visit https://medicaid.georgia.gov/

For more help:

What are my options to enroll in coverage?

There are various ways to enroll in coverage on Georgia Access. You can work with a
certified Georgia Access enrollment partner or use the Georgia Access portal. Certified
Georgia Access enrollment partners include web brokers, agents, and insurance companies.

What help do certified Georgia Access enrollment partners provide?

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Certified Georgia Access enrollment partners can help you shop for and compare available
health insurance plans, understand your eligibility results for financial assistance, enroll in
coverage, and answer your questions.

Once you set up an account with a certified Georgia Access enrollment partner, you will be
able to update and manage your information, view your Georgia Access notices, receive
your eligibility results, and enroll in a plan.

Certified Georgia Access enrollment partners and the Georgia Access Contact Center
provide the following services for consumers who request assistance:

Spanish-speaking representatives
Notice language translation in Spanish
Language line for 250 languages and dialects
Teletypewriter (TTY) line at 711
Large print notices
Braille services

If you need any of the above services, contact a certified Georgia Access enrollment partner
or call the Georgia Access Contact Center at 888-687-1503. These accommodations are
provided at no cost to you.

If you need in-person help, you can find a local agent in your area on GeorgiaAccess.gov.

Thank you,
Georgia Access

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The determinations or assessments in this notice were made by the State of Georgia based upon 45 CFR 155.305,
155.410, 155.420-430 and 42 CFR 435.603, 435.403, 435.406 and 435.911.

Privacy Disclosure: The State of Georgia protects the privacy and security of the personally identifiable information (PII).
This notice was generated by the State of Georgia. The PII used to create this notice was collected from information you
provided on your application for health insurance coverage through Georgia Access. The State may have used data from
federal, state, and consumer reporting agencies to determine eligibility for the individuals on your application. The State of
Georgia only shares information about your application and eligibility, including this notice, with certified Georgia Access
enrollment partners with whom you have granted explicit authority to provide health insurance coverage through the
Georgia Access shopping and enrollment experience. You may revoke this authority at any time. This collection of and
authorized sharing of information does not constitute a breach of security under O.C.G.A. §§ 10-1-910 - 10-1-912. The State
of Georgia will provide notice if a breach of security of PII occurs in accordance with Federal law.

Nondiscrimination: Georgia Access does not exclude people or treat them differently because of race, color, national
origin, age, disability, religion, or sex (including pregnancy, sexual orientation, and gender identity). If you think you have
been discriminated against or treated unfairly for any of these reasons, you can file a consumer complaint with the Office of
Commissioner of Insurance and Safety Fire by visiting https://oci.georgia.gov/file-consumer-insurance-complaint.

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Reference number: 6220236

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