I understand that if I do not have employer-sponsored health insurance or if my health insurance is not considered “affordable”, then I may be able to apply for Affordable Care Act (ACA) Marketplace health insurance.

I understand that MISTR’s Partners may assist me with information, resources, and/or assistance to complete my ACA enrollment, but that the choice of whether to enroll and which plan to choose is mine alone.

I understand that if my tax credit doesn’t cover the cost of my monthly insurance premium, that I quality for financial assistance under the MISTR’s ACA Health Insurance Subsidy Program, where FOLXFOUNDATION will pay a portion or all of my monthly insurance premiums each month during calendar year 2022. I understand that FOLXFOUNDATION also may assist with assistance with co-pays and/or deductibles for which I am responsible if I qualify for such assistance based upon my income and family size in accordance with FOLXFOUNDATION policy. However, FOLXFOUNDATION will only offer financial assistance with the plans listed on MISTR.

I understand that in order to obtain FOLXFOUNDATION assistance for my monthly ACA premiums, I must remain adherent to my medical treatment plan each month during 2022. Medical treatment plan adherence can be documented by follow-up patient visits, periodic lab reports, and/or prescription fill records. I understand that I may lose program assistance if I fail to abide my treatment plan.

I understand that remaining in care at FOLXFOUNDATION via MISTR is a condition of receiving assistance under this program. Should I discontinue care or choose another healthcare provider, I understand that I may lose FOLXFOUNDATION health insurance assistance under this program.

I understand that if my FOLXFOUNDATION-subsidized ACA Marketplace health insurance policy results in a refund for any reason during the term of FOLXFOUNDATION assistance, this refund belongs to FOLXFOUNDATION. In the event that the insurer issues the refund in my name or mails the refund directly to me, I understand that I must immediately contact FOLXFOUNDATION and make arrangements to submit the refund check to FOLXFOUNDATION.

I understand that FOLXFOUNDATION assistance funds will not be used to pay/cover any federal penalty fees I may have incurred for not enrolling in an ACA health insurance plan prior to 2019.

I understand that in order to receive FOLXFOUNDATION assistance under this program, I must apply all of my available estimated premium tax credits per month in full and up front at the time of enrollment in an ACA Marketplace health insurance plan.

I understand that FOLXFOUNDATION assistance funds will not pay for services rendered outside of MISTR.

I understand that FOLXFOUNDATION assistance will ONLY be provided to me and NOT to any of my family or other household members, unless the family member or household member is also enrolled in MISTR’s ACA Health Insurance Subsidy Program. The insurance plan benefits document may list other household members as long as the costs for my individual health plan are clearly separated.

I understand that if I move my residence outside of FOLXFOUNDATION’s service area, then my enrollment in the MISTR’s assistance program may be discontinued. Monthly premium assistance and any co-payment or deductible assistance for which I am eligible from FOLXFOUNDATION will cease as of the date I move out the FOLXFOUNDATION service area, but I may qualify for other assistance from MISTR’s ACA Health Insurance Subsidy Program Partners.

I acknowledge that it is my responsibility to promptly notify (within three (3) business days) FOLXFOUNDATION of any personal or household changes I may have experienced in order to avoid incurring any further healthcare costs, changes in premium amount, or other fees through the ACA Marketplace. These changes include, but are not limited to, the following: Increases or decreases in household income, marriage/divorce, birth or adoption of a child, changes to household composition, gaining or losing eligibility for employer-sponsored insurance, Medicaid or Medicare. I further acknowledge that FOLXFOUNDATION will NOT pay for any federal penalty fees (e.g., costs, taxes, duties, or levies) owed to the IRS.

As part of my ACA Marketplace health insurance enrollment or re-enrollment, I understand that proof of income may be required at the time of application and at least every six (6) months.

I understand that as a condition of having FOLXFOUNDATION provide financial support for my health insurance costs under the ACA, I authorize the exchange of my personal identifying information for the purpose of providing, coordinating, evaluating, and managing my health insurance services to contracted MITSR providers and other providers that I request to assist me with enrollment activities. The shared information may include my complete name, address, Social Security Number, phone number, date of birth, and insurance details.

I understand that it is my responsibility to promptly notify MISTR of any communication, notices, or letters I receive related to the ACA health insurance policy for which FOLXFOUNDATION is making payments on my behalf – including, but not limited to ACA Marketplace requests for documents, premium payments past due, policy terminations, etc. – in order to avoid termination of my ACA health insurance policy.

I acknowledge by accepting the terms and conditions of MISTR’s ACA Health Insurance Subsidy Program that I have read the information above, and that I fully understand this information. I also understand that failure to comply with the requirements stated in this acknowledgement form may result in my loss of health insurance assistance from MISTR’s ACA Health Insurance Subsidy Program