2021 HealthConnect Form - United Way of Dane County

Is HealthConnect currently paying your health insurance premium?*
- Yes
- No
Step 1. Information about you
First Name*
Middle Initial
Last Name*
Suffix
Date of birth*
Month
Day
Year
Home address*
City*
State
Zip Code*
County
Is your mailing address different with your home address?
- Yes
- No
If different, write your mailing address.
Mailing address*
City*
State
Zip Code*
County
Contact Information
Phone*
Email
What is the best way that we can contact you if we have questions about your application?
Preferred contact method
- Phone
- Email
- Text
Phone - main number*
Email*
Phone number*
How much money do you make a year (your annual household income)? You must write the same amount as you wrote on your Health Insurance Marketplace application.*
How many people are in your household? You must write the same number as you wrote on your Health Insurance Marketplace application.*
Do any of the person being covered under this policy use tobacco? If you or a family member in your house use tobacco (smoke) you will pay a separate charge (more money) for health insurance. HealthConnect will not pay the tobacco surcharge (separate charge). You must pay the extra charge every month.*
- Yes
- No
Race / Ethnicity*
- White / Caucasian - for example, German, Irish, Lebanese, and so on.
- Black / African American - for example, African American, Haitian, Nigerian, and so on.
- Latino / Hispanic - for example, Mexican, Mexican American, Puerto Rican, Cuban, Argentinean, Colombian, Dominican, Nicaraguan, Salvadoran, Spaniard, and so on.
- Native American / American Indian - for example, Navajo, Mayan, Tlingit, and so on.
- Asian / SE Asian - for example, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Hmong, Laotian, Thai, Pakistan, Cambodian, and so on.
- Native Hawaiian / Other Pacific Islander - for example, Native Hawaiian, Guamanian, Chamorro, Samoan, Fijan, Tongan, and so on.
- Multi Racial
- Other
Other race (please specify)*
Preferred language*
- English
- Spanish
- Other
Specify your preferred language*
Step 2. Information about your health insurance
Look at your Health Insurance Marketplace application. Which insurance plan did you choose?*
- Dean
- GHC
- Quartz
Dean Health Plan Name (Plan ID)*
- Dean Silver Copay Plus 4800X (38345WI0010095)
- Dean Silver Classic 5000X (38345WI0010098)
- Dean Silver Value Copay 5000X (38345WI0010099)
- Dean Silver HSA-E 4500X (38345WI0010122)
- Dean Focus Network Silver Value Copay 5000X (38345WI0080046)
- Dean Focus Network Silver HSA-E 4500X (38345WI0080048)
GHC - SCW Plan Name (Plan ID)*
- Silver Simple Choice 4550X Ded/7900 MOOP 94% (94529WI024005006)
- Silver 4900 Ded/7900 MOOP 94% (94529WI024005706)
- Silver 8000X Ded/8550 MOOP 94% (94529WI024006206)
- Select Silver Simple Choice 4550X Ded/7900 MOOP 94% (94529WI024001806)
- Select Silver 4900 Ded/7900 MOOP 94% (94529WI024005806)
- Select Silver 8000X Ded/8550 MOOP 94% (94529WI024006406)
Quartz Health Insurance Plan Name (Plan ID)*
- Quartz ONE Silver I301-06 37833WI051010106
- Quartz ONE Silver I301-06 With Dental 37833WI038010106
- Quartz ONE Silver I302-06 37833WI051001806
- Quartz ONE Silver I302-06 With Dental 37833WI038002806
- Quartz ONE Silver I303-06 37833WI051001906
- Quartz ONE Silver I303-06 With Dental 37833WI038002906
- Quartz ONE Silver I304-06 Deductible 37833WI054003606
What is your member number for your health plan? If you don’t have a member number yet, what is your Health Insurance Marketplace (HealthCare.gov) application number?*
- Health plan member number
- HealthCare.gov Application /ID #
Health plan member number*
HealthCare.gov Application /ID #*
How many people will be covered under this plan?*
Before you bought insurance on the Health Insurance Marketplace this year, what insurance did you have? (check appropriate box)*
- None - I was uninsured
- BadgerCare
- Health Insurance Marketplace Plan
- Other (employer/ parent’s insurance policy/ other private insurance, COBRA, etc.)
If Other, please explain type or name of insurer.*
If you had BadgerCare, what was your HMO? (select one)
- Dean
- Group Health Cooperative-GHC
- Quartz
Step 3. Information about your health insurance premium subsidy
Has HealthConnect helped you pay for health insurance at any time since 2014?*
- Yes
- No
If yes, what was the first year you received Health Connect assistance?*
Look at your Health Insurance Marketplace application. Find the Premium Tax Credit section. How much of the health insurance tax credit are you eligible for?*
Did you select the “Advance Payment” option for your Advance Premium Tax Credit? You must select the “Advance Payment” option in the Health Insurance Marketplace to be eligible for financial help from HealthConnect.*
- Yes
- No
Look at your Health Insurance Marketplace application. How much is your monthly insurance premium?*
What month will your insurance coverage begin?*
- January
- February
- March
- April
- May
- June
- July
- August
- September
- October
- November
- December
How did you first hear about HealthConnect?*
- Insurer/ Broker
- Enrollment Assistor/Navigator
- 2-1-1
- Service Provider
- Word of Mouth
- Flyer/print material
- Social Media (Facebook, Instagram, etc)
- Other
Do you want to write any comments about your application?
Step 5. Read & sign this application
You must check ALL of the boxes to submit your application.*
- a. All of the information I wrote on this application is true. I give permission to United Way and my insurance company to talk about the information on my application to decide if I am eligible for the HealthConnect.
- b. I understand that I have to pay the monthly tobacco surcharge if I or a family member in my house smoke or use tobacco.
- c. I understand that if I am approved for financial help from HealthConnect, United Way will pay my health insurance premium (monthly payment) directly to my insurer starting the month I am approved and ending in December 2021, as long as I remain eligible. If I have already paid the premium for the month I am approved, HealthConnect assistance will begin the following month.
- d. I understand that the HealthConnect program will not pay or reimburse me for any health insurance premium payments I made before my application was approved.
- e. I understand that HealthConnect will not pay any tax penalties that result from having 2 different insurance plans at the same time.
- f. I understand that HealthConnect pays for my 2021 health insurance premium only.
- g. I understand that HealthConnect assistance may not be used to cover outstanding debts from prior coverage.
- h. I give permission and consent to be contacted in the future by United Way of Dane County as it relates to my experience with the HealthConnect program.
If you want an electronic copy of your application, enter your email address. You should print and keep a copy of this application.
Email
By placing your initials in the box below you are consenting to release your information listed above to the HealthConnect Program and to receive communication regarding your application status.
Enter First and Last Name initials into the box below.*
Phone
This field is for validation purposes and should be left unchanged.

Step 1. Information about you

Step 2. Information about your health insurance

Step 3. Information about your health insurance premium subsidy

Step 5. Read & sign this application

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United Way of Dane County