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Printable Form 1095-C Broward Florida: What You Should Know

ACCESS Florida Application You may choose any state or local program as a “public charge exclusion”. (This covers a great deal of costs that otherwise would be included in your income.) If you cannot get public medical/dental care, private healthcare, etc., it makes no difference if your family income is 100 percent or less of the Federal poverty level. If you are a new adult, enter “New” in the “Date of Birth” column. You also can enter a date of birth, the same date, or a different date in the Year column. If you are a previously “covered” person, enter the “Last Change of Employer/Occupational Status” to find out if you are eligible for a new “public charge exclusion”. If you receive Social Security Disability Insurance payments in the future, you should look at the “Current Status of Payments for Disability” to see if you qualify. If you already get Social Security Disability Insurance payments, and they were earned when you were newly “covered”, they are not counted as public charge exemptions. If you receive Medicaid payments in the future, you should look at the “Current Status of Payments for Nursing Home Care” to see if you qualify. If you already are receiving Medicaid payments, they are counted as public charge exemptions. If the “Current Status of Payments for Long Term Care Services” is below “Pending” you don't qualify. If the “Current Status of Payments for Hospitalization Services” is below “Pending” you qualify. If you currently do not have “public charge” exemptions, fill in “Exempt”. If you currently have public charge exemptions, just leave this section blank unless one of the other areas describes you. If you have income less than 250% of “Federal Poverty Level”, enter one or more “Additional Medicaid Exemptions” in the “Additional Medicaid Exemptions” text box below. If you have income between 250% and 400% of “Federal Poverty Level,” enter one or more “Additional Medicaid Exemptions” in the “Other Income Exemptions” text box. If you have income greater than 400% of “Federal Poverty Level,” enter one or more “Public charge exemptions” in the “Other Income Exemptions” text box. If a family member's household assets exceed 2,000 in assets, enter a value in the “Additional Assets” box below.

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