mdhhs-5764, MARKETPLACE: OPEN ENROLLMENT RESPONSE

Michigan Department of Health and Human Services (MDHHS)

Michigan Drug Assistance Program (MIDAP)

(Revised 9-24)

This response form is only used to make the first payment for your new policy. You are required to submit a detailed bill/invoice and all other supporting documents to MIDAP within 30 days. No additional payments will be made on your behalf without a bill/invoice from the insurance company.

section 1

Is this a 2025 Marketplace Policy? Yes No If yes, fill out the information below.

MIDAP Member ID Number

Last Name	First Name	Date of Birth

Address	City	State	Zip Code

Phone Number	Email Address

Will there be any changes to your Health Insurance Policy and/or payment information for the upcoming year? Yes No

If no, sign here stating nothing has changed. The following information is not required but you must still return this form to MIDAP. However, it is recommended that you complete the following fields to allow Premium Assistance to verify that there have been no changes to your health insurance information. If yes, fill out the information below and return this form to MIDAP.

How many people on this policy are active MIDAP clients?

Name of Health Insurance Company

Payment Address for Health Insurance Company	City	State	Zip Code

Insurance Company Account/Policy/ID Number

Monthly Premium Amount before Advanced Premium Tax Credit (APTC)

APTC Amount	Due Date for Premium

Billing Period: From To

Have you contributed any premium payments towards this policy?	Yes No

If yes, how much?	Date paid

Were you eligible for the APTC in 2024?	Yes No

If yes, did you apply 100% of the APTC towards your premiums?	Yes No

Note: You are required to apply 100% of the APTC toward your premiums, if eligible. To apply for a Marketplace plan, go to www.healthcare.gov.

MIDAP currently covers all metal levels – Bronze, Silver, Gold and Platinum. Once you have made your selection, return your Marketplace Eligibility Letter and Open Enrollment Response form to MIDAP. The response form can be returned to MIDAP by fax, mail or through your MIDAP online account at milogin.michigan.gov. Michigan Drug Assistance Program Michigan Department of Health and Human Services ATTN: Premium Assistance Program PO Box 30727 Lansing, MI 48909 Fax: 517-335-7723

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.