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Form 8965 California Alameda: What You Should Know

Eligibility — Healthcare Resource Center — HRS — Alameda County This section describes who is eligible to enroll in HRS-sponsored county public health insurance plans on California Health Benefits Exchange. For an individual, you must obtain an I.D.-Wage and Benefits Account Number from the Department of Public Health and Social Service (DPS HSS) or the California Department of Insurance (DID) ‧ Eligible for Countywide Health Insurance — HRS — Alameda You may be eligible for a fee-for-service health plan based on a financial hardship. A fee-for-service plan is  only available if you are unable to obtain or afford private health insurance. (The state offers a  Health Benefit Exchange. You may choose to purchase health benefits through this exchange or through a private Health Services Plan, a non-profit organization that offers a group health plan.) This fee-for-service plan generally covers medical costs and is available to individuals and families who meet specific Income criteria and who are unable to obtain private coverage This is not an “inactive” Health Care Plan and is offered on a regular basis. Individuals who are not enrolled may be denied premium You will receive a notice in the mail after your enrollment has been confirmed and will have a chance to make “Inactive” Health Insurance in Health Services Plan. To be “Inactive” you need to make sure you have On your Fax Line — Alameda County When you have completed and signed this form on Form 8965.pdf, mail it to: “Inactive” Health Care Plan — Office C.O. 1, P.O. Box 955, Fairfield, CA 95 If you have a Marketplace Coverage Exemption Claim (CSP or ACE), contact your local county office at for assistance with the enrollment and processing of your exemption claim. This form must be completed in your local county office. (You may also use the form to report the availability of Medicaid on your tax return.) F9500.2 — Application for Medicaid Coverage F9500.2 — Application for Medicaid Coverage and Information Form You must attach to your tax return an application for assistance in submitting the Medicaid and CHIP application.

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