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If you need this information in a language other than English, or you need assistancereading this letter, we can help you. Call 1-855-355-5777 (TTY: 1-800-662-1220).

adam b beaudoin4309 40TH ST APT 1LSUNNYSIDE, NY 11104-3843

December 4, 2014Account ID: AC0002420940

Dear adam bley beaudoin,

We have redetermined your household’s eligibility on November 20, 2014 for enrollment throughNew York State of Health based on updated information we recently received.

Below are the results of our determination:

Household Member Eligibility Result Next Stepsadam bley beaudoinMarketplace ID:HX0003281673

Eligible to receive advancepremium tax credits to help payfor the cost of health coverage.You can apply all or part ofthis credit to your monthly healthplan premium.

Please refer to section "Howmuch Advanced Premium TaxCredit do I qualify for?" foradditional information about youreligibility for tax credits.

Eligible to receive cost sharingreductions which can help lowerthe amount you pay out of pocketfor deductibles, co-insurance,and co-payments. You mustselect a silver level qualifiedhealth plan to receive thisbenefit.

Pick a health plan - Youcan find more information aboutchoosing a health plan in the“Health Plan Enrollment” sectionof this letter.

You will receive writtenconfirmation from us once youhave selected a health plan.

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Household Member Eligibility Result Next StepsThis eligibility is effective as ofJanuary 1, 2015.

More information about your eligibility result can be found in the “How we made our decision”section of this letter.

How much Advanced Premium Tax Credit do I qualify for?

adam bley beaudoin is eligible to receive advance premium tax credits of $317.00 per month. Youcan apply all or part of this credit to your monthly premium when you enroll in a qualified healthplan.

Health Plan Enrollment

Next Steps for Picking a Plan:

• Sign into your NY State of Health account at http://www.nystateofhealth.ny.gov

• Check to see if any action is required on your part

• If you need to pick a plan, you can do it online

• After you pick a plan, you will receive confirmation from us by email or mail (dependingon what you said you would prefer)

• You will get this confirmation even if you pick the same plan for next year

• If you don’t have internet access and want to pick a plan over the phone, call NY Stateof Health at 1-855-355-5777

How We Made Our Decision

Household Member How we made our decisionadam bley beaudoinMarketplace ID:HX0003281673

Your advance premium tax credit is based on the number ofpeople in your household, your household income, and the costof plans available in your county. Depending on the cost of plansavailable in your county, your advance premium tax credit may be$0. You told us your household income is $17,125.00.

You are eligible for cost-sharing reductions because yourhousehold income of $17,125.00 is within the allowable incomelimit of $28,725.00.

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Household Member How we made our decisionYou are not eligible for Medicaid because the household incomeyou provided to us of $17,125.00 is over the allowable incomelimit of $16,105.00.

Reporting Changes during the year

Over the next year, you are obligated to report to New York State of Health any changes thatwould affect your eligibility for enrollment in health insurance within 30 days of such a change.You need to tell us if:

• You move;

• Your income changes (only if you are receiving financial assistance);

• Your eligibility for health insurance from a job changes;

• Your household changes, for example, you marry/divorce, become pregnant, or have achild(ren); adopt a child(ren) or if a child(ren) is placed for adoption with you;

• You become qualified for other insurance;

• Change in full-time student status (if applicable to application members);

• Change in immigration status;

• Change how you plan to file your taxes, for example, if you will claim new dependents(only if you are receiving financial assistance).

To report changes you may go to your My Account at http://www.nystateofhealth.ny.gov or contactus. If you do not report changes, and the changes affect your eligibility for advance premium taxcredits, you may have to pay back some or all of the subsidies you received.

Additional Plan Enrollment Information for Qualified Health Plans

Next steps for enrollment in a Qualified Health Plan:

• If someone in your family is eligible to enroll in a qualified health plan and has not selecteda plan, you need to choose a qualified health plan in order for your coverage to start.You may select a qualified health plan anytime during an open enrollment period or ifyou qualify for a special enrollment period.More information on open enrollment periods and special enrollment periods can befound in section "Enrollment in your Qualified Health Plan".

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• Once you have chosen a qualified health plan, you will receive an invoice from the healthplan if you have a premium responsibility.

• After paying your premium responsibility (if applicable), your qualified health plan willsend your insurance ID card and other information about your benefits and availableproviders in your network to you.

If you have also selected a dental plan, you will receive a separate invoice and information aboutyour benefits and available providers in your network from this dental plan.

Enrollment in your Qualified Health Plan

• If you have a premium responsibility and if you do not make your monthly premiumpayments on time, you could lose your health insurance. Your health plan will becommunicating with you about your premium payments.

• You will be able to change your plan at any time during the open enrollment period.The next annual open enrollment period will begin on November 15, 2014 and will endon February 15, 2015. If you missed the deadline to enroll in a plan for 2014 (endedon March 31, 2014), you may not be able to enroll in a health insurance plan throughNew York State of Health until the next open enrollment period (November 15, 2014through February 15, 2015), unless you qualify for a special enrollment period. Shouldyou qualify for a special enrollment period, this will allow you to select a new plan within60 days of a qualifying event.

Examples of events that may qualify you for a special enrollment period are:

ο Gaining a dependent due to marriage, birth, adoption or placement for adoption;

ο Gaining or losing eligibility for financial assistance to help pay for your healthinsurance such as tax credits or cost-sharing reductions;

ο Moving and gaining access to new coverage

If you think you qualify for a special enrollment period, please call us for help.

You have the right to terminate your health insurance and enroll into another health plan if youcancel your policy within 10 days of enrolling.

What Benefits are Included?

You will receive a benefit package from your health plan. The benefit package will cover a widerange of services, including doctor’s visits, inpatient hospital care, lab tests, prescription and non-prescription drugs and much more.

For any questions about what services your benefit plan covers, please call your health plandirectly.

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Your tax subsidy is based on your projected annual income. The IRS will reconcile your advancepremium tax credit (APTC) with the income you report on your federal income tax return. If yourincome is higher than what you told us on your application, you may have to pay more taxes. Ifyour income is lower than what you told us on your application, you may receive a tax refund.

• If, at any time, you want to lower the risk of owing taxes related to your coverage, youmay lower the amount of Advanced Premium Tax Credit and choose to pay more foryour monthly premium now. To opt for a higher monthly premium, contact us or log intoyour account to lower the amount of your Advance Premium Tax Credit.

• If you have access to your employer(s) sponsored health insurance: youremployer(s) may be required to contribute to the cost of your health insurance. NYState of Health must tell your employer that you are eligible to get help paying forhealth insurance because your employer(s) may be required to contribute to the costof your health insurance. Your employer(s) have the right to appeal your tax subsidydetermination if they disagree with it. Your employer cannot discriminate against youbased on your eligibility for subsidies.

• Every year you will be required to renew your eligibility for premium tax credits andcost-sharing reductions (if applicable). Renewal will happen during the qualified healthplan open enrollment period. You can change your health insurance plan during openenrollment, as determined by the Federal government.

If you are eligible for Cost-Sharing Reductions:

• This means you will pay less when you go to the doctor or get a prescription and youryearly deductible is lower. For additional information on the health care costs, pleasecontact your health plan directly.

• To receive cost-sharing reductions, you must be eligible and select a Silver Level healthplan. Your maximum out-of-pocket costs may change if you do not select a Silver Levelhealth plan.

Additional Benefits for the APTC Premium Payment Program

• To use the benefits of the APTC Premium Payment Program and potentially reduce yourpremium to $0, you must be eligible and select a Silver Level health plan and use theentire amount of your tax credit. You will still be responsible to pay any cost sharing,like co-pays for doctor’s visits or prescriptions. Your maximum out-of-pocket costs maychange if you do not select a Silver Level health plan.

If you think we made a mistake

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If you think we’ve made the wrong decision about your application for insurance, you can call usat 1-855-355-5777 (TTY: 1-800-662-1220) to discuss your concerns. We will do our best to helpyou. But, whether or not you use this informal process, you can ask us for a formal appeal.You can formally appeal most of the decisions NY State of Health makes, including:

• Your eligibility to enroll in health insurance

• Your eligibility for Medicaid or Child Health Plus

• The amount of financial assistance you will receive toward your monthly health insurancebill

• The amount of financial assistance you will receive toward your out-of-pocket expenseswhen you use health care services

• Your eligibility for a special enrollment period

• Whether or not we made a decision about your eligibility quickly enough.

For information on how to ask for an appeal, see the attached sheet titled “Filing an Appeal.”There are deadlines to appeal so you should act quickly.

How to Contact New York State of Health

Contact us if you have any questions about this letter. Let us know if you need help applying foror accessing your health insurance. You can contact us in any of the following ways:

• Online at http://www.nystateofhealth.ny.gov

• By calling 1-855-355-5777 (TTY: 1-800-662-1220)

• By mail at:

NY State of HealthPO Box 11727Albany, New York 12211

Sincerely,

New York State of Health, The Official Health Plan Marketplace

Legal Reference:

This decision is based on Section 366(1)(b) of the Social Services Law.

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Eligibility standards for enrollment through the Marketplace may be found at 45 CFR §155.305.

Applicant has the right to appeal an eligibility determination pursuant to 45 CFR §155.355 and155.505(b).

Pursuant to 45 CFR §155.330, the Marketplace must redetermine the eligibility of an enrolleethrough the Marketplace during the benefit year if it verifies new information.

PHL 2511(6)(a) is broad authority for the Commissioner to establish standards for individualenrollment including mechanisms for presumptive eligibility and annual recertification.

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How to Request an Appeal and Additional Information

Filing an Appeal

An appeal is a chance for you to explain why you disagree with our decision. There are severalways to ask for one. You can:

• Call 1-855-355-5777 (TTY: 1-800-662-1220)

• Mail your request to: New York State of Health PO Box 11729, Albany, NY 12211.

• If you want to ask for an appeal another way, please call us and speak with a customerservice representative.

You have 60 days from the date on your eligibility notice to ask for an appeal.

After you request an appeal, you will receive a letter from us letting you know that we received yourrequest. You will then receive a second letter telling you when your appeals hearing will be held.

The hearing is a formal meeting where you will have the opportunity to explain why you disagreewith the eligibility decision we have made. Your hearing will be conducted by an impartial hearingofficer. During the hearing you can talk with him or her about why you think we made a mistake.

We will conduct your hearing by telephone. To prepare for the hearing:

• You can have someone with you at the hearing if you want to. That person can be afriend, a relative or a lawyer. You can also represent yourself.

• Before the hearing you can look at and review the documents we used to make ourdecision.

• We will not ask you to resubmit documents or information you have already provided.You may, however, provide any information or documents you need to help usunderstand your concerns.

While you are waiting for the hearing, we may again try to resolve the issue informally. You canalso provide new information or documents that will help us understand your concerns during theinformal process.

Keeping your health insurance while you appeal a change in eligibility

If you are already enrolled in a Qualified Health Plan, Medicaid or Child Health Plus through NewYork State of Health, you or your household members may keep health coverage while you appeal.If you want to keep your coverage, ask for aid to continue when you make your appeals request.

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• Under some circumstances, you may keep your coverage until we decide your appeal.If you have Medicaid coverage, you have ten (10) days from the date on this notice toask us to have your Medicaid continued.

• For Child Health Plus and advance premium tax credits in a Qualified Health Plan, youwill keep the level of coverage or the amount of the assistance you had before askingfor an appeal.

Some important things to note:

• The result of your appeal could change what health coverage you qualify for. It couldalso change what others in your household qualify for.

• Additionally, if you requested aid to continue for advance premium tax credits, Medicaidor Child Health Plus and you lose your appeal, you could have to pay back some or allof the assistance you received during the appeals process.

If you have any questions, first call 1-855-355-5777 (TTY: 1-800-662-1220)

HIPAA Privacy Notice

New York State is committed to protecting your privacy. To learn more about New York Stateof Health’s privacy practices go to www.nystateofhealth.ny.gov or call customer service at1-855-355-5777 (TTY: 1-800-662-1220).

You must include this bar code page when youfax or mail any documents to New York Stateof Health. The bar code is needed to link thedocuments you send to your New York State ofHealth account and to process your application.Without the bar code, your application and/ordocuments may take longer to process.

*AC0002420940*