Why did you give me this notice?
I am/We are legally required to give you this notice by applicable law and our agreement with the federal government.
I/We respect your personal information and want you to fully understand how I/we may use and share your information.
What information will you ask me to give you?
I /We must collect certain information about you, called Personally Identifiable Information (“PII”) in order to help you complete your application for health insurance. PII is information that can be used to identify you or trace your identity.
These are a few examples of PII. This is not a complete list.
name, address, date of birth, telephone number
social security number
household income, marital status
race or ethnicity
credit or debit card numbers
How will you use my information?
I/We will use only the information that we need to help you obtain health insurance through the Federally-facilitated Exchange (“FFE”) and to provide Authorized Functions approved by the FFE, or other service as permitted under applicable law.
These are a few of the authorized functions that we may conduct. This is not a complete list:
Helping with your application for insurance
Answering question about your eligibility
Helping to enroll you in a qualified health plan
Helping with filing appeals of eligibility determinations
Correcting errors in your application
Will you share my information with anyone?
I/We may only share your information as described in this notice.
I/We may share your information with certain Federal or State agencies, the health insurance issuer that you select or subcontractors that help me/us to provide services to you.
What happens if I don’t share my information with you?
If you do not want to share your information, you may not be able to enroll in a health insurance plan.
Will you keep my information safe?
Yes. I am/We are required to keep your information safe. I/ We have developed privacy and security policies that I/we must follow to make sure that I/we protect your PII.
Definition of PII
Personally Identifiable Information or PII means that information which can be used to distinguish or trace an individual’s identity, such as their name, social security number, biometric records, among others, alone or when combined with other personal or identifying information that is linked or linkable to a specific individual, such as date and place of birth, mother’s maiden name, etc. Additional details about the meaning of PII is contained in the government’s guidance, OMB Memoranda M‐07‐16 (issued May 22, 2007).
Legal Authority for Collection
ABEs have been granted the legal authority to collect this information by Section 1312(e) of the Affordance Care Act (“ACA”), which required that the Secretary of the U.S. Department of Health and Human Services establish procedures under which Agents and Brokers may participate in an Exchange. ABEs are further permitted by federal regulation (45 C.F.R. 155.220) to enroll individuals in a QHP offered on an Exchange and to assist individuals in applying for enrollment in a QHP through the Exchange, Advance Payments of the Premium Tax Credits (“APTCs”) and Cost‐Sharing Reductions (“CSRs”) to the extent permitted to do so under State law and regulation.