Last modified: 1/26/2021
Benefit Advisors Insurance Agency, LLC will not disclose your personally identifiable information except as provided herein.
Permission to Collect & Submit Information
You authorize Benefit Advisors Insurance Agency, LLC to collect and use certain personally identifiable information (such as your social security number). You further authorized Benefit Advisors Insurance Agency, LLC to submit your information to the Federal Health Insurance Marketplace and to communicate with the Marketplace about your eligibility and enrollment in any qualified health plan, insurance affordability program, and exemption from individual shared responsibility. You represent and warrant that to the best of your knowledge the information you provide to Benefit Advisors Insurance Agency, LLC is current and correct. You authorize Benefit Advisors Insurance Agency, LLC to verify the information provided by you, to communicate with you or your authorized representative, and to provide your information to others for purposes of enrollment in a qualified health plan or insurance affordability program.
The Marketplace for State of Wisconsin residents is run by the Centers for Medicare & Medicaid Services, a component of the U.S. Department of Health and Human Services. Your information will be used to determine eligibility for: (1) enrollment in a qualified health plan through the Marketplace, (2) insurance affordability programs (such as Medicaid, Children’s Health Insurance Program, advanced payment of the premium tax credits, and cost sharing reductions), and (3) certifications of exemption from the individual responsibility requirement. Information you provide to us may also be used as part of the ongoing operation of the Marketplace, including activities such as verifying continued eligibility for all programs, processing appeals, reporting on and managing the insurance affordability programs for eligible individuals, performing oversight and quality control activities, combatting fraud, and responding to any concerns about the security or confidentiality of the information.
Information submitted to the Marketplace may be used to verify and process applications, determine eligibility, and operate the Marketplace. In addition to the Centers for Medicare & Medicaid Services, selected information may be shared with other agencies, including:
- Other federal agencies, (such as the Internal Revenue Service, Social Security Administration and Department of Homeland Security), state agencies (such as Medicaid or CHIP) or local government agencies. The Centers for Medicare & Medicaid Services may use the information you provide in computer matching programs with any of these groups to make eligibility determinations, to verify continued eligibility for enrollment in a qualified health plan or Federal benefit programs, or to process appeals of eligibility determinations.
- Other verification sources including consumer reporting agencies
- Employers identified on applications for eligibility determinations
- Applicants/enrollees, and authorized representatives of applicants/enrollees
- Agents, Brokers, and issuers of Qualified Health Plans, as applicable, who are certified by CMS who assist applicants/enrollees
- CMS contractors engaged to perform a function for the Marketplace
- Anyone else as required by law or allowed under the Privacy Act System of Records Notice associated with this collection (CMS Health Insurance Exchanges System (HIX), CMS System No. 09-70-0560, as amended, 78 Federal Register, 8538, March 6, 2013, and 78 Federal Register, 32256, May 29, 2013).
While providing the requested information is voluntary, failing to provide it may delay or prevent Benefit Advisors Insurance Agency, LLC from determining your eligibility to participate in, enrolling you in, or helping you to obtain exemption from the above described programs. To the extent that we create, collect, disclose, access, maintain, store, or use your personally identifiable information, we will provide you with means to access your personally identifiable information upon request.
This statement provides the notice required by the Privacy Act of 1974 (5 U.S.C. § 552a(e)(3)). You can learn more about how the Centers for Medicare & Medicaid Services handle your information at: https://www.healthcare.gov/how-we-use-your-data.