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Health Insurance M an r k e t p l a c e Coverage O p tons and Your Health CoverageForm Approved OMB No. 12100149 (expires 1312017)PART A: General Information Beginning in 2014 when key parts of the
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Health Insurance Marketplace
Individuals who purchase health insurance through the marketplace
By providing accurate information about income, household members, and other required details on the application form
To help individuals and families find affordable health insurance coverage
Income, household members, current health insurance coverage, and qualifying life events
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