Mere Benefits is a DBA of Health Wealth Simplified LLC, managed by Kate Spilsbury, Licensed Insurance Agent #9527400

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Please enter your Projected Annual Household Income for 2026.

(Typically, In line 11 of your previous year's tax return.)

For more information on how to project your income, please click HERE to check the guide

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I consent to receive marketing communications from Health Wealth Simplified DBA Mere as described in our Privacy Policy. I understand that I can unsubscribe at any time.I consent to receive communications from Health Wealth Simplified LLC, DBA Mere, including but not limited to SMS notifications, emails, ringless voicemails, and phone calls. These communications may include information about health insurance plans, updates, and promotional offers. Some communications may be automated or managed by an AI bot. Message frequency may vary. Message and data rates may apply. You can opt out of these communications at any time by replying STOP to any message.

I acknowledge that some virtual meetings may be recorded and transcribed using Fathom AI Notetaker, a HIPAA-compliant tool used by Mere to support accurate documentation. This platform operates under a Business Associate Agreement and stores data securely. I understand that meeting summaries or transcripts may be retained and used only for service-related purposes.

I understand that my consent remains in effect until I revoke it. And I may revoke or modify my consent at any time by emailing info@merebenefits.com.

Consent

I authorize Kate Spilsbury to be my health insurance agent for myself and my household. This allows Kate Spilsbury to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Kate Spilsbury to use my confidential information for the following purposes:

  1. Search for an existing Marketplace application.

  2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

  3. Provide ongoing account maintenance and enrollment assistance.

  4. Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing info@merebenefits.com

    I acknowledge your request to enroll me in the most suitable health plan available based on your expertise, which may be a $0 monthly plan premium. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

AGREEMENTS, please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage.

Renewal of coverage to make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2026 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2026 TAX YEAR. If I’m married at the end of 2026, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and who's premium for coverage is paid in whole or in part by advance payments of the premium tax credit. IF ANY OF THE ABOVE CHANGES I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2026 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I

Agent of Record: Kate Spilsbury

NPN: 9527400

Phone Number: (904) 654-5450

Email Address: info@merebenefits.com

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I understand that my consent remains in effect until I revoke it. And I may revoke or modify my consent at any time by emailing worley@merebenefits.com.

Consent

I authorize Worley Richards to be my health insurance agent for myself and my household. This allows Worley Richards to enroll me, or my family, in a Qualified Health Plan on the Federally Facilitated Marketplace. By agreeing to this, I give permission for Worley Richards to use my confidential information for the following purposes:

  1. Search for an existing Marketplace application.

  2. Complete applications for eligibility and enrollment in a Marketplace plan or other government insurance programs.

  3. Provide ongoing account maintenance and enrollment assistance.

  4. Respond to inquiries from the Marketplace regarding my application. The Agent will keep my personal information private and secure, using it only for the purposes listed above. I confirm that the information I provide on my application will be accurate to the best of my knowledge. I understand that I am not obligated to share additional personal information beyond what is required for the application. I can revoke or modify my consent at any time by emailing worley@merebenefits.com

    I acknowledge your request to enroll me in the most suitable health plan available based on your expertise, which may be a $0 monthly plan premium. If zero premium plans are unavailable, I authorize you to enroll me in the next best available plan. I grant you access to my healthcare.gov account for submitting necessary information. By signing below, I confirm my understanding and agreement to the terms outlined in this attestation.

AGREEMENTS, please read the attestations below and sign if you agree.

I agree to have my information used and retrieved from government data sources for this application. I have consent for all people I’ll list on the application for their information to be retrieved and used from government data sources.

I understand that I’m required to provide true answers and that I may be asked to provide additional information, including proof of my eligibility for a Special Enrollment Period if I qualify. If I don’t, I may face penalties, including the risk of losing my eligibility for coverage.

Renewal of coverage to make it easier to determine my eligibility for help paying for coverage in future years, I agree to allow the Marketplace to use my income data, including information from tax returns, for the next 5 years. The Marketplace will send me a notice, let me make any changes, and I can opt out at any time.

TAX ATTESTATION

I understand that I’m not eligible for a premium tax credit if I’m found eligible for other qualifying health coverage, like Medicaid, the Children’s Health Insurance Program (CHIP), or a job-based health plan. I also understand that if I become eligible for other qualifying health coverage, I must contact the Marketplace to end my Marketplace coverage and premium tax credit. If I don’t, the person who files taxes in my household may need to pay back my premium tax credit.

I understand that because the premium tax credit will be paid on my behalf to reduce the cost of health coverage for myself and/or my dependents: I must file a federal income tax return for the 2026 tax year. I MUST FILE A FEDERAL INCOME RETURN FOR THE 2026 TAX YEAR. If I’m married at the end of 2026, I must file a joint income tax return with my spouse. I also expect that: No one else will be able to claim me as a dependent on their 2026 federal income tax return. I’ll claim a personal exemption deduction on my 2026 federal income tax return for any individual listed on this application as my dependent who is enrolled in coverage through this Marketplace, and who's premium for coverage is paid in whole or in part by advance payments of the premium tax credit. IF ANY OF THE ABOVE CHANGES I understand that it may impact my ability to get the premium tax credit. I also understand that when I file my 2026 federal income tax return, the Internal Revenue Service (IRS) will compare the income on my tax return with the income on my application. I

Agent of Record: Worley Richards

NPN: 7918700

Phone Number: (602) 606-7785

Email Address: worley@merebenefits.com

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Mere Benefits is a DBA of Health Wealth Simplified LLC, managed by Kate Spilsbury, Licensed Insurance Agent #9527400

Please make sure the spelling is accurate.

NOTE:

  • Social Security Number of ALL the household members on the application will be required AT THE TIME OF THE APPLICATION

2026 ACA Renewal Agreement Form

Important: Auto-renewal will not be available for 2026.


To keep your health coverage, you must have an appointment and finalize your plan selection during that time. Follow-up appointments will not be available due to the high volume of renewals and the majority of Americans needing to enroll.

What You Need to Know

  • Appointment Required:
    -I understand that my 2026 plan cannot be renewed without a scheduled appointment.

  • All Decision-Makers Must Be Present:
    I understand all decision-makers on my health plan must attend the appointment to finalize coverage.

  • One Appointment Only:
    I understand I need to be prepared to make final decisions during my appointment. Follow-up appointments will not be available.

  • Coverage Ending:
    I understand that my coverage should end on December 31, 2025 if I take no action, but I must confirm my 2026 plan to avoid a lapse in coverage.

  • Plan Terminations:
    If I choose not to have coverage in 2026, I understand that I must contact the Marketplace to terminate my coverage. Mere cannot terminate my policy. Failure to actively terminate coverage could result in tax penalties or repayment issues.

  • Premium Payment:
    I understand that premiums must be paid in full and up to date at the time of enrollment. The insurance carrier requires payment for the new plan at least by the day prior to the effective date of coverage. If I owe past-due premiums, any payment will first apply to my outstanding balance, and my new plan may not take effect.

  • Provider Networks:

    I understand that if I want to keep my current provider(s), I must contact them directly and ask which ACA Marketplace plan networks and companies they will be participating with in-network for 2026.

    While Mere strives to assist with provider lookups, due to the limited time available for appointments and the difficulty in reaching provider offices, this service will not be offered during the enrollment period. Providers must be researched in advance.

    I understand I am responsible for providing this information before my scheduled appointment, and it is preferred that I include it on this form. If I do not include it on this form, I may call 904-654-5450 to have it added to my file prior to my appointment.

    I also understand that providers may leave the network during the year. If my provider becomes out-of-network mid-year, I will need to find a new provider.

    Losing a provider does not qualify me to change plans unless I have a Special Enrollment Period (SEP).

Enrollment Deadlines

  • For a January 1, 2026 start date: Enrollment is November 1 – December 15, 2025.

  • For a February 1, 2026 start date: Enrollment is December 16 – January 15, 2026.

If I enroll on December 16 or later, I risk not having insurance for January 2026 unless I qualify for a Special Enrollment Period (SEP).

Estimate Your 2026 Subsidy.

You can get an idea of what your subsidy and potential rate increases might look like if Congress allows enhanced subsidies to expire by using the KFF Calculator (this is only an estimate for planning):
https://www.kff.org/interactive/how-much-more-would-people-pay-in-premiums-if-the-acas-enhanced-subsidies-expired/Accurate numbers will be available starting November 1, 2025.

Employer Group Health Benefits

Are you or any household member offered group health benefits through an employer?

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Other Considerations

List any specific things the Mere Benefits agent should be aware of when looking at options for 2026, including any must-haves, things you don’t use, or anything you want to avoid.

We will do our best to find a plan that accommodates your wishes, but please understand there are no perfect options.

© Copyright 2025. Mere Benefits.

All Right Reserved

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