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Welcome to the Rock County Community Premium Assistance Application Portal

Are you suddenly without Medicaid coverage or health insurance?

Thank you for visiting the Application Portal. If you’ve found yourself suddenly without Medicaid coverage or Health Insurance, Rock County Community Premium Assistance Program is here to help.

What is the Rock County Community Premium Assistance Program?

This program assists individuals and families who cannot afford the full cost of their health insurance premiums through the Health Insurance Marketplace. If you qualify, the Rock County Community Premium Assistance Program will pay the difference between the actual cost of your health insurance premiums and the federal subsidy.

Who qualifies for this program?

To qualify, you need to meet the following criteria:

  • Reside in Rock County, Wisconsin
  • Have a household income between 100-150% of the current year federal poverty level
  • Enroll in any Silver-level plan that is available in Rock County

What information am I required to provide?

With the application, you must provide:

  1. Proof of Income/Address (Paystub, W-2, etc.)
  2. Proof of Health Insurance Enrollment (Print-out of Confirmation Page, Screenshot of Confirmation Page, or Confirmation Email from the Federal Marketplace Exchange)

How do I apply for premium assistance?

At this website, you can download the application and upload necessary documents to submit your application for premium assistance.

NOTE: All documents must be submitted at once for your application to be considered complete.

For more information, contact:

HealthNet of Rock County, Inc.
23 W. Milwaukee Street
Janesville, WI 53548

608-314-1923
data@healthnet-rock.org

Download

Rock County Community Premium Assistance Application

Step 2: Upload completed application & related documents

Please complete the following information upload the necessary documents to complete your application:

Please leave this field empty.

Name:

Address:

City, State, Zip:

Telephone Number:

Email Address:

FIle upload section

This form accepts pdf, tif,jpg, png and gif files. All others will be rejected and your form will not be sent. Note: Files larger than 2 MB may be rejected. If this happens, please email them to HealthNet.

Completed Application:

Address & Income Verification (Pay Stub, W-2, etc):

Proof of Health Insurance Enrollment (Print-out of Confirmation Page, Screenshot of Confirmation Page, or Confirmation Email from the Federal Marketplace Exchange):

Please enter any questions and/or notes for HealthNet staff: