On-Exchange California Application

Enrollment Trigger

Enrollment Trigger (see full list) * 🛈

Date of Event (MM-DD-YY) *

Other Trigger Info *

Requested Eff Date (1st of any month following enrollment) *

1. The Basics

Address - Residence *

City *

Zip Code *

Address - Mailing if different

Phone Number *

Email for Confirmation * 🛈

2. Household

Number of Family Members (see info) * 🛈

Primary Member

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #2

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #3

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #4

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #5

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #6

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #7

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

Member #8

First Name *

Last Name *

Date of Birth * +

Marital Status *

SS# * 🛈

Enrolling? *

Gender *

Relationship *

3. Tax Status

How does household file taxes? * 🛈

Do you plan to file for this year and next? * 🛈

4. Eligibility

Are you offered Affordable health insurance through an Employer? * 🛈

Is everyone a US Citizen? *

For non-citizens, list members and document type, ID#, expiration date, and card ID#. Help here on how to find this info. 🛈

Does any member have Medicare? * 🛈

If "Yes", which members?

Is any member Disabled? * 🛈

If "Yes", which members? *

Medical expenses in past 3 months? * 🛈

If "Yes", which members? *

Member of a Federally Registered Indian Tribe? * 🛈

If "Yes", which members? *

Any children in foster care? * 🛈

If "Yes", which members? *

Are any children full time students? * 🛈

If "Yes", which members? *

Is any member pregnant? * 🛈

If "Yes", which member and due date? *

Is any member involved in a lawsuit? * 🛈

If "Yes", which members? *

Did you or someone in your household lose health coverage because of a strike or lockout? 🛈

5. Income

Important Note: Income below certain thresholds will result in either medi-cal or no tax credit.

Above 138% for adults (See income chart) or 266% for children under 19 offers tax credits, Covered Ca plans, and potentially richer silver plans. No penalty if income comes in under estimate when filing taxes have been applied since 2014 since income is variable. Email us at help@calhealth.net with any questions!

Best household Estimate for Income (for year coverage exists)? (click on "?" for guidance) * 🛈

Income Breakdown (see Instruction "?" mark) * 🛈

If my income is below the medi-cal limit (below: 138% for adults/266% for children under 19), enroll me in the standard plans with no tax credit. *

Enroll in standard plans

Enroll in medi-cal

Enroll kids in medi-cal only

5. Plan Selection

You can run your quote HERE. Make sure to put in income estimate and select "On Exchange" to see tax credit effect.

Medical

Carrier (Anthem Blue Cross and Blue Shield are two separate carriers) * 🛈

Metal Level * 🛈

Network * 🛈

Dental (if enrolling)

Carrier 🛈

Network *

5. Almost Complete!

E-Signature * 🛈

clear

Today's Date * 🛈 +

By signing, you agree to these terms and conditions.

What to Expect:

Email Confirmation - Usually received within 24 hours (business hours 9am-5pm Monday-Friday) of completed application with plan, rate, and effective date.

Covered California Confirmation by Mail - Usually within 5 business days from email confirmation

1st Invoice from Carrier - Usually within 5 days of Covered Ca letter

IMPORTANT: 1st invoice activates the account and must be paid within 15 days of enrollment (email confirmation). We can take first payment by phone after email confirmation or you can pay with invoice. You can also access pay by phone options here.

Save & Return

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