On-Exchange Texas Application

Enrollment Trigger

Enrollment Trigger (see full list) * 🛈

Date of Event (MM-DD-YY) *

Other Trigger Info *

Requested Eff Date (Earliest: 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#. 🛈

Does any member have Medicare? * 🛈

If "Yes", which members?

Is any member Disabled? * 🛈

If "Yes", which members? *

Were any members found not eligible for Medicaid or Children's Health Insurance in the past 90 days? * 🛈

If "Yes", which members? *

Member of a Federally Registered Indian Tribe? * 🛈

If "Yes", which members? *

Any children in foster care? *

If "Yes", which members? *

Is any member currently incarcerated (detained or jailed)? *

If "Yes", which members? *

Is any member pregnant? * 🛈

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

Has any member used tobacco 4 or more times a week in the past 6 months? * 🛈

If "Yes", which members? *

5. Income

Important Note: Income below 100% on income chart below will result in either medicaid (if pregnant or disabled) or NO subsidy.

Above 100% (See income chart below) offers subsidies, Texas Exchange plans, and potentially richer silver plans. No penalty has been applied since 2014 if income comes in under estimate when filing taxes since income is variable. Email us at help@texasplans.com with any questions!

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

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

If my income is below the medicaid limit (below: 100% on chart below, enroll me in the standard plans with no tax credit. *

Enroll in standard plans with no tax credit

Enroll in medicaid

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 * 🛈

Metal Level * 🛈

Network * 🛈

Plan Name ( please be exact, Thanks!) *

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.

Federal Exchange Confirmation by Mail - Usually within 5 business days from email confirmation

1st Invoice from Carrier - Usually within 5 days of Federal Exchange notification

IMPORTANT: 1st invoice activates the account and must be paid within 15 days of enrollment (email confirmation). Payment is made directly with the carrier.

Save & Return

Save your progress and complete this form later. (optional)