Let's get to know you

ACA Marketplace Intake

Primary Applicant

First Name *

Last Name *

Date of Birth *

Gender *

MaleFemale

Do you use tobacco? *

YesNo

Include a spouse?Include dependent(s)?

Zip Code *

County *

The county you live in — this decides which plans are available to you.

Doctors & facilities

If a question below does not apply to any applicant, simply type N/A.

Prescription RX from last 12 months

Annual Household Adjusted Gross Income

▸ ⓘ See the 400% FPL income limit chart

Household size	400% FPL
1	$62,600
2	$84,600
3	$106,600
4	$128,600
5	$150,600
6	$172,600
7	$194,600
8	$216,600
9	$238,600
10	$260,600

Official reference: HealthCare.gov — Federal Poverty Level (FPL)

Household size *

Everyone on your tax return — you, your spouse if you file jointly, and anyone you claim as a dependent. Together with your income, this is what sets your subsidy.

Is dental or vision important to you?

Comments

Phone *

Email *