Covered CA On Exchange
If you believe you qualify for a subsidy based on your income, you’ll be able to chose between our Platinum90 HMO, Gold80 HMO, Silver94 HMO, Silver87 HMO, Silver73 HMO, Silver70 HMO, Bronze60 HMO, Bronze60 HDHP HMO Health Plans.
If you used our Shop & Compare Tool and were estimated you qualify for a subsidy based on your income, use this form. If you’re not sure, please contact our sales team.
If you are new to Covered California or already have a Covered CA account, click Apply Online.
Off Exchange
If you are applying for either the Jade15 HMO Platinum, Amber50 HMO Silver, Platinum90 HMO, Gold80 HMO, Silver70 HMO, Bronze60 HMO, Bronze60 HDHP HMO Health Plan and you DO NOT qualify for a subsidy based on your income, fill out this form.
If you used our Shop & Compare Tool and were not told you qualify for a subsidy based on your income, use this form. If you’re not sure, please contact our sales team.
One Time Credit Card Authorization Form
(Visa/Mastercard Only)
Special Enrollment Attestation Form
Use if you have a Qualifying Life Event outside of the Open Enrollment Period (Nov 1- Jan 31).
If you already have an account with Covered CA, click Apply Online, to update your information.
