Health Plan Needs Analysis
For self-employed, 1099 workers, W-2 employees, and anyone exploring better options
Back
Next
1. What is your current employment status?
*
Self-Employed / 1099
W-2 Employee
Small Business Owner with Employees
Unemployed
Other
2. If W2 employed, does your employer offer health benefits?
Yes, and I’m enrolled
Yes, but I declined coverage
No
Not applicable / Self-Employed
Will you be losing coverage soon?
Yes
No
If you have Empoyees how many are full time?
How many are part time employees?
Back
Next
3.What Is your Current Marital Tax Status?
*
Single
Married
Married filing seperate
Divorced
4. Who needs coverage?
*
Just me
Me + Spouse
Me + Kids
Me + Spouse + Kids
What's your estimated annual household income?(After taxes/dedutions-To calculate ACA subsidy eligibility)
*
Under $25,000
$25,000–$45,000
$45,001–$75,000
$75,001–$100,000
$100,000-$150,00
$150,000-$200,000
200,00+
How many people do you file as in household on your taxes?
*
1
2
3
4
5
6
More than 6
Back
Next
4. Do you currently have health insurance?
*
Yes, through the Marketplace (ACA)
Yes, through my employer
Yes, a private plan
No, I’m uninsured
5. How much do you currently pay monthly for health insurance?
*
$0-$399
$400–$799
$800-1000
$1000-1500
$1500+
I don't have insurance
Back
Next
Have you experienced any of these life changes in the last 60 days? (Check all that apply)
*
Lost health coverage (job loss, aging off parent plan, Medicaid loss, etc.)
Got married or divorced
Had a baby or adopted a child
Moved to a new ZIP code or state
Became a U.S. citizen or lawfully present immigrant
Released from incarceration
Change in income
Employer coverage ended or became unaffordable
None of the above
Back
Next
What is your Zip Code?
*
What is the birthdate of the oldest member of the family who will be needing insurance?
*
Back
Next
Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Thank you for your responses. This will help me determine the best options for your individual situation. We may need to followup with a phone call or Zoom call depending on the complexity. Once I review your answers, I will followup via email with next steps. The email will be coming from vanessa@thehealthplanhub.com
Submit
Should be Empty: