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By submitting this form, you agree that a licensed insurance agent from CYA Insurance Agency may contact you by phone, text, or email to discuss your health coverage options. You can unsubscribe at any time.

CYA Insurance Agency is a licensed, independent insurance agency. We are not affiliated with the government or Medicare.

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Once your form is submitted, you'll be prompted to schedule a convenient appointment time with one of our agents.

If you are legally "Married", select Yes

If you are separated, but not divorced, select Yes

If you are in a common law marriage. As long as you're living together, and your marriage is recognized in the state where you live, or in the state where the common law marriage began, and filing a joint federal tax return, select Yes

If you are a victim of domestic violence or spousal abandonment. Spousal abandonment means this person can't locate their spouse after making a reasonable attempt to find them, also known as desertion, select No

If you are widowed, select No

IMPORTANT: 👇

• Household income pertains to the year in which you carry the insurance.

• Total household income includes incomes from everybody in the household who’s required to file a tax return.

• If married, or filing a joint tax return, you must also include your significant other's income, even if they are not applying for coverage.

• Your tax credit is determined by your household's AGI, adjusted gross income. For more information about how to determine your AGI refer to the IRS website or your tax professional: https://www.irs.gov/filing/adjusted-gross-income#calculateAGI

List a person's name if they:

• Were denied state (Medicaid) by the state since the date shown because their income is too high.

• Were denied state (Medicaid) by the state because their state doesn't cover people with their household type (for example, some states don't cover adults who aren't taking care of children).

• Are a child denied State (Medicaid) by the state since the date shown because he or she needs to wait a month or more before starting coverage (called the waiting period).

• Had their (Medicaid) coverage end since the date shown because a change in state rules makes them not eligible for state (Medicaid).

Don't list a person's name if they:

• Never applied for State (Medicaid).

• Were found not eligible for state (Medicaid) by the Marketplace, instead of the state (Medicaid) agency.

• Were denied or found no longer eligible for state (Medicaid) since the date shown but had changes in income or family size since the denial or loss of coverage (unless the denial was based on immigration status).

• Applied for state (Medicaid) with the state but haven't received a response.

• Were denied state (Medicaid) coverage because they didn't turn in paperwork that the state asked for.

Select a person's name if they:
• Could get health coverage through one or more of their jobs, even if they're not currently enrolled or don't plan to enroll.
• Could get health coverage through a job, even if the employer's plan isn't currently in Open Enrollment.
• Don't think they can afford the coverage that's being offered.

Don't select a person's name if:
• They aren't offered coverage at all.
• They don't work enough hours to qualify.
• Their coverage offer is through someone else's job, like a spouse or parent. We'll ask about these offers later.
• The only type of coverage available through a job is a Health Reimbursement Arrangement (HRA).
• However, if a person is offered an HRA and another group health insurance plan, select their name.
• Their only option for coverage is COBRA continuation coverage or retiree coverage.

In 2026, a job-based health plan is considered "affordable" if your share of the monthly premium in the lowest-cost plan offered by the employer is less than 9.96% of your household income.

• The lowest-cost plan must also meet the minimum value standard.
  If you’re the employee, affordability is based on only the premium you’d pay for self-only (individual) coverage.

• For coverage starting January 1, if you’re offered job-based coverage through a household member’s job, affordability is based on the premium amount to cover everyone in the household.

• Total household income includes incomes from everybody in the household who’s required to file a tax return.

If the premiums aren’t considered affordable for the employee and the household, they may qualify for savings in a Marketplace plan. But, if the premium is considered affordable for the employee, but not for other members of the household, then only the other household members may qualify for savings.

After you click submit, be sure to schedule your appointment on our Calendly.