Covered CA

DETERMINE YOUR INCOME

Please complete the form below to help us determine whether or not you are eligible for a subsidy through Covered California. Please note any fields marked with an * are required.

**PLEASE NOTE: If you are married, you must file your taxes as
Married Filing Jointly to qualify for a subsidy. If you file as Married Filing Separately, you WILL NOT qualify for any subsidy amount.

What Counts as Income?

In order to determine how much financial help you can get, you will need to estimate your household income for the current year.
Include income from anyone you claim on your taxes.

If you think your income may change in the future and aren’t sure how much costs are going to change, click on the Shop & Compare link below:
Shop & Compare Health Insurance Plans | Covered California™

**If your estimated income changes during the year,
please be sure to update your Covered California account accordingly.**
_{What Counts as Income instructions are current as of 04/08/2024.}

Covered CA – Determine Your Income

Which Get Benefits agent is assisting you? *

Kelli Ramirez

Matt Munowitch

Nicole Wilson

OtherOther

First Name of Primary Applicant *

Last Name of Primary Applicant *

Date of Birth *

Zip Code *

Phone Number *

Please enter the best number to reach you on.

Email Address *

Gross Taxable Income for your Household *

$.00

Be sure to include your spouse’s income if you are married and file your taxes as Married Filing Jointly.

Number of People in your Household *

**If claiming a dependent who has worked and has income, you may need to talk to an accountant FIRST to determine your income.**

Are you married, and file your taxes as Married Filing Jointly? *

Yes

No

Do you have any Dependents you claim on your taxes? *

Yes

No

Spouse’s First Name *

Spouse’s Last Name *

Spouse’s Date of Birth *

Claimed Dependent’s First Name *

Claimed Dependent’s Last Name *

Claimed Dependent’s Date of Birth *

Claimed Dependent’s First Name