Open Enrollment Marketplace What is needed for Open Enrollment Marketplace? Streamlined intake for enrolling in ACA or private health plans Captures essential details for regulatory compliance and plan matching Suitable for individuals, couples, or families Ensures a flexible, efficient experience with thorough information collection Designed to maximize your access to affordable, high-quality coverage Open Enrollment Marketplace Newsletter First NameLast NameEmailPhoneZip CodeCounty– Select –Anderson CountyAndrews CountyAngelina CountyAransas CountyArcher CountyArmstrong CountyAtascosa CountyAustin CountyBailey CountyBandera CountyBastrop CountyBaylor CountyBee CountyBell CountyBexar CountyBlanco CountyBorden CountyBosque CountyBowie CountyBrazoria CountyBrazos CountyBrewster CountyBriscoe CountyBrooks CountyBrown CountyBurleson CountyBurnet CountyCaldwell CountyCalhoun CountyCallahan CountyCameron CountyCamp CountyCarson CountyCass CountyCastro CountyChambers CountyCherokee CountyChildress CountyClay CountyCochran CountyCoke CountyColeman CountyCollin CountyCollingsworth CountyColorado CountyComal CountyComanche CountyConcho CountyCooke CountyCoryell CountyCottle CountyCrane CountyCrockett CountyCrosby CountyCulberson CountyDallam CountyDallas CountyDawson CountyDeaf Smith CountyDelta CountyDenton CountyDeWitt CountyDickens CountyDimmit CountyDonley CountyDuval CountyEastland CountyEctor CountyEdwards CountyEl Paso CountyEllis CountyErath CountyFalls CountyFannin CountyFayette CountyFisher CountyFloyd CountyFoard CountyFort Bend CountyFranklin CountyFreestone CountyFrio CountyGaines CountyGalveston CountyGarza CountyGillespie CountyGlasscock CountyGoliad CountyGonzales CountyGray CountyGrayson CountyGregg CountyGrimes CountyGuadalupe CountyHale CountyHall CountyHamilton CountyHansford CountyHardeman CountyHardin CountyHarris CountyHarrison CountyHartley CountyHaskell CountyHays CountyHemphill CountyHenderson CountyHidalgo CountyHill CountyHockley CountyHood CountyHopkins CountyHouston CountyHoward CountyHudspeth CountyHunt CountyHutchinson CountyIrion CountyJack CountyJackson CountyJasper CountyJeff Davis CountyJefferson CountyJim Hogg CountyJim Wells CountyJohnson CountyJones CountyKarnes CountyKaufman CountyKendall CountyKenedy CountyKent CountyKerr CountyKimble CountyKing CountyKinney CountyKleberg CountyKnox CountyLa Salle CountyLamar CountyLamb CountyLampasas CountyLavaca CountyLee CountyLeon CountyLiberty CountyLimestone CountyLipscomb CountyLive Oak CountyLlano CountyLoving CountyLubbock CountyLynn CountyMadison CountyMarion CountyMartin CountyMason CountyMatagorda CountyMaverick CountyMcCulloch CountyMcLennan CountyMcMullen CountyMedina CountyMenard CountyMidland CountyMilam CountyMills CountyMitchell CountyMontague CountyMontgomery CountyMoore CountyMorris CountyMotley CountyNacogdoches CountyNavarro CountyNewton CountyNolan CountyNueces CountyOchiltree CountyOldham CountyOrange CountyPalo Pinto CountyPanola CountyParker CountyParmer CountyPecos CountyPolk CountyPotter CountyPresidio CountyRains CountyRandall CountyReagan CountyReal CountyRed River CountyReeves CountyRefugio CountyRoberts CountyRobertson CountyRockwall CountyRunnels CountyRusk CountySabine CountySan Augustine CountySan Jacinto CountySan Patricio CountySan Saba CountySchleicher CountyScurry CountyShackelford CountyShelby CountySherman CountySmith CountySomervell CountyStarr CountyStephens CountySterling CountyStonewall CountySutton CountySwisher CountyTarrant CountyTaylor CountyTerrell CountyTerry CountyThrockmorton CountyTitus CountyTom Green CountyTravis CountyTrinity CountyTyler CountyUpshur CountyUpton CountyUvalde CountyVal Verde CountyVan Zandt CountyVictoria CountyWalker CountyWaller CountyWard CountyWashington CountyWebb CountyWharton CountyWheeler CountyWichita CountyWilbarger CountyWillacy CountyWilliamson CountyWilson CountyWinkler CountyWise CountyWood CountyYoakum CountyYoung CountyZapata CountyZavala CountyAdd P.O. Box information if applicable? YesPO Box DetailsPLEASE READ THOROUGHLY Prescription names, doses, frequencies and quantities: If you’re not taking prescriptions, please type N/A. If you take something as needed, please let me know how often it is refilled. If you require brand name over generic medications, please specify. If you have something in a tube, I need to know the tube size and how often it is refilled. If you use GoodRx or any savings programs to pay for any medications, please add those below and make a note indicating by using (*) If you’re getting any medications through a savings program, please leave this off the list as it will not be factored into the prescription plan. Please leave off any medications/infusions/injections etc. that are given to you by a doctor or any supplies that are already covered under Part B.Prescription names, doses, frequencies and quantities…Please list your doctors and their specialitiesWill you file your Annual Taxes as an individual or joint? Individual JointProjected Current Years Adjusted GROSS IncomeWill you claim any dependents this year? Yes NoPlease list names, dates of birth (mm/dd/yyyy) and gender (M/F) for all dependentsPreferred method of communication Email Text CallBest time to have a call? 9am-Noon Noon-5pm 5pm-9pm AnytimeSave & ResumeSubmit
