Tip for State-specific (CA, NY, CO, etc.)

Some state marketplaces have extended Open Enrollment periods — check your state

Tip for State-specific (CA, NY, CO, etc.)

State-based marketplaces may offer different plan options than HealthCare.gov

Tip for State-specific (CA, NY, CO, etc.)

Navigators and certified application counselors provide free help — use them

ACA Marketplacemoderate

State-Based Marketplace Application

State-specific (CA, NY, CO, etc.) · State-based marketplaces

State-specific marketplace application in states operating their own exchanges (17 states + DC).

Form Details

Total fields: 60
Auto-fillable: 38 (63%)
Time without BeneFill: 45 minutes
Time with BeneFill: 12 minutes
Time saved: 33 minutes
Filled by: patient
Frequency: annual
State-specific: Yes — form may vary by state

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Where to Submit This Form

🌐

Apply through your state's health insurance marketplace

States running their own marketplace include CA, CO, CT, DC, ID, KY, MA, MD, ME, MN, NJ, NM, NV, NY, PA, RI, VT, VA, WA. Visit your state's marketplace website.

🌐

Call your state marketplace's customer service line

Each state marketplace has its own phone number — check the state website.

🏢

In-person help through state-certified assisters or Navigators

Many state marketplaces offer storefront locations or community enrollment events.

Filing Deadline

Open Enrollment periods vary by state — some extend beyond the federal deadline. Special Enrollment Periods follow similar 60-day qualifying event rules.

Required Attachments

📎 Social Security Numbers for all household members
📎 Immigration documents (if applicable)
📎 Income documentation (pay stubs, tax returns, self-employment records)
📎 Current health coverage information

Processing Time

Online: typically instant eligibility determination. Paper applications: 1-2 weeks.

What Happens Next

Select a plan and pay your first month's premium. If eligible for Medicaid or CHIP, you may be auto-enrolled or directed to the appropriate program.

Tips for This Form

✓ Some state marketplaces have extended Open Enrollment periods — check your state
✓ State-based marketplaces may offer different plan options than HealthCare.gov
✓ Navigators and certified application counselors provide free help — use them
✓ If you qualify for both Marketplace and Medicaid, the application will route you to the right program

More ACA Marketplace Forms

Special Enrollment Period (SEP) Verification

Marketplace-specific · Marketplace

Documentation of qualifying life event (job loss, marriage, birth, move) for enrollment outside open enrollment. Must enroll within 60 days of qualifying event.

Income Verification / Data Matching Response

Marketplace-specific · Marketplace

Documentation resolving income discrepancies between application and IRS data. Failure to respond may result in APTC adjustment or loss of coverage.

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Disclaimer: BeneFill™ provides form-filling assistance and informational guidance only. It is not affiliated with, endorsed by, or sponsored by the State-based marketplaces or any government agency. The information provided is for general informational purposes and does not constitute legal, medical, financial, or tax advice. Always verify form requirements and submission details directly with the issuing agency.