apply.coveredca.com Open in urlscan Pro
2a02:26f0:6c00:2a3::2a46  Public Scan

Form analysis
2 forms found in the DOM

<form class="locale-options">
  <div class="form-group segmented-control"><!-- react-text: 15 --><!-- /react-text --><!-- react-text: 16 --><!-- /react-text -->
    <div class="controls"><span><button id="locale-options-0" class="segmented-option btn selected btn-primary" data-value="en"><span class="wrapper-text">English</span></button></span><span><button id="locale-options-1"
          class="segmented-option btn btn-default" data-value="es"><span class="wrapper-text">Español</span></button></span></div><!-- react-text: 24 --><!-- /react-text --><!-- react-text: 25 --><!-- /react-text -->
  </div>
</form>

<form>
  <h5>Answer these questions to find out if you qualify for help to lower your health care costs.</h5><br>
  <div class="row">
    <div class="col-xs-12 col-sm-5 col-md-5">
      <div class="form-group drop-down formitem"><label for="screeningquestions-enrollyear"><span>Coverage
            Year:</span><!-- react-text: 73 --><!-- /react-text --><!-- react-text: 74 --><!-- /react-text --><!-- react-text: 75 --><!-- /react-text --></label><!-- react-text: 76 --><!-- /react-text -->
        <div class="Select has-value is-searchable Select--single"><input type="hidden" name="enrollYear" value="2022">
          <div class="Select-control">
            <div class="Select-multi-value-wrapper" id="react-select-screeningquestions-enrollyear--value">
              <div class="Select-value"><span class="Select-value-label" role="option" aria-selected="true" id="react-select-screeningquestions-enrollyear--value-item">2022</span></div>
              <div class="Select-input" style="display: inline-block;"><input id="screeningquestions-enrollyear" aria-activedescendant="react-select-screeningquestions-enrollyear--value" aria-expanded="false" aria-haspopup="false" aria-owns=""
                  role="combobox" value=""></div>
            </div><span class="Select-arrow-zone"><span class="Select-arrow"></span></span>
          </div>
        </div><!-- react-text: 85 --><!-- /react-text --><!-- react-text: 86 --><!-- /react-text --><!-- react-text: 87 --><!-- /react-text -->
      </div><br>
      <div class="form-group required numeric-input"><label for="screeningquestions-zip"><span>What is your Zip Code?</span><!-- react-text: 92 --><!-- /react-text --><span
            class="tooltip-container"><a href="#" class="tooltip-info-icon" id="screeningquestions-zip-tooltip-anchor" aria-expanded="false" aria-describedby="screeningquestions-zip-tooltip-text"><span class="sr-only"><span>More information</span></span></a><span
              id="screeningquestions-zip-tooltip-text" class="tooltip" role="tooltip" aria-hidden="true" aria-labelledby="screeningquestions-zip-tooltip-anchor" style="display: none;"><span>Enter the residence address zip code
                here.</span></span></span><!-- react-text: 99 --><!-- /react-text --></label><!-- react-text: 100 --><!-- /react-text --><input type="number" name="zip" id="screeningquestions-zip" placeholder="Ex: 90210" required="" autocomplete="on"
          for="screeningquestions-zip" class="form-control" aria-describedby="screeningquestions-zip-error-required"><!-- react-text: 102 --><!-- /react-text --><!-- react-text: 103 --><!-- /react-text --></div><span></span>
    </div>
  </div><label for="screeningquestions-householdincomeperyear"><span>What is your total household income per year?</span></label><!-- react-text: 107 -->&nbsp;&nbsp;<!-- /react-text --><span
    class="tooltip-container"><a href="#" class="tooltip-info-icon" id="screeningquestions-householdincomeperyeartooltip-tooltip-anchor" aria-expanded="false" aria-describedby="screeningquestions-householdincomeperyeartooltip-tooltip-text"><span class="sr-only"><span>More information</span></span></a><span
      id="screeningquestions-householdincomeperyeartooltip-tooltip-text" class="tooltip" role="tooltip" aria-hidden="true" aria-labelledby="screeningquestions-householdincomeperyeartooltip-tooltip-anchor" style="display: none;"><span>Enter an
        estimated amount of your total annual household income. Enter the gross amount (before taxes are deducted), and be sure to include the income of all household members.</span></span></span>
  <div class="row">
    <div class="col-xs-12 col-sm-5 col-md-5">
      <div class="form-group required"><!-- react-text: 117 --><!-- /react-text --><!-- react-text: 118 --><!-- /react-text --><input type="text" name="householdincomeperyear" maxlength="50" id="screeningquestions-householdincomeperyear" required=""
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          aria-describedby="screeningquestions-householdincomeperyear-error-required"><!-- react-text: 120 --><!-- /react-text --><!-- react-text: 121 --><!-- /react-text --></div>
    </div>
  </div><label for="screeningquestions-howmanypeopleinhousehold"><span>How many people are in your household?</span></label><!-- react-text: 124 -->&nbsp;&nbsp;<!-- /react-text --><span
    class="tooltip-container"><a href="#" class="tooltip-info-icon" id="screeningquestions-howmanypeopleinhouseholdtooltip-tooltip-anchor" aria-expanded="false" aria-describedby="screeningquestions-howmanypeopleinhouseholdtooltip-tooltip-text"><span class="sr-only"><span>More information</span></span></a><span
      id="screeningquestions-howmanypeopleinhouseholdtooltip-tooltip-text" class="tooltip" role="tooltip" aria-hidden="true" aria-labelledby="screeningquestions-howmanypeopleinhouseholdtooltip-tooltip-anchor" style="display: none;"><span>Enter the
        number of household members including you.</span></span></span>
  <div class="row">
    <div class="col-xs-12 col-sm-5 col-md-5">
      <div class="form-group drop-down formitem"><!-- react-text: 134 --><!-- /react-text --><!-- react-text: 135 --><!-- /react-text -->
        <div class="Select is-searchable Select--single">
          <div class="Select-control">
            <div class="Select-multi-value-wrapper" id="react-select-screeningquestions-howmanypeopleinhousehold--value">
              <div class="Select-placeholder">Select One</div>
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            </div><span class="Select-arrow-zone"><span class="Select-arrow"></span></span>
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        </div><!-- react-text: 144 --><!-- /react-text --><!-- react-text: 145 --><!-- /react-text --><!-- react-text: 146 --><!-- /react-text -->
      </div>
    </div>
  </div><span>
    <h5>Enter the age of each person in your household, and tell us if they need coverage.</h5><br>
  </span>
  <div class="col-sm-12 col-md-12 seemyresultswrapper">
    <div class="col-sm-8 col-md-9">&nbsp;&nbsp;</div>
    <div class="col-sm-4 col-md-3"><button id="account-creation-access-code-invalid-modal-button" type="submit" disabled="" class="btn btn-primary btn-block"><span>See My Results</span></button></div>
  </div>
</form>

Text Content

COVERED CALIFORNIA

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Need Help?Expand

Get help over the phone (800) 787-6921

 * Call Us
 * Live Chat
 * Find Local Help
 * FAQs


SHOP AND COMPARE

Tell us a little bit about yourself

The information below will help us determine your potential health coverage
program eligibility. You may qualify for help to lower your health care costs.

ANSWER THESE QUESTIONS TO FIND OUT IF YOU QUALIFY FOR HELP TO LOWER YOUR HEALTH
CARE COSTS.


Coverage Year:
2022


What is your Zip Code?More informationEnter the residence address zip code here.
What is your total household income per year?  More informationEnter an
estimated amount of your total annual household income. Enter the gross amount
(before taxes are deducted), and be sure to include the income of all household
members.

How many people are in your household?  More informationEnter the number of
household members including you.
Select One


ENTER THE AGE OF EACH PERSON IN YOUR HOUSEHOLD, AND TELL US IF THEY NEED
COVERAGE.


  
See My Results