Affordability Questionnaire Form

Find out your Marketplace eligibility today!

Beginning in 2023, if the employee’s cost for dependent coverage exceeds the ACA’s affordability threshold, then the dependents may be eligible for subsidized individual exchange coverage.

Family Glitch

Learn more about the “family glitch” and how it affects you. Then read about what changes are being made to the Affordable Care Act in 2023.

Learn More

Submit Questionnaire Below

Fill out the form below and we’ll be in touch with your Marketplace eligibility.

Your Name*
First Last
Your Email*
Your Phone Number*
Address*
City State / Province / Region ZIP / Postal Code
Employer Name*
Household Income/Size
Are you married?*
Number of tax dependent children?*
Number of members of tax household?*
What is your household income?*
Cost of Coverage Questions
What is the per-pay period Cost of EE+Child(ren) coverage through your Employer?*
How often are you paid?*
Is your Spouse offered affordable coverage through their employer (if any)?*
This field is for validation purposes and should be left unchanged.
This field is for validation purposes and should be left unchanged.

The next step is easy, call 877-872-4578 Or, Contact Us

About Main Street Insurance Group

We’re an independent insurance agency offering a comprehensive suite of insurance solutions to protect you from the unexpected.

We don’t just sell insurance. We work closely with clients to help them make important and informed decisions every day when it comes to protection and their future.

We offer comprehensive insurance solutions in North and South Carolina and throughout the Southeast.

Medicare Disclaimer:
We do not offer every plan available in your area. Any information we provide is limited to those plans we do offer in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.

Find out your Marketplace eligibility today!

Beginning in 2023, if the employee’s cost for dependent coverage exceeds the ACA’s affordability threshold, then the dependents may be eligible for subsidized individual exchange coverage.

Contact Us

Family Glitch

Submit Questionnaire Below

Fill out the form below and we’ll be in touch with your Marketplace eligibility.

Household Income/Size

Cost of Coverage Questions

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