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Open Enrollment 2023 Screening - Save Time and Skip the Line!
Answer the below questions about your current situation. If you need help determining the answer to any of the questions, schedule an appointment through our automated scheduling system by calling 732-523-1789. Follow the prompts to schedule an appointment to discuss open enrollment and private health insurance options.

Please note we no longer have appointments available in December. If you need coverage for January, we will provide you with information and guidance to apply on your own. We can also schedule an appointment with an LRRC Navigator in January to review your application and compare plans for February coverage.

IF YOU ARE CURRENTLY ACTIVE ON NJ FAMILYCARE PLEASE NOTE:
NJ FamilyCare will not be terminating anyone who is no longer eligible for coverage until the federal public health emergency ends (date unknown at this time). If you are currently active on NJ FamilyCare and believe you are no longer eligible, do not fill out this form. You will be eligible for a Special Enrollment Period to enroll in private insurance coverage when you receive notice that you are being terminated. If you need private insurance for 2023, please call the LRRC to discuss your situation. In the interim, if you receive a renewal packet, do not ignore it! All renewal packets must be returned by the due date.
What is your first and last name?
Can we contact you through e-mail? (Response time for e-mail is 2 business days. Response time for a phone call is 4 business days.) *
Best Contact Number *
Preferred E-mail Address *
Home Address *
City *
State *
Zip Code *
What is your family size? *
Count everyone who will appear on your tax return (Form 1040). Do not include unborn children
Who Needs Insurance (Check All That Apply)? *
Required
What is your birthday? *
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What is your spouse's birthday?
MM
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DD
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YYYY
What is your current medical insurance? *
List all the insurance providers for all family members seeking coverage. Include Medicaid in any State, Commercial, or Private Insurance. Write "uninsured" if you do not have insurance. 

IF YOU ARE CURRENTLY ACTIVE ON NJ FAMILYCARE PLEASE SEE NOTE IN THE INSTRUCTIONS ABOVE.
Is anyone in your family pregnant? *
Did you file a tax return last year? *
How much income will your family receive in 2023 (estimated)? *
Enter the amount of income that anyone on your tax return is expected to receive in 2023. For those that receive income from an employer, enter the amount expected to receive before taxes. For those that are self-employed or receive rental income, enter the estimated net income (after expenses). For those who are self-employed, we recommend speaking to your accountant to calculate this number. Please note that this projected amount can change throughout the year. The number you are providing is an estimate.
Did you ever receive insurance through The Marketplace? *
If you are currently receiving insurance through The Marketplace, do you have any changes of income since last year's application?
Clear selection
Do you or your spouse's employer offer the option of medical insurance? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *
If an employer does give you the option of purchasing insurance, does the employer also offer an option for the spouse to join the plan? Enter yes whether or not you would consider enrolling in the plan, and regardless of the price. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER. *
If an employer does give you the option of purchasing insurance, enter the amount it would cost the EMPLOYEE to buy the CHEAPEST possible EMPLOYEE only plan. DO NOT ANSWER THIS QUESTION UNTIL YOU ARE CERTAIN THAT YOU KNOW THE ANSWER.
Please enter a monthly dollar amount
If an employer does give you the option of purchasing insurance, what is the cost of the cheapest COUPLE plan? 
Please enter a monthly dollar amount
If an employer does give you the option of purchasing insurance, what is the cost of the cheapest FAMILY plan? 
Please enter a monthly dollar amount
Additional notes for the LRRC Case Manager
Please use this space to write any additional information that will help the Case Worker understand your situation.
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