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Input Values

Date of Birth:	(MM/DD/YYYY)
Effective Date:
Deductible:	$500 $1,000 $1,500 $2,000 $2,000 HDHP $3,000 $4,000 $5,000 $7,500 $10,000
Gender:	Male Female
Smoker Status:	Smoker Non-Smoker
Maternity Coverage:

A Non-Smoker is defined as an individual that neither presently smokes or uses any tobacco products and has not smoked or used any tobacco products, regardless of frequency, during the 12 months immediately preceding the date of the Nebraska CHIP application.