1. Rates are standardized for Covered Ca plans so these are the best
rates available with full tax credit based on your submitted information.
2. As Certified Covered California agents, there is no cost for our service. We can help you throughout the year with your account and coverage.
3. There is no obligation with online app submittal. Simply do not pay first month's premium to cancel the policy never effective. The first payment activates the policy.
By signing, you agree to the following:
1. To file a federal income tax return on or before the due date for the return (including extensions of time for filling) to claim the Advanced Premium Tax Credit (APTC), if applicable.
2. To report changes to Covered California that affect my eligibility, including: income, household size and address. These changes could affect the plans and APTC for which I am eligible.
3. I cannot switch plans outside of the Open Enrollment Period unless I have a qualifying life event. Some of the qualifying life events are a permanent move that results in access to new plans, birth or adoption of a child, marriage or domestic partnership.
1. I understand that every participating health plan has its own rules for resolving disputes or claims, including, but not limited to, any claim asserted by me, my enrolled dependents, heirs, or authorized representatives against a health plan, any contracted health care providers, administrators, or other associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or items, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), or premises liability.
2. I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept, and agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law) and give up my right to a jury trial and cannot have the dispute decided in court, except as applicable law provides for judicial review of arbitration proceedings.
3. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plan's coverage document, which is available online at CoveredCA.com for my review, or I can call Covered California for more information.
1. Covered California checks other agencies' computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if you and other people on this application qualify for health insurance.
2. Covered Ca partners with Experian for identity verification. Experian will use information from other agencies to help check your identity. This information will never be presented to outside parties. This information will not affect your credit score. The report will be called "CMS Proofing Services" and will be taken off your Experian consumer report after 25 months.
3. The 4 identity verification questions will be emailed to you securely or a representative will call to complete this step.
4. Your signature is consent to access your identity information through the Federal Data Services Hub Remote ID Proofing Service
You can apply for free or low cost health care through Medi-Cal or Covered California at any time of the year. To enroll in a health plan through Covered California, you must have a qualifying life event during the special enrollment period (outside of the Open Enrollment Period). If you are eligible for Medi-Cal you can enroll through the year. Please make sure your application is true and correct. If you provide false information, your coverage may be cancelled. The U.S. Department of Health and Human Services may also fine you for providing false information.
You may be fined up to $25,000 if you negligently or with intentional disregard for the rules provide false information in your application.
You may be fined up to $250,000 if you knowingly lie on your application.
Covered California may request that you provide documents to show you qualify for coverage.
Medi-Cal Estate Recovery Alert
The Medi-Cal program must seek repayment from the estates of certain deceased Medi-Cal members for payments made, including managed care premiums, for nursing facility services, home and community-based services, and related hospital and prescription drug services provided to the deceased Medi-Cal member on or after the member's 55th birthday. If a deceased member does not leave an estate or owns nothing when they die, nothing will be owed. For more information you may visit the Estate Recovery website at http://dhcs.ca.gov/er or call (916) 650-0590.
Covered California Nondiscrimination Policy
Covered California complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Covered California does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
Covered California provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats and other formats).
Covered California also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.
If you need these services, contact the Civil Rights Coordinator at (916) 228-8764 or by email at CivilRights@covered.ca.gov .
If you believe that Covered California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with the Civil Rights Coordinator.
You can file a grievance in person in any of the following ways:
Mail: Civil Rights Coordinator, P.O. Box 989725, West Sacramento, CA 95798-9725
Phone: (916) 228-8764
Fax: (916) 228-8909
You can also file a civil rights complaint with the Office for Civil Rights at the U.S. Department of Health and Human Services.
Mail: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201
Phone: (800) 868-1019 or TTY: (800) 537-7697
Online: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available on the U.S. Department of Health and Human Services Office for Civil Rights website.
I certify (or declare) under penalty of perjury under the laws of the State
of California that the foregoing is true and correct.
If you are found eligible for Medi-Cal, you must tell your county eligibility worker about any changes that may affect your eligibility for health insurance within 10 days of the change.
These changes include, but are not limited to:
I have understood all the questions on this application and provided true and correct answers to such questions to the best of my knowledge. Where I do not have personal knowledge of an answer, I have made every reasonable attempt to verify (or confirm) the information with someone who has personal knowledge of the answer.
I know that if I am not truthful there may be a civil and/or criminal penalty for perjury (under California Penal Code Section 126, perjury is punishable by imprisonment for up to four years).
I know that all information disclosed on this application will be used to determine eligibility of every person applying for health insurance on this application. The information will be kept private as required by federal and California law.
I understand that if I have received advanced premium tax credits for health coverage through Covered California during the previous benefit year, I must have filed or will file a federal income tax return for that benefit year.
By entering my full name on the application, I agree that this digital signature shall have the same force and effect as if I signed this application by my own hand.