Application for Health Insurance

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1 TM Application for Health Insurance Your destination for affordable health insurance, including Medi-Cal See Inside Application 2 19 Attachments A F Frequently Asked Questions The state of California created Covered California to help you and your family get health insurance. Use this application to see what insurance choices you qualify for: You can get this application in other languages Español Apply faster through Covered California at CoveredCA.com Or call: (TTY: ) You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m Heccrbq Hmoob STATE OF CALIFORNIA

2 Things to know What you need to know when you apply Employer and income information for everyone in your family. We keep your information private and secure, as required by law. Apply faster online When you re done CoveredCA.com results sooner! Covered California If you don t have all the information we ask for, sign and send in your application anyway. Get help with this application Online: CoveredCA.com Phone: Call our Customer Service Center at In person: CoveredCA.com or call office in person or call our Customer Service Center at Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 1

3 Start application here (use blue or black ink only) Step 1: Tell us about the adult who will be our main contact for this application First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Home City (home address) State County If it is not the same Mailing address or P.O. Box City State County Home Cell ( ) Home Cell ( ) Mail Yes If yes, Yes If yes, Yes If yes, If no, Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 2

4 Step 2: Tell us about yourself and your family You must include these people on this application: Your spouse own Complete Step 2 for each person in your family. Start with yourself! additional person. Person 1 yourself First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Self Male Female Married Divorced Separated Yes If yes, Yes If yes, No If no, CoveredCA.com. Person 1 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 3

5 Step 2: Person 1 Federal income tax information benefit Yes If yes, Yes If yes, Yes If yes, Yes Yes Yes not Yes To see if you have satisfactory status, Yes Yes Yes Yes If yes, Yes Yes Yes Yes If yes, Yes Yes Yes Tell us about your race (Optional: Filipino Japanese Korean Laotian Guamanian or Samoan Yes If yes, Salvadoran Guatemalan Puerto Rican are a federally recognized Person 1 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

6 Step 2: Person 1 Yes If yes, No If no, to Where do you work now? JOB 1: One-time payment Employer name JOB 2: One-time payment Employer name Are you self-employed? JOB 1: Yes If yes, No If no, to JOB 2: Yes If yes, No If no, to Do you have other income? Yes If yes, No If no, to Where does this income come from? How often do you get paid? (check one) How much? One-time payment One-time payment Does your from month to month? this Optional) next Optional) Do you have deductions? Yes If yes, No If no, Type of deduction How often do you get or pay for this deduction? (check one) How much? Student loan interest Student loan interest One-time payment One-time payment Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

7 Step 2: Person 2 the next person If you have more than four people First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) If it is not the same Home State County If it is not the same Mailing address or P.O. Box State County Home Cell ( ) Home Cell ( ) Male Female Married Divorced Separated Yes If yes, Yes If yes, No If no, Federal income tax information benefit Yes If yes, Dependent Yes If yes, Person 2 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

8 Step 2: Person 2 Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does Yes Did Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Tell us about this person's race (Optional: Filipino Japanese Korean Laotian Guamanian or Samoan Yes If yes, Salvadoran Guatemalan Puerto Rican a federally recognized Person 2 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

9 Step 2: Person 2 Yes If yes, No If no, to Where does this person work now? JOB 1: One-time payment Employer name JOB 2: One-time payment Employer name Is this person self-employed? JOB 1: Yes If yes, No If no, to JOB 2: Yes If yes, No If no, to Does this person have other income? Yes If yes, No If no, to Where does this income come from? How often does this person get paid? (check one) How much? One-time payment One-time payment Does this person's from month to month? this Optional) next Optional) Does this person have deductions? Yes If yes, No If no, Type of deduction How often does this person get this deduction? (check one) How much? Student loan interest Student loan interest One-time payment One-time payment Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 8

10 Step 2: Person 3 the next person First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) If it is not the same Home State County If it is not the same Mailing address or P.O. Box State County Home Cell ( ) Home Cell ( ) Male Female Married Divorced Separated Yes If yes, Yes If yes, No If no, Federal income tax information benefit Yes If yes, Dependent Yes If yes, Person 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

11 Step 2: Person 3 Yes If yes, No If no,. Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does Yes Did Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Tell us about this person's race (Optional: Filipino Japanese Korean Laotian Guamanian or Samoan Yes If yes, Salvadoran Guatemalan Puerto Rican a federally recognized Person 3 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 10

12 Step 2: Person 3 Yes If yes, No If no, to Where does this person work now? JOB 1: One-time payment Employer name JOB 2: One-time payment Employer name Is this person self-employed? JOB 1: Yes If yes, No If no, to JOB 2: Yes If yes, No If no, to Does this person have other income? Yes If yes, No If no, to Where does this income come from? How often does this person get paid? (check one) How much? One-time payment One-time payment Does this person's from month to month? this Optional) next Optional) Does this person have deductions? Yes If yes, No If no, Type of deduction How often does this person get this deduction? (check one) How much? Student loan interest Student loan interest One-time payment One-time payment Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 11

13 Step 2: Person 4 the next person First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) If it is not the same Home State County If it is not the same Mailing address or P.O. Box State County Home Cell ( ) Home Cell ( ) Male Female Married Divorced Separated Yes If yes, Yes If yes, No If no, Federal income tax information benefit Yes If yes, Dependent Yes If yes, Person 4 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 12

14 Step 2: Person 4 Yes If yes, No If no,. Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does Yes Did Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Tell us about this person's race (Optional: Filipino Japanese Korean Laotian Guamanian or Samoan Yes If yes, Salvadoran Guatemalan Puerto Rican a federally recognized Person 4 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 13

15 Step 2: Person 4 Yes If yes, No If no, to Where does this person work now? JOB 1: One-time payment Employer name JOB 2: One-time payment Employer name Is this person self-employed? JOB 1: Yes If yes, No If no, to JOB 2: Yes If yes, No If no, to Does this person have other income? Yes If yes, No If no, to Where does this income come from? How often does this person get paid? (check one) How much? One-time payment One-time payment Does this person's from month to month? this Optional) next Optional) Does this person have deductions? Yes If yes, No If no, Type of deduction How often does this person get this deduction? (check one) How much? Student loan interest Student loan interest One-time payment One-time payment Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

16 Step 3: Please read and sign this application You can choose an authorized representative City State County Date Privacy statement you provide on it is private and confidential. Covered only If you do not provide it, For more information or to see Covered California Covered California Department of Health Care Services Step 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

17 Step 3: Please read and sign this application at Covered California at California at CoveredCA.com office If someone on the application qualifies for Medi-Cal: For parents whose child or children qualify for Medi-Cal: Your rights and responsibilities Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

18 Step 3: Please read and sign this application Your right to appeal: appeal means to tell someone at decision. can explain my case to me. Renewal of insurance 3 years 2 years 1 year OR CoveredCA.com Step 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

19 Step 3: Please read and sign this application Certified Enrollment Counselor Certified Enrollment Entity Step 4: Mailing information and checklist Mail your signed application to: Covered California Did you remember to: Sign page 17 A few more questions 1. Would you like to be considered for all Medi-Cal programs? Yes If you check yes 2. Have you had any recent changes in your life that made you want to apply for health insurance? If yes Moved to California Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 18

20 Step 4: Mailing information and checklist How did you hear about Covered California? Radio ad Mailer Friend or family Certified Enrollment Counselor Employer Government Office Need more information about other programs? Or to apply CalFresh CalWORKs Access for Infants and Mothers (AIM) Child Health and Disability Prevention (CHDP) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Family Planning, Access, Care, Treatment (Family PACT) In-Home Supportive Services Program (IHSS) Women, Infants, and Children (WIC) Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

21 Attachment A: For federally recognized American Indians or Alaska Natives Complete this if you or a family member is American Indian or Alaska Native. make a copy of this Person 1: First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Yes If yes, Yes If no, Yes Yes If yes, No If no, Person 2: First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Yes If yes, Yes If no, Yes Yes If yes, No If no, Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 20

22 Attachment A: For federally recognized American Indians or Alaska Natives Person 3: First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Yes If yes, Yes If no, Yes Yes If yes, No If no, Person 4: First name Middle name Last name Suffix (examples: Sr., Jr., III, IV) Yes If yes, Yes If no, Yes Yes If yes, No If no, Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 21

23 Attachment B: Tell us about your family s health insurance. Tell us about the health insurance you have now examples Yes If yes, No If no, Name Person 1: Yes Person 2: Yes Person 3: Yes Person 4: Yes What type? Employer-sponsored insurance Peace Corps Employer-sponsored insurance Peace Corps Employer-sponsored insurance Peace Corps Employer-sponsored insurance Peace Corps Attachment B Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 22

24 Attachment B: Tell us about your family's health insurance Employer health insurance only Yes If yes, No If no, Name Name (for example, Jr., Sr., III, IV) Employer name This person: How much does this person pay in monthly premiums? Does this health plan meet the minimum value standard*? Person 1: Person 2: Person 3: Plans to enroll Plans to enroll Plans to enroll Yes Yes Yes Person 4: Plans to enroll Yes minimum value standard.* Quarterly Yearly * Minimum value standard Go back to the application Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 23

25 TM Attachment C: Employer Insurance Form This form is only necessary for those who are applying for health insurance through a job minimum value standard.* Quarterly Yearly Employee information Employee: First name Middle name Last name (Optional) Employer information Note for employer: Employer name: Employer address City State address. minimum value standard* Quarterly Yearly * Minimum value standard Go back to the application Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

26 Attachment D: Choose your health insurance plan. CoveredCA.com or call Medi-Cal and Covered California plans Covered California plans Only Name (for example, Jr., Sr., III, IV) Health plan name Metal tier Metal number Plan type Person 1: Platinum Gold Silver Person 2: Platinum Gold Silver Person 3: Platinum Gold Silver Person 4: Platinum Gold Silver EPO HMO PPO EPO HMO PPO EPO HMO PPO EPO HMO PPO Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

27 Attachment E: Step 2 references Immigration status Use this list for "Applying for health insurance" may qualify for health insurance visa petition Self-employment Use this list for "Are you self-employed?" for more information. Depreciation Repairs and maintenance Examples of other income Use this list for "Do you have other income?" Retirement or pension income Rent or royalty income Jury duty pay Miscellaneous Deductions Use this list for "Do you have deductions?" Certain self-employment expenses Student loan interest deduction Educator expenses Domestic production activities deduction Preguntas? Go back to the application Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com.

28 Attachment F: Federal Poverty Guidelines Number of people in your household If your annual household income is less than: If your annual household income is between: You may be eligilble for Medi-Cal. You may be eligilble for insurance with financial help through Covered California. Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

29 Frequently Asked Questions Getting help through Covered California 1. What is Covered California? Covered California. 2. What is Medi-Cal? 3. What is Access for Infants and Mothers (AIM)? 4. How can Covered California help me? 5. What health insurance is offered through Covered California? cannot refuse to cover you 6. Can I get health insurance through Covered California? 7. Can I get health insurance even if my income is too high? Frequently Asked Questions Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 28

30 Frequently Asked Questions Getting help through Covered California 8. How do I apply? Online: CoveredCA.com and simple terms. By phone: Call Covered California at By fax: Fax your application to By mail: Covered California In person: CoveredCA.com or call How much does it cost? CoveredCA.com 10. Do I need health insurance now that health reform has started? or Medi-Cal. adjustment. CoveredCA.com or call your local county social services office or Covered California. 11. I am currently enrolled in Medi-Cal. Can I get health insurance through Covered California? 12. What if I already have health insurance? insurance. Frequently Asked Questions Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com.

31 Frequently Asked Questions Getting help through Covered California 13. I don t have all the information I need to answer the questions on the application. What should I do? us at Can I get help with my application or with choosing a plan? Yes! Help is free. Certified Enrollment Counselors or Online: CoveredCA.com and simple terms. By phone: Call Covered California at In person: CoveredCA.com or call How can I choose a health insurance plan? CoveredCA.com to easily need medical care. Or, Care Options at What will happen after I apply? Financial assistance 17. I don't make a lot of money. What programs are available to help me get health insurance? A. Assitance with monthly premiums. Premium less in taxes. B. Medi-Cal: meet certain requirements. cost to you. Frequently Asked Questions Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 30

32 Frequently Asked Questions Financial assistance 18. If my income changes, will my premium assistance change immediately? 19. If my income changes, how will the change affect me when I file my taxes? amount of premium assistance and reduce your 20. What if I didn t file taxes last year? 21. What if my income changes after I apply? Other questions 22. Does everyone on the application have to be a U.S. citizen or U.S. national? national. 23. Will my family and I qualify for the same program? 24. This application asks for a lot of personal information. Will Covered California share my personal and financial information? insurance. 25. Will I be able to use my new Covered California health insurance plan right away? 26. What do you mean by disability? decisions. daily activities. You do not Frequently Asked Questions Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. Or visit CoveredCA.com. 31

33 Frequently Asked Questions Other questions 27. I have a pre-existing condition or disability. Can I get health insurance through Covered California? 28. I just found out I am pregnant. Can I apply for health insurance that will cover me during my pregnancy? 29. I just had a new baby. What should I do about health insurance? formsandpubs/forms/forms/mc330.pdf Will I qualify for health insurance if I am not a citizen or do not have satisfactory immigration status? 31. Where can I get information about becoming registered to vote? 32. What does self-employed mean? 32. I am a federally recognized American Indian or an Alaska Native. How can Covered California help me? Premium assistance 33. What if I don t agree with the decision Covered California makes? Online: CoveredCA.com. By phone: Call Covered California at By fax: By mail: In person: For a list of Certified Enrollment Counselors and CoveredCA.com or call Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 32

34 Extra help may be available CalFresh or visit or apply online at. Welltopia by DHCS Cool videos Like Welltopia by DHCS on Facebook! Go to: facebook.com/dhcswelltopia Follow Earned Income Tax Credit (EITC) Child Tax Credit Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sábados de 8 a.m. a 5 p.m. O visite CoveredCA.com. 33

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36 Getting help in other languages You can get help with this application in other languages. Call Podemos ayudarle en español a llenar esta solicitud. Llame al SPANISH VIETNAMESE TAGALOG HMONG Like Covered California on Facebook! Go to: Facebook.com/CoveredCA Follow

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