CA-SingleStreamApp 66MAX 092713 With Edit

Application for Health Insurance
Your destination for affordable health insurance, including Medi-Cal

See Inside
Things to know
TM
Application 219 Attachments AF Frequently Asked Questions 2027 2832
Covered California is the place where individuals and families can get affordable health insurance. With just one application, youll find out if you qualify for free or low-cost health insurance, including Medi-Cal.
The state of California created Covered California to help you and your family get health insurance.
Having health insurance can give you peace of mind and help make it possible for you to stay healthy. With insurance, youll know you and your family can get health care when you need it.
You can get this application in other languages

Espaol
1-800-300-0213 1-800-300-1533
Ting Vit 1-800-652-9528 Tagalog

Heccrbq 1-800-738-9116 1-800-983-8816 1-800-778-7695
Use this application to see what insurance choices you qualify for:
Free or low-cost insurance from Medi-Cal Low-cost insurance for pregnant women through Access for Infants and Mothers (AIM) Affordable private health insurance plans Help paying for your health insurance
1-800-996-1009 1-800-921-8879 1-800-906-8528 1-800-771-2156 1-800-826-6317
You may qualify for a free or low-cost program even if you earn
as much as $92,000 a year for a family of 4. even if they already have insurance now. You can use this application to apply for anyone in your family,
Hmoob
Apply faster through Covered California at CoveredCA.com

Or call: 1-800-300-1506 (TTY: 1-888-889-4500) You can call Monday to Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m.
Call 1-800-300-1506 to get this application in other formats such as large print.
STATE OF CALIFORNIA Health Insurance Application (09/13) | CCFRM604
Things to know
What you need to know when you apply
Social Security numbers for applicants who are U.S. citizens, or document information for immigrants with satisfactory status who need insurance. Proof of citizenship or immigration status is required only for applicants. Employer and income information for everyone in your family. Your federal tax information. For example, the person who files taxes as head of household and the dependents claimed on your taxes. Information about health insurance that you or any family member gets through a job. We ask about income and other information to make sure you and your family get the most benefits possible. We keep your information private and secure, as required by law. Well use your information only to see if you qualify for health insurance. Families that include immigrants can apply. You can apply for your child even if
you arent eligible for coverage. Applying for your eligible child wont affect your immigration status or chances of becoming a permanent resident or citizen. through Medi-Cal.
If you dont file taxes, you can still qualify for free or low-cost insurance If you are a federally recognized American Indian or Alaska Native who is
getting services from an Indian Health Services funded tribal health program or urban Indian health program, you may still qualify for health insurance through Covered California.
Apply faster online When youre done
Apply online at CoveredCA.com. It's safe, secure, and fast and you will get results sooner! Send your completed and signed application to: Covered California P.O. Box 989725 West Sacramento, CA 95798-9725 If you dont have all the information we ask for, sign and send in your application anyway. We can call you to help you finish your application.
Get help with this application
We're here to help you! You can get help at no cost. Online: CoveredCA.com Phone: Call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500). 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. In person: We have trained Certified Enrollment Counselors and Certified Insurance Agents who can help you. For a list of Certified Enrollment Counselors and Certified Insurance Agents near where you live or work, or a list of county social services offices near you, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500). This help is free! If you have a disability or other need, we can provide assistance with completing this application at no cost to you. You can go to your local county social services office in person or call our Customer Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).
Need help?
Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). 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.
Start application here (use blue or black ink only) Step 1:

First name Home address City (home address) State ZIP code County
Tell us about the adult who will be our main contact for this application
Middle name Last name Suffix (examples: Sr., Jr., III, IV) Apartment #
Check here if you do not have a home address. You must give us a mailing address below. heck here if your mailing address is the same as your home address. C If it is not the same, you must give us your mailing address below: Apartment # State ZIP code County
Mailing address or P.O. Box (if different from home address) City (mailing address) Best phone number to reach you Number:
Home Cell Work
Other phone number Number:
Home Cell Work
What language should we write to you in? How would you like to get information about this application?
What language do you want us to speak to you in?
Phone
Mail
Email Email address: _____________________________________________________________________________________________________________________________________
Infants less than one year old are eligible for Medi-Cal if their mother was on Medi-Cal or AIM at the time of delivery. You do not need to fill out an application to get Medi-Cal for an infant born to a mother with Medi-Cal or AIM at the time of delivery. Call your county social services office when your baby is born to make sure your baby is covered. Or fill out the information below.
Optional: If the following information is provided, the infant may be automatically eligible for Medi-Cal. You do not have to fill out Step 2 of this application for the infant. Are you applying for a child less than 1 year old?
Yes No Yes No
Yes
If yes, did the childs mother have Medi-Cal or AIM when the child was born? If yes, will the childs mother be listed on this application?
No
If yes, the mother is Person #_____________________ on this application If no, what is the mothers first and last name? _______________________________________________________________________ Please provide the mothers Medi-Cal number, AIM number, or SSN___________________________________________________________
Preguntas?
Llame a Covered California al 1-800-300-1506 (TTY: 1-888-889-4500). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 6 p.m. y los sbados de 8 a.m. a 5 p.m. O visite CoveredCA.com.
Step 2:
Tell us about yourself and your family
Your income and family size help us decide what programs you qualify for. With this information, we can make sure everyone gets the best coverage possible.
You must include these people on this application:

Your spouse Your children who live with you All parents living in the home with their child Anyone on your federal income tax return, if you file one. You dont need to file taxes to apply for health insurance. If you are claimed as a dependent on someone else's tax return, you must include all members of the tax filing household that claimed you, and any family members living with you. his or her own application if they want health insurance. Anyone else who lives with you for example, a boyfriend, girlfriend, or roommate will need to file
Complete Step 2 for each person in your family. Start with yourself!
To apply for more than four people on this application, make a copy of pages 68 for each additional person. Well keep all your information private, as required by law. Well use personal information only to see if you qualify for health insurance. You do not need to provide the immigration status or Social Security number (SSN) for those in your family who are not applying for health insurance.
Person 1 Tell us about yourself

First name Are you: Middle name Last name Are you: Suffix (examples: Sr., Jr., III, IV) Relationship to you
Self
Male Female
Date of birth (month / day / year)
Single Never married Married Divorced Registered domestic partner Separated Widowed Are you pregnant? Yes No If yes, how many babies are expected? _____________

What is the expected delivery date? _______________________________________________________________________________________
Applying for health insurance Even if you have insurance now, you might find better coverage or lower costs.
Are you applying for health insurance for yourself?
Yes
If yes, answer the questions below.
No
If no, go to the next page.
If you do not have an SSN, what is the reason? Social Security number (SSN)
Adoption Taxpayer Identification Number (ATIN) _________________________________________________________ _ _ _ _ _ _ _ _ _ Individual Taxpayer Identification Number (ITIN) __________________________________________________________ Religious exemption I do not qualify for an SSN
You must provide a Social Security number (SSN) if you or a family member wish to apply for health insurance,
or if you file taxes as head of household. We use Social Security numbers (SSNs) to check income and other information. Even if you are not applying, giving your SSN will help us review your application faster. If someone who is applying does not have an SSN and would like help getting one, call 1-800-300-1506 (TTY: 1-888-889-4500 ) or visit CoveredCA.com.
Person 1 continued on next page
Need help?
Step 2:
Person 1
(continued)
Federal income tax information If you dont file taxes, you can still qualify for free or low-cost insurance through
Medi-Cal. We will keep your information private. We will use your information only to decide if you qualify for health insurance.
Are you going to file taxes for the benefit year? Does anyone claim you as a dependent on their taxes? If yes, who? Person #_______________________ on this application
Yes No
If yes, how will you file?
Yes No
Head of household Single Married filing jointly Married filing separately
his person is a parent without custody who is not listed on this application T
This person is a parent without custody Yes No
Do you have other health insurance or are you offered insurance through a job? If yes, fill out Attachment B on pages 22 and 23. Do you have a physical, mental, emotional, or developmental disability? Yes No See FAQ #26 for more information on what it means to have a disability.
Do you need help with long-term care or home and community-based services? Yes No
Are you a U.S. citizen or U.S. national? Yes No If you are not a U.S. citizen or U.S. national, answer these questions: Do you have satisfactory immigration status? Yes To see if you have satisfactory status, go to Attachment E on page 26 for a list.
Then write the document information here. In most cases your document ID number will be your Alien Registration Number.
Document type: __________________________________________ ID number: ____________________________________________________________________________ Country of issuance:___________________________________________________________________ Expiration date: ____________________________________________________________________ Name as it appears on the document: ______________________________________________________________________________________________________________________________________ Have you lived in the U.S. since 1996? Are you, your spouse, or an unmarried dependent child an honorably discharged veteran or active-duty member of the U.S. armed forces?
Yes No
Do you receive Medicare benefits?
Yes No
Did you have a medical expense in the last 3 months that you need help paying for?
Yes
No
Yes No Yes No Yes No No Yes No
Do you live with any children under the age of 19? If yes, do you take care of the child or children? Are you 18 to 20 years old and a full-time student? Are you 18 to 26 years old?
Yes
Yes
No
If yes, were you in foster care in any state on your 18th birthday?
Yes No How many parents live with you? ______________ Are you temporarily living out of state? Yes No
Are you 18 years old or younger? If you would like to choose a health insurance plan now, check here and fill out Attachment D on page 25.
Tell us about your race Please tell us about yourself. This information is confidential and will only be used to make
sure that everyone has the same access to health care. It will not be used to decide what health insurance you qualify for.
What is your race? (Optional: Check all that apply) Are you of Hispanic, Latino, or Spanish origin? (Optional) Yes No
White Asian Indian Black or African Cambodian American Chinese American Indian Filipino or Alaska Native Hmong
Japanese Guamanian or Chamorro If yes, check which ones: Korean Samoan Mexican, Mexican American, Chicano Laotian Salvadoran Guatemalan Other Vietnamese _________________________________ Cuban Puerto Rican Native Hawaiian ther Hispanic, Latino or Spanish O
origin:_______________________________
Check here if you are a federally recognized American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Preguntas?
Step 2:
Do you work now?
Person 1
Yes
(continued)
Attach an extra page if you need more space. If no, go to other income on this page.
Tell us about your current job and how you get money
No
Where do you work now? If you have more jobs, attach another sheet of paper.
JOB 1: How do you get paid?

Employer name (Optional) JOB 2: How do you get paid?
Hourly: How many hours per week?______________ Daily: How many days per week?______________ Weekly Every two weeks Twice a month Monthly One-time payment
How much do you get paid (before taxes)? $

Employer name (Optional)
Hourly: How many hours per week?______________ Daily: How many days per week?______________ Weekly Every two weeks Twice a month Monthly One-time payment
How much do you get paid (before taxes)? $
Are you self-employed?

JOB 1: Are you self-employed? Type of work
Yes
No
If no, go to other income on this page.
How much net income will you get from self-employment this month? Amount: $_______________________________ Net income means the profits left over after expenses are paid. Attachment E on page 26 lists what could be counted.
JOB 2: Are you self-employed? Type of work
Yes
No
How much net income will you get from self-employment this month? Amount: $_______________________________ Net income means the profits left over after expenses are paid. Attachment E on page 26 lists what could be counted.
Do you have other income? Other income is money you get from something other than your job. Do not include child support
payments, veterans payments, or Supplemental Security Income (SSI). Go to Attachment E on page 26 to see examples of other income. Do you have other income?
Yes
No
If no, go to income change on this page. How much?
Where does this income come from?
How often do you get paid? (check one)
Hourly: How many hours per week?________________ Every two weeks Daily: How many days per week?____________________ Twice a month Weekly Monthly One-time payment Hourly: How many hours per week?________________ Every two weeks Daily: How many days per week?____________________ Twice a month Weekly Monthly One-time payment
Does your income change from month to month? If it does, answer the two questions below.
What do you expect your total income to be this year? (Optional) $
If you expect your income to change next year, what will the new total income be? (Optional)
Do you have deductions? If you pay for certain things that can be deducted on a federal income tax return, telling us about them
may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 26 lists other types of deductions. Do you have deductions? Type of deduction
Yes
No
If no, go to the next page. How much?
How often do you get or pay for this deduction? (check one)
Alimony paid Student loan interest Other Alimony paid Student loan interest Other
Need help?
Step 2:
First name
Person 2 Tell us about the next person living in your home.

If you have more than four people on this application, make a copy of pages 68 for each additional person.
Middle name Last name Suffix (examples: Sr., Jr., III, IV) Relationship to you
Check here if this person's home address is the same as the main contact's home address. If it is not the same, you must give us this person's home address below: Apartment # State ZIP code County
Home address City (home address)
Check here if this person does not have a home address. You must give us a mailing address below. Check here if this person's mailing address is the same as the main contact's mailing address. If it is not the same, you must give us this person's mailing address below: Apartment # State ZIP code County
Mailing address or P.O. Box (if different from home address) City (mailing address) Best phone number to reach this person Number:
Home Cell Work
Other phone number Number: (
Home Cell Work
Email address: What language should we write to this person in? Is this person: What language does this person want us to speak to him or her in?
Male Female
Is this person:
Single Never married Married Divorced Registered domestic partner Separated Widowed Is this person pregnant? Yes No If yes, how many babies are expected?______________

What is the expected delivery date? __________________________________________________________________________________________
Applying for health insurance Even if this person has insurance now, you might find better coverage or lower costs.
Is this person applying for health insurance?
Yes
No
If no, SSN information is optional.
Social Security number (SSN)
If this person does not have an SSN, what is the reason?
Adoption Taxpayer Identification Number (ATIN) _________________________________________________________ _ _ _ _ _ _ _ _ _ Individual Taxpayer Identification Number (ITIN) __________________________________________________________ Religious exemption Child less than 1 year old Does not qualify for an SSN
Federal income tax information If this person didnt file taxes, he or she can still qualify for free or low-cost insurance
through Medi-Cal. We will keep the information private and use it only to decide if the person qualifies for health insurance.
Is this person going to file taxes for the benefit year? Does anyone claim this person as a dependent on their taxes? If yes, who? Person #_______________________ on this application
Yes No If yes, how will he or she file? Head of household Single Dependent Married filing jointly Married filing separately
Yes No
his person is a parent without custody who is not listed T

on this application
This person is a parent without custody
Preguntas?
Step 2:
Person 2
(continued)
Does this person have other health insurance or is this person offered insurance through a job? If yes, fill out Attachment B on pages 22 and 23. Do you have a physical, mental, emotional, or developmental disability? Yes No See FAQ #26 for more information on what it means to have a disability. Is this person a U.S. citizen or U.S. national?
Yes No
Do you need help with long-term care or home and community-based services? Yes No
Yes No Yes
To see if this person has satisfactory status, go to Attachment E on page 26
If this person is not a U.S. citizen or U.S. national, answer these questions: Does this person have satisfactory immigration status?
for a list. Then write the document information here. In most cases your document ID number will be your Alien Registration Number.
Document type: ___________________________________________________________________________ ID number: ___________________________________________________________________________ Country of issuance:____________________________________________________________________ Expiration date: ___________________________________________________________________ Name as it appears on the document: ______________________________________________________________________________________________________________________________________ Has this person lived in the U.S. since 1996? Yes or active-duty member of the U.S. armed forces? Does this person receive Medicare benefits?
No
Is this person, this person's spouse, or an unmarried dependent child an honorably discharged veteran
Yes No
Did this person have a medical expense in the last 3 months that he or she needs help paying for?
Yes
No
Yes No
Does this person live with any children under the age of 19? If yes, does this person take care of the child or children? Is this person 18 to 20 years old and a full-time student? Is this person 18 to 26 years old?
Yes No Yes No
Yes No Yes No
How many parents live with this person? _________________
Yes No Yes No
If yes, was this person in foster care in any state on his or her 18th birthday?
Is this person 18 years old or younger?
Is this person temporarily living out of state?
Yes No
Is this person of Hispanic, Latino, or Spanish origin? (Optional) Yes No
Tell us about this person's race

What is this person's race? (Optional: Check all that apply)
White Black or African

American
Asian Indian Cambodian Chinese Filipino Hmong
Japanese
American Indian
or Alaska Native
If yes, check which ones: Korean Mexican, Mexican American, Chicano Samoan Laotian Salvadoran Guatemalan Other Vietnamese _____________________________ Cuban Puerto Rican Native Hawaiian O ther Hispanic, Latino or Spanish origin:_______________________________
Guamanian or Chamorro
Check here if this person is a federally recognized American Indian or Alaska Native, and fill out Attachment A on pages 20 and 21.
Need help?
Step 2:
Person 2 (continued)
Attach an extra page if you need more space.
Tell us about this person's current job and how he or she gets money
Does this person work now?
Yes
No
Where does this person work now? If he or she has more jobs, attach another sheet of paper.
JOB 1: How does this person get paid? Hourly: How many hours per week?______________

Weekly
Every two weeks
Daily: How many days per week?______________ Twice a month Monthly One-time payment Daily: How many days per week?______________ Monthly One-time payment
How much does this person get paid (before taxes)? $

Weekly
Every two weeks
Twice a month
Is this person self-employed?

JOB 1: Is this person self-employed? Type of work
Yes
No
How much net income will this person get from self-employment this month? Amount: $_______________________ Net income means the profits left over after expenses are paid. Attachment E on page 26 lists what could be counted.
Yes
No
Does this person have other income? Other income is money you get from something other than your job. Go to Attachment E on
page 26 to see examples of other income. Do not include child support payments, veterans payments, or Supplemental Security Income (SSI). Does this person have other income? Where does this income come from?
Yes
No
How often does this person get paid? (check one)
Does this person's income change from month to month? If it does, answer the two questions below.
What do you expect this person's total income to be this year? (Optional) $
If you expect this person's income to change next year, what will the new total income be? (Optional)
Does this person have deductions? If this person pays for certain things that can be deducted on a federal income tax return, telling us
about them may lower the cost of health insurance. Do not include self-employment expenses. Attachment E on page 26 lists other types of deductions. Does this person have deductions? Type of deduction
Yes
No
How often does this person get this deduction? (check one)
Preguntas?
Step 2:
First name

Home Cell Work
Home Cell Work
Male Female
Is this person:

Yes
No
If this person does not have an SSN, what is the reason? Social Security number (SSN)
Yes No

on this application
Need help?
Step 2:
Person 3
(continued)
Yes
No
Does this person have other health insurance or is this person offered insurance through a job? If yes, fill out Attachment B on pages 22 and 23.
Yes No
Do you have a physical, mental, emotional, or developmental disability? Do you need help with long-term care or home and Yes No See FAQ #26 for more information on what it means to have a disability. community-based services? Yes No Is this person a U.S. citizen or U.S. national?
Yes No Yes
No
Yes No
Yes No
If yes, does this person take care of the child or children? Is this person 18 to 20 years old and a full-time student? Is this person 18 to 26 years old?
Yes No
Does this person live with any children under the age of 19?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No

Japanese Guamanian or Chamorro If yes, check which ones: Korean Mexican, Mexican American, Chicano Samoan Laotian Salvadoran Guatemalan Other Vietnamese ______________________________ Cuban Puerto Rican Native Hawaiian ther Hispanic, Latino or Spanish O
origin:_______________________________
Preguntas?
10
Step 2:
Yes
No

Weekly
Every two weeks

Weekly
Every two weeks
Twice a month

Yes
No
Yes
No
Yes
No
Yes
No
Need help?
11
Step 2:
First name

Home Cell Work
Home Cell Work
Male Female
Is this person:

Yes
No
If this person does not have an SSN, what is the reason? Social Security number (SSN)
Yes No

on this application
Preguntas?
12
Step 2:
Person 4
(continued)
Yes
No
Does this person have other health insurance or is this person offered insurance through a job? If yes, fill out Attachment B on pages 22 and 23.
Yes No
Do you have a physical, mental, emotional, or developmental disability? Do you need help with long-term care or home and Yes No See FAQ #26 for more information on what it means to have a disability. community-based services? Yes No Is this person a U.S. citizen or U.S. national?
Yes No Yes
No
Yes No
Yes No
If yes, does this person take care of the child or children? Is this person 18 to 20 years old and a full-time student? Is this person 18 to 26 years old?
Yes No
Does this person live with any children under the age of 19?
Yes No Yes No
Yes No Yes No
Yes No Yes No
Yes No

Japanese Guamanian or Chamorro If yes, check which ones: Korean Mexican, Mexican American, Chicano Samoan Laotian Salvadoran Guatemalan Other Vietnamese ____________________________ Cuban Puerto Rican Native Hawaiian ther Hispanic, Latino or Spanish O
origin:_______________________________
Need help?
13
Step 2:
Yes
No

Weekly
Every two weeks

Weekly
Every two weeks
Twice a month

Yes
No
Yes
No
Yes
No
Yes
No
Preguntas?
14
Step 3:
Please read and sign this application
You can choose an authorized representative

You can choose someone to be your authorized representative. An authorized representative is a person you allow to see your application and talk with us about it now and in the future. Name of authorized representative Address City State ZIP code County Apartment #
By signing, you allow this person to sign your application, to get official information about this application, and to act for you on all future matters with this agency.
Your signature
Date
Privacy statement
This application is for health insurance through Covered California or for benefits through the Department of Health Care Services (DHCS). The personal and medical information you provide on it is private and confidential. Covered California or the Department of Health Care Services (DHCS) need it to identify you and the other people on this application and to administer our programs. We will share your information with other state, federal and local agencies, contractors, health plans and programs only to enroll you in a plan or program, or to administer programs, and with other state and federal agencies as required by law. You must answer all of the questions on this application unless they are marked optional. If your application is missing anything that we require we will contact you to get it. If you do not provide it, we will not be able to make a decision on your application. You may have to submit a new application, or you may not be able to get health insurance through Covered California, or your application for benefits may be denied. In most cases, you have the right to see personal information about you that is in federal and state records. You can see it in an alternative format (such as large print) if you need that. For more information or to see Covered California records, contact the Privacy Officer at: Covered California Attn: Privacy Officer P.O. Box 989725 West Sacramento, CA 95798-9725 Phone: 1-800-300-1506 TTY: 1-888-889-4500 For the Department of Health Care Services, contact the Information Protection Unit at: P.O. Box 997413, MS 4721 Sacramento, CA 95899-7413 Phone: 1-866-866-0602 TTY: 1-877-735-2929
These state and federal laws give us the right to collect and keep the information on the application: Covered CA: 42 U.S.C. 18031; CA Government Code 100502(k) and 100503(a) DHCS: CA Welfare and Institutions. Code 14011 and Article 3, Chapters 5 and 7, Parts 2 and 3, Division 9 We must give you this Privacy Statement under CA Civil Code section 1798.17. You can see Covered California's Privacy Policy at CoveredCA.com. See DHCS' Notice of Privacy Practices at dhcs.ca.gov.
Step 3 continued on next page
Need help?
15
Step 3:
Please read and sign this application (continued)

I understand that any changes in my information or information of any member(s) in the applicants household may affect the eligibility of other members of the household. I confirm that no one applying for health insurance on this application is confined, after the disposition of charges (judgment), in a jail, prison, or similar penal institution or correctional facility. However, all inmates may apply for Medi-Cal regardless of their incarceration status. I understand that I must report income changes to Covered California because it may affect the amount of premium assistance (or tax credits) that I may be eligible to receive. I also understand if I receive too much premium assistance (or tax credits) during the benefit year, I will have to repay the extra premium assistance back to the IRS when I file my federal income taxes for the benefit year. I give my permission to Covered California to check other agencies computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if I and other people on this application qualify for health insurance. If someone on the application qualifies for Medi-Cal: I know that if Medi-Cal pays for a medical expense, any money I or anyone on this application get from other health insurance or legal settlements related to that expense will go to Medi-Cal as payment for the expense until the expense is paid in full. For parents whose child or children qualify for Medi-Cal: I know I will be asked to help the agency that collects medical support from any parent on this application who does not live with the child and does not send support for the child. If I think that helping will harm me or my children, I can tell the Medi-Cal program and I will not have to help.
Your rights and responsibilities

The information I gave on this application is true as far as I know. I know that I may be subject to a penalty if I do not tell the truth. I understand that the information I give will be used only to see if those in my family who are applying for health insurance will qualify. I understand that Covered California and the Medi-Cal program will keep my information private, as the law requires. For more information, or access to personal information in records maintained by Covered California and the Medi-Cal program, I can contact the Privacy Officer at 1-800-300-1506 (TTY: 1-888-889-4500). I understand that to be eligible for Medi-Cal, I am required to apply for other income or benefits to which I or any member of my household is entitled, unless he or she has good cause for not doing so. Examples of such income or benefits are pensions, government benefits, retirement income, veterans benefits, annuities, disability benefits, Social Security benefits (also called OASDI or Old Age, Survivors, and Disability Insurance), and unemployment benefits. But such income or benefits do not include public assistance benefits, such as CalWORKs or CalFresh. If I have a question about a possible source of income, I can call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) for help. I know that I must tell Covered California or my county social services office about changes to anything I wrote on this application. To report changes, I can call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500) or visit CoveredCA.com. Or, I can call my county social services office. I know that Covered California must not discriminate against me or anyone on this application because of race, color, national origin, religion, age, sex, sexual orientation, marital status, veterans status or disability. If I think Covered California has discriminated against me, including the failure to provide reasonable accommodations as required under state and federal law, I can make a complaint by visiting www.hhs.gov/ocr/office/file or http://oag.ca.gov/ contact/general-comment-question-or-complaint-form. If I believe that Covered California has discriminated against me or anyone else on this application in connection with a Medi-Cal eligibility determination, I can also file a complaint with the Department of Health Care Services, Office of Civil Rights by calling 1-916-440-7370 (TTY: 1-916-440-7399).
Your rights and responsibilities continued on next page
Preguntas?
16
Step 3:
Your right to appeal:
(continued)
Your rights and responsibilities (continued)

Renewal of insurance To make it easier to continue to get health insurance in future years, I agree to allow Covered California to use computer sources, such as the IRS, to check my income. If the sources show I am still eligible, my insurance coverage can be renewed for another 12 months and I wont have to fill out a renewal form or send other paperwork. I understand that if I choose not to allow Covered California to use computer sources, I must complete a renewal packet every 12 months in order to continue my health insurance. I agree to allow Covered California or the Medi-Cal program to check my information for:
If I think Covered California or the Medi-Cal program has made a mistake, I can appeal its decision. To appeal means to tell someone at Covered California or the Medi-Cal program that I think its decision is wrong and ask for a fair review of the action. I know that I can find out how to appeal by calling 1-800-300-1506 (TTY: 1-888-889-4500). I know that I must file an appeal within 90 days of the decision. I know that I can represent myself or have someone else represent me in my appeal, such as an authorized representative, a friend, a relative, or a lawyer. I know that if I need help, someone at Covered California, the Medi-Cal program, or the county social services office can explain my case to me.
5 years 4 years 3 years 2 years 1 year

OR
I do not want Covered California to check my tax returns

at renewal.
Declaration and signature This is required.

I declare under penalty of perjury that what I say below is true and correct. I understood all questions on this application and gave true and correct answers as far as I know. Where I did not know the answer myself, I made every reasonable attempt to confirm the answer with someone who did know. I know that if I do not tell the truth on this application, there may be a civil or criminal penalty for perjury that may include up to four years in jail. (See California Penal Code Section 126.) I know that the information on this application will be used to decide if the people who are applying qualify for health insurance. Covered California will keep the information private, as required by federal and California law. I agree to notify Covered California by calling 1-800-300-1506 (TTY: 1-888-889-4500) or visiting CoveredCA.com if anything changes on this application for any person applying for health insurance. Signature of applicant or authorized representative:
______________________________________________________________________________________________________________________________________________________________
Date: ___________________________________________________________
Step 3 continued on next page
Need help?
17
Step 3:
(continued)
Complete this section if you are a Covered California certified individual helping someone fill out this application.
I certify that as a Certified Enrollment Counselor, Certified Insurance Agent, or Certified Plan-Based Enroller, I helped the applicant complete this application and that this service was free of charge. I also certify that I gave true and correct answers to all questions on this application as far as I know. I explained to the applicant, in easy-to-understand language, the risk to the applicant of providing inaccurate information, and the applicant understood the explanation.
Certified Enrollment Counselor

Name: Certified Enrollment Entity Name: Name:
CEC number CEE number License number Certification number
Certified Insurance Agent Certified Plan-Based Enroller

Name: Certified individuals signature: Plan:__________________________________________________
_______________________________________________________________________________________
Date: ___________________________________________________
The state will not compensate the Covered California Certified Enrollment Entity unless the Certified Enrollment Counselor fills out this section completely and correctly when the application is submitted.
Step 4:
Mailing information and checklist

Did you remember to:
Tell us about everyone in your family and household,
Mail your signed application to:

Covered California P.O. Box 989725 West Sacramento, CA 95798-9725
even if they dont need insurance? See page 3 for the list of whom to include.
Ask your employer about any job-related insurance
you may qualify for?

Sign this application on page 17? If you chose an
authorized representative, also sign page 15.
A few more questions
(Optional)
1. Would you like to be considered for all Medi-Cal programs?
Yes No There are other Medi-Cal programs for people 65 years old or older, people with a disability or people with special health care needs.
If you check yes, we will contact you to get information about your property and assets. If yes, check all that apply.
2. Have you had any recent changes in your life that made you want to apply for health insurance?
Moved to California Gained citizenship or lawful presence Loss of health insurance Gained dependent (by birth, marriage, or
adoption)
No longer incarcerated Newly eligible for premium assistance Applying for Medi-Cal Federally recognized American Indian
or Alaska Native
Other
When did this life event occur? (month, day, year) _________________________________________________________________________________________________________________________
Preguntas?
18
Step 4:
Check all that apply.
Mailing information and checklist
(continued)
How did you hear about Covered California?

Outreach and education program TV ad Radio ad Email Mailer Internet search Social media (e.g., Facebook, Twitter, etc.) Web Mobile app Billboard Transit Sign in retail store Friend or family Brochure Certified Insurance Agent Certified Enrollment Counselor Employer Church CoveredCA.com website Pharmacy Provider/Hospital Government Office Other____________________________________________________
Need more information about other programs?

Beginning January 1, 2014, would you and or your household like to share the information you just provided in a referral to your local Health and Human Services Agency for other programs? Families that include immigrants can apply. You can apply for your child even if you arent eligible for coverage. Applying for your eligible child wont affect your immigration status or chances of becoming a permanent resident or citizen. To apply for nutrition or cash assistance before January 1, 2014, visit benefitscal.org. Or to apply in person, call 1-877-847-3663 for a list of places near where you live or work. For benefits after January 1, 2014, check which programs you want a referral for:
CalFresh
A program that helps people pay for food. Benefits are renewed monthly on a debit card that can be used to buy most foods at many markets and stores. It is also known as the Supplemental Nutrition Assistance Program (SNAP). Visit www.calfresh.ca.gov for more information. A program that gives cash assistance and support services to low income families with children to help pay for housing, food and other necessary expenses.
CalWORKs
You may also find more information about these programs online: Access for Infants and Mothers (AIM) A program that helps pregnant women get health care aim.ca.gov Child Health and Disability Prevention (CHDP) A preventive program that delivers periodic health assessments and services to low-income children dhcs.ca.gov/services/chdp Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) A Medi-Cal program for children and young adults under the age of 21 it allows for regular checkups to identify health care needs, followed by diagnosis and treatment when necessary dhcs.ca.gov/services/Pages/EPSDT.aspx Family Planning, Access, Care, Treatment (Family PACT) A program that provides no-cost family planning services to low-income men and women, including teens familypact.org In-Home Supportive Services Program (IHSS) A program that will help pay for services provided to you so that you can remain safely in your own home cdss.ca.gov/agedblinddisabled/pg1296.htm Women, Infants, and Children (WIC) A nutrition program for pregnant women, new mothers, and children under the age of 5 wicworks.ca.gov
Need help?
19
Attachment A:

For federally recognized American Indians or Alaska Natives
Complete this if you or a family member is American Indian or Alaska Native.

Federally recognized American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban Indian health programs. They also may not have to pay out-of-pocket costs (such as co-pays) and may get special enrollment periods. Be sure to complete this form and send it in with your application and your proof of Native American or Alaska Native heritage. You may send a document from a federally recognized Indian tribe that shows you are a member of the tribe or affiliated with the tribe (such as a tribal enrollment card or certificate of degree of Indian blood.) If you think you qualify for Medi-Cal, you do not have to send proof of your Native American or Alaska Native heritage. See the chart on page 27 to see if you can qualify for Medi-Cal. If you need to tell us about more than four people who are American Indians or Alaska Natives, make a copy of this page, and be sure to send it with your application. Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Person 1: First name
Is this person a member of a federally recognized tribe?
Yes No
If yes, write the name of the tribe: ________________________________________________________________________________ and state of the tribe: ________________________________________________________
Has this person ever gotten a service from the Indian Health Service, a tribal health program, or urban Indian health program, or through a referral from one of these programs?
Yes No Yes No
Yes If yes, answer the questions below. No If no, continue the application.
If no, is this person eligible to get services from the Indian Health services, tribal health programs, or urban Indian health programs, or through a referral from one of these programs?
Does this person get income from any of the sources below?
Payments to the tribe that come from natural resources, usage rights, leases, or royalties Amount $__________________________________ Weekly Every two weeks Monthly Other________________________________________________________ Payments from leases or royalties for the use of Indian trust land for natural resources, farming, ranching, or fishing Amount $__________________________________ Weekly Every two weeks Monthly Other________________________________________________________ Money from selling things that have cultural value Amount $__________________________________ Weekly Every two weeks
Person 2: First name Middle name
Monthly Other________________________________________________________
Last name Suffix (examples: Sr., Jr., III, IV)
Yes No
Yes No Yes No
Monthly Other________________________________________________________
20
Preguntas?
Attachment A:
Person 3: First name
For federally recognized American Indians or Alaska Natives (continued)

Middle name Last name Suffix (examples: Sr., Jr., III, IV)
Yes No
Yes No Yes No
Person 4: First name Middle name
Monthly Other________________________________________________________
Last name Suffix (examples: Sr., Jr., III, IV)
Yes No
Yes No Yes No
Monthly Other________________________________________________________
Need help?
21
Attachment B:
make a copy of this page.
Tell us about your familys health insurance
If you need to tell us about more than four people who have other health insurance,
Tell us about the health insurance you have now

Answer these questions for everyone who needs help paying for health insurance. Does anyone have other health insurance now? Other insurance may include COBRA, employer-sponsored insurance, Peace Corps, retiree health plan, TRICARE/CHAMPUS, veterans health program, Indian Health Service, tribal health program, urban Indian health program, or other health insurance not listed here. You may have additional health insurance that you do not have to tell us about. The following are examples of additional coverage (not considered minimum essential coverage) you do not have to tell us about: flex savings plans, health savings accounts, disability insurance, or insurance available in another country. If you have private health insurance you bought on your own, check the box for "Other health insurance." Also tell us if anyone has insurance that is not listed above.
Yes No
If yes, fill in this page. If you need more space, attach another sheet of paper. If no, go to page 23. What type? (choose one)
Name First, middle, last Person 1: Has this person been offered affordable full coverage health insurance for January 2014? Yes No
COBRA Employer-sponsored insurance Peace Corps Retiree health plan TRICARE/CHAMPUS COBRA Employer-sponsored insurance Peace Corps Retiree health plan TRICARE/CHAMPUS COBRA Employer-sponsored insurance Peace Corps Retiree health plan TRICARE/CHAMPUS COBRA Employer-sponsored insurance Peace Corps Retiree health plan TRICARE/CHAMPUS
Veterans health program Indian Health Service Tribal health program Urban Indian health program Other health insurance Veterans health program Indian Health Service Tribal health program Urban Indian health program Other health insurance Veterans health program Indian Health Service Tribal health program Urban Indian health program Other health insurance Veterans health program Indian Health Service Tribal health program Urban Indian health program Other health insurance
Person 2: Has this person been offered affordable full coverage health insurance for January 2014? Yes No
Attachment B continued on next page
Preguntas?
22
Attachment B:
Employer health insurance
Tell us about your family's health insurance

Answer these questions for everyone who needs help paying for health insurance.
(cont'd)
We need to know about any health insurance you could get through someones job. You can use Attachment C, Employer Insurance Form, on page 24 to help you complete this section. Answer these questions or use Attachment C only if someone in the household qualifies for health insurance from someones job.
Is anyone on this application offered health insurance by an employer?

This could be someone elses job, such as a parent's or a spouse's. It could also include COBRA, TRICARE, federal or state employer, private employer, or Peace Corps plans. You may have additional health insurance that you do not have to report to us. The following are examples of additional coverage (not considered minimum essential coverage) you do not have to include: flex savings plan; health savings accounts; disability insurance; insurance available in another country; coverage only for accident; general liability insurance and automobile liability insurance; workers' compensation; benefits for long-term care, nursing home care, home health care, or community-based care; Medicare supplemental health insurance, and restricted coverage of pregnancy-related services under Medi-Cal.
Yes No
If yes, answer these questions. If you need more space, attach another sheet of paper. If no, go back to the application to continue. Employer name (Optional) This person: How much does this person pay in monthly premiums? Does this health plan meet the minimum value standard*?
Name Name First, middle, last, suffix

(for example, Jr., Sr., III, IV)
Person 1:
Is enrolled now Plans to enroll

Start date_____________________________
Person 2:
Is not enrolled Is enrolled now Plans to enroll

Start date_____________________________
Yes No I don't know Yes No I don't know Yes No I don't know Yes No I don't know
Person 3:

Start date_____________________________
Person 4:

Start date_____________________________
Is not enrolled
What change will the employer make for the new plan year (if known)?
How much will the employee have to pay in premiums for that plan? $________________________ How often? _______________________________________
Employer wont offer health coverage Employer will start offering health coverage to employees or change the
premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs.)
Weekly Every 2 weeks Quarterly Monthly Twice a month Yearly

Date of change ___________________________________
* Minimum value standard means that a plan pays at least 60% of the total cost of plan benefits provided to the employee. (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Go back to the application to continue
Need help?
23
Attachment C:

Employer Insurance Form

TM
This form is only necessary for those who are applying for health insurance through a job. It is not necessary for some health insurance programs offered through Covered California , including Medi-Cal. If you are not sure whether or not to use this form, call Covered California to ask: 1-800-300-1506 (TTY: 1-888-880-4500). If more than one job offers health coverage, use a separate form for each employer.
How much will the employee have to pay in premiums for that plan? $________________________ How often? _______________________________________
What change will the employer make for the new plan year (if known)?
Employer wont offer health coverage Employer will start offering health coverage to employees or change the
premium for the lowest-cost plan available only to the employee that meets the minimum value standard.* (Premium should reflect the discount for wellness programs.)
Weekly Every 2 weeks Quarterly Monthly Twice a month Yearly

Date of change ___________________________________
Employee information
Fill in your name and Social Security number (SSN) (optional). Then make a copy of this page or take the application to your employer. Ask your employer to fill in the rest of the page. If you copy the page, be sure to send it with your application. Middle name Last name Employee: First name Social Security number (SSN) (Optional)
_ _ _ _ _ _ _ _ _
Employer information Ask the employer for this information
Note for employer: To complete the Covered California application, we need to know about health insurance that your employee or their dependents might be able to get from you. Please complete the information below, even if your company does not offer health insurance. Employer Identification Number (EIN)
Employer name:
_ _ _ _ _ _ _ _ _
Employer address City Who can we contact about employee health coverage at this job? Phone number Email address State Employer phone number ZIP code
We do not offer health insurance. This employee does not qualify for coverage under our plan. The employee qualifies for coverage under our plan beginning on _____________________________________________ (start date).
Whats the name of the lowest cost, self-only health plan this employee could enroll in at this job? Consider only those plans that meet the minimum value standard* set by the Federal Patient Protection and Affordable Care Act of 2010. If youre not sure, ask your health insurance issuer. Name:_______________________________________________________________________________________________________________ How much would the employee have to pay in premiums for the lowest cost? $__________________ How often? _______________________________________
No plans meet the minimum value standard*.

* Minimum value standard means that a plan pays at least 60% of the total cost of plan benefits provided to the employee. (Section 36B(c)(2)(C)(ii) of the Internal Revenue Code of 1986)
Weekly Every 2 weeks Quarterly Monthly Twice a month Yearly Other _________________________________________
Preguntas?
24
Attachment D:
make a copy of this page.
Choose your health insurance plan
If you need to tell us about more than four people who would like to choose a health plan,
If you think you qualify for Medi-Cal or premium assistance and would like to choose your health insurance plan, write the name or metal tier of the plans you want below. To learn more about private health insurance plans provided by Covered California, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500). To learn more about available Medi-Cal plans in your county, call Health Care Options at 1-800-430-4263 (TTY: 1-800-430-7077), or visit healthcareoptions.dhcs.ca.gov. To see if you qualify for Medi-Cal or premium assistance, look at the chart on page 27.
Medi-Cal and Covered California plans

Name First, middle, last, suffix
(for example, Jr., Sr., III, IV)
Covered California plans Only

Metal tier Metal number Plan type
Health plan name
Person 1:
Platinum Gold Silver Bronze inimum Coverage Plan M Platinum Gold Silver Bronze inimum Coverage Plan M Platinum Gold Silver Bronze M inimum Coverage Plan Platinum Gold Silver Bronze M inimum Coverage Plan
EPO HMO PPO EPO HMO PPO EPO HMO PPO EPO HMO PPO
Person 2:
Person 3:
Person 4:
Declaration and signature

I declare under penalty of perjury that what I say below is true and correct. If I am determined eligible by Covered California to enroll in the plan I selected above, I understand that by signing this page I am entering into a contract with the issuer of that plan. I am at least 18 years of age, or I am an emancipated minor, and mentally competent to sign a contract. If I am eligible for and enrolling in a Medi-Cal plan, I understand if I want to change my plan, I must call Health Care Options at 1-800-430-4263 (TTY: 1-800-430-7077). Or visit healthcareoptions.dhcs.ca.gov. 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 about the membership in the health plan, the delivery of services, medical or hospital malpractice (a claim that medical services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered), or premises liability. I understand that, if I select a health plan that requires binding arbitration to resolve disputes, I accept the use of binding arbitration 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. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plans coverage document, which is available online at CoveredCA.com for my review, or, I can call Covered California for more information. I do not give up my right to a State hearing of any issue, which is subject to the State hearing process. Signature of applicant, or responsible party, or authorized representative:
______________________________________________________________________________________________________________________________________________________________
Date: ___________________________________________________________
Need help?
25
Attachment E:
Immigration status
Step 2 references
Use these lists to answer the questions in Step 2.
Self-employment
Use this list for "Are you self-employed?"
You can subtract these items from your gross income to find your net self-employment income. See Instructions for Schedule C at irs.gov for more information. Car and truck expenses (workday travel, not commuting) Depreciation Employee wages and fringe benefits Property, liability, or business interruption insurance Interest (for example, mortgage interest paid to banks) Legal and professional services Rent or lease of business property and utilities Commissions, taxes, licenses, and fees Advertising Contract labor Repairs and maintenance Certain business travel and meals
Use this list for "Applying for health insurance"

If you have one of these immigration statuses, you may qualify for health insurance: Lawful Permanent Resident (LPR, or Greencard holder) Lawful Temporary Resident (LTR) Asylee Refugee Cuban/Haitian entrant Paroled into the U.S. Conditional entrant granted before 1980 Battered spouse, child, or parent Victim of trafficking and his or her spouse, child, sibling, or parent Individual with non-immigrant status (includes worker visas, student visas, and citizens of Micronesia, the Marshall Islands, and Palau) Temporary Protected Status (TPS) or applicant for Temporary Protected Status (TPS) Deferred Enforced Departure (DED) Deferred action status - individuals with deferred action under the Department of Homeland Security's deferred action for childhood arrivals in process (DACA) are not considered to be lawfully present Granted withholding of deportation or withholding of removal, under the immigration laws or under the Convention against Torture (CAT) Applicant for withholding of deportation or withholding of removal, under the immigration laws or under the Convention against Torture (CAT) Applicant for special immigrant juvenile status Applicant for adjustment to LPR status, with approved visa petition Applicant for asylum Registry applicants with Employment Authorization Document (EAD) Order of supervision (with EAD) Applicant for cancellation of removal or suspension of deportation (with EAD) If your immigration status is not listed above, you may still qualify for health insurance and should still apply.
Examples of other income

Use this list for "Do you have other income?"
Unemployment benefits Social Security benefits Retirement or pension income Rent or royalty income Alimony received Investment income Capital gains Farming or fishing income Canceled debts Court awards Jury duty pay Miscellaneous
Deductions
Use this list for "Do you have deductions?"
Certain self-employment expenses Student loan interest deduction Tuition and fees Educator expenses IRA contribution Moving expenses Penalty on early withdrawal of savings Health savings account deduction Alimony paid Domestic production activities deduction Certain business expenses of reservists, performing artists, and fee-basis government officials
Preguntas?
26
Attachment F:
Number of people in your household
Federal Poverty Guidelines
Estimate what type of health insurance you may be eligible for in 2014
If your annual household income is less than:
If your annual household income is between:
1 2 3 4 5
$15,860* $21,400 $26,950 $32,500 $38,050
$15,860 $45,960 $21,400 $62,040 $26,950 $78,120 $32,500 $94200 $38,050 $110,280
You may be eligilble for Medi-Cal.
You may be eligilble for insurance with financial help through Covered California.
Need help?
27
Frequently Asked Questions

Getting help through Covered California
1. What is Covered California?
Covered California is the new marketplace that makes it possible for individuals and families to get free or lowcost health insurance through Medi-Cal, or to get help paying for private health insurance available through Covered California. Our goal is to make it simple and affordable for Californians to get health insurance. Covered California is a partnership of the California Health Benefit Exchange and the California Department of Health Care Services.
5. What health insurance is offered through Covered California?

You will have a wide variety of health plans to choose from. Health insurance companies cannot refuse to cover you because you have been sick before or could not get coverage. Covered California offers four groups of private health insurance plans: platinum, gold, silver, and bronze, plus a minimum coverage plan. Each group offers a different level of coverage, from high to low. Health insurance plans that cover more of your medical expenses will usually have a higher premium but allow you to pay less when you receive medical care. Platinum plans have the highest premium, but they pay 90% of your health care expenses. Gold plans pay pay 80% and silver plans pay 70% of your health care expenses. Bronze plans have the lowest premium but pay just 60% of covered health expenses. If you qualify for Medi-Cal, the coverage and costs are different and may be free for you.
2. What is Medi-Cal?
Medi-Cal is Californias version of the federal Medicaid program. It is free or low-cost health insurance for California residents who qualify.
3. What is Access for Infants and Mothers (AIM)?

AIM is low-cost health insurance program for pregnant women who dont have health insurance and whose income is too high for no-cost Medi-Cal. AIM is also available to women who have private health insurance plans with a maternity-only deductible or co-payment greater than $500.
6. Can I get health insurance through Covered California?

Any Californian can get health insurance through Covered California if he or she is a state resident and cannot get affordable health insurance through a job. Applicants may qualify for a free or low-cost health plan, or for financial help that can lower the cost of premiums and co-pays. The amount of financial help is based on household size and family income. Applicants qualify if their income meets the income limits.
4. How can Covered California help me?

Covered California can help you choose a private insurance plan that meets your health needs and budget. We offer some of the states best known health plans, and some regional or local plans too. We can explain the costs and benefits of health insurance plans clearly, so you can compare the different choices available to you. You will know exactly what youre getting and how much you have to pay before you choose your plan.
7. Can I get health insurance even if my income is too high?

Yes. Any Californian who qualifies can purchase private health insurance through Covered California regardless of income. We use your income to help us find the health insurance that is most affordable for your family.
Frequently Asked Questions continued on next page
Preguntas?
28

Getting help through Covered California (continued)
8. How do I apply?
You can apply for health insurance through Covered California in the following ways: Online: Visit CoveredCA.com. We provide information about each health insurance plan, explained in clear and simple terms. By phone: Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). You can call Monday through Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. The call is free! By fax: Fax your application to 1-888-329-3700. By mail: Mail the Covered California application to: Covered California P.O. Box 989725 West Sacramento, CA 95798-9725 In person: We have trained Certified Enrollment Counselors or Certified Insurance Agents who can help you. Or you can visit your county social services office. This help is free! For a list of places near where you live or work, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
(continued) 10. Do I need health insurance now that health reform has started?
Starting in January 2014, most people over 18 years old will be required to have health insurance or pay a tax penalty. Coverage may include insurance through your job, coverage you buy on your own, Medicare, or Medi-Cal. But, some people are exempt from having health insurance. Those people include, but are not limited to, people whose religious beliefs are opposed to accepting benefits from a health insurance plan, people who are incarcerated, people who are members of a federally recognized American Indian tribe, and those people who have to pay more than 8% of their income for health insurance, after taking into account any employer contributions or premium assistance. In 2014, the penalty will be 1% of your yearly income or $95, whichever is higher. The penalty will go up each year. By 2016, the penalty will be 2.5% of your yearly income or $695, whichever is higher. After 2016, the tax penalty will increase each year based on a cost-of-living adjustment. For more information about penalties, visit CoveredCA.com or call your local county social services office or Covered California.
9. How much does it cost?

The cost depends on what health insurance programs and financial assistance you qualify for, as well as which plan you choose. You can use the cost calculator at CoveredCA.com to find the cost and see if you qualify for help paying insurance.
11. I am currently enrolled in Medi-Cal. Can I get health insurance through Covered California?
If your income changes during the year or at your annual renewal, you may qualify for other health insurance and premium assistance through Covered California.
12. What if I already have health insurance?

If you already have affordable health insurance from your employer, you do not need to do anything. But you can still apply anyway to find out if you or your family members qualify for free or low-cost health insurance. If you apply, be sure to complete Attachment B and send it in with your application.
Need help?
29

Getting help through Covered California (continued)
13. I dont have all the information I need to answer the questions on the application. What should I do?
If you dont have all the information, sign and submit your application anyway. We will call you to tell you what to do within 10 to 15 calendar days after we get your application. If you don't hear from us, please call us at 1-800-300-1506 (TTY: 1-888-889-4500).
(continued) 15. How can I choose a health insurance plan?

If you qualify for private health insurance plans through Covered California, you can visit CoveredCA.com to easily shop and compare health insurance plans. Covered California health plan brochures are also available for you. Covered California will offer choices of private health insurance plans and Medi-Cal plans. You can choose the level of coverage that best meets your health needs and budget. You can choose to pay a higher monthly cost (called a premium) so that you pay less out of pocket when you need medical care. Or, you can choose to pay a lower monthly cost but pay more out of pocket when you need care. If you qualify for Medi-Cal, the coverage and costs are different, and they may even be free. To learn more about available Medi-Cal plans in your county, call Health Care Options at 1-800-430-4263 (TTY: 1-800-430-7077). Or, visit healthcareoptions.dhcs.ca.gov.
14. Can I get help with my application or with choosing a plan?

Yes! Help is free. Certified Enrollment Counselors or Certified Insurance Agents are available in communities across the state to give you information about new health insurance choices and help you apply. You can also get help by visiting your county social services office. You can get help in many different languages. Get help with your application or with choosing a plan: Online: Visit CoveredCA.com. We provide information about each health insurance plan, explained in clear and simple terms. By phone: Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). You can call Monday through Friday, 8 a.m. to 6 p.m., and Saturday, 8 a.m. to 5 p.m. The call is free! In person: We have trained Certified Enrollment Counselors and Certified Insurance Agents who can help you. Or you can visit your county social services office. This help is free! For a list of places near where you live or work, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
16. What will happen after I apply?

We will send you a letter within 45 days to tell you which program you and your family members qualify for. If you don't hear from us, please call us at 1-800-300-1506 (TTY: 1-888-889-4500).
Financial assistance
17. I don't make a lot of money. What programs are available to help me get health insurance?
Starting on January 1, 2014, people who need health insurance may be able to get help in one of these ways: A. Assitance with monthly premiums. Premium assistance is available to help make health insurance affordable. People who qualify for premium assistance may take them in advance (before they file taxes) to make their monthly premiums lower. Or they can take them at the end of the year and pay less in taxes. The amount of assistance for monthly premiums depends upon your household size and family income. B. Medi-Cal: Medi-Cal is Californias Medicaid program, paid for with federal and state taxes. Its health insurance for low-income California residents who meet certain requirements. If your income is within the Medi-Cal limits for your family size, you will receive Medi-Cal coverage at no cost to you.
Preguntas?
30

Financial assistance
(continued) 18. If my income changes, will my premium assistance change immediately?
No, your premium assistance will not change immediately. We will process any new information we have. And, we will tell you if the amount of your premium assistance changes.
(continued) 23. Will my family and I qualify for the same program?
Depending on your household size or family income, you or your family may qualify for different programs. For example, you may qualify for affordable private health insurance available through Covered California. However, your child may qualify for free Medi-Cal. We will tell you which health insurance you and other members qualify for.
19. If my income changes, how will the change affect me when I file my taxes?
It is important to report income changes to Covered California that impact the amount of premium assistance (or tax credits) that you receive. If your income decreases, you may qualify to receive a higher amount of premium assistance and reduce your out-of-pocket expenses even more. However, if your income increases, you may receive too much premium assistance and may be required to repay some of it back when you file your taxes for the benefit year.
24. This application asks for a lot of personal information. Will Covered California share my personal and financial information?
No. The information you provide is private and secure, as required by federal and state law. We use your information only to see if you qualify for health insurance.
20. What if I didnt file taxes last year?

If you didn't file taxes last year, you can still apply for health insurance and get premium assistance. We will use your income to help us find the health insurance that is most affordable for you and your family. If you qualify for premium assistance, you must file taxes for the benefit year.
25. Will I be able to use my new Covered California health insurance plan right away?
If you are applying between October and December, 2013, health plans start providing services as early as January 1, 2014. If you are applying after January 1, 2014, your health plan may be able to start providing services as soon as the month after you apply.
26. What do you mean by disability?

You may have a disability and qualify for Medi-Cal if: You are deaf or have a serious hearing loss. You are blind or have a serious vision loss, even when wearing glasses. You have an intellectual or cognitive disability and have difficulty remembering, concentrating or making decisions. You have an ambulatory condition and have difficulty walking or climbing the stairs. You have difficulty bathing or dressing or doing similar daily activities. You have a physical, mental or emotional condition and have difficulty doing errands (such as shopping or visiting a doctors office) without help. You do not have to be receiving special assistance services in your home or living in any kind of nursing facility or assisted living facility.
21. What if my income changes after I apply?

If your income changes, it may change what kind of health insurance you qualify for. If you have private health insurance through Covered California, call to report any change in your income that may affect your eligibility within 30 days. If you have Medi-Cal and your income changes, contact your county social services office within 10 days.
Other questions
22. Does everyone on the application have to be a U.S. citizen or U.S. national?
No. You may qualify for health insurance through Medi-Cal even if you are not a U.S. citizen or a U.S. national.
Need help?
31

Other questions
(continued) 27. I have a pre-existing condition or disability. Can I get health insurance through Covered California?
Yes, you can get health insurance regardless of any current or past health conditions or disability. Starting in 2014, most health insurance plans cant refuse to cover you or charge you more just because you have a pre-existing health condition or disability.
(continued) 31. Where can I get information about becoming registered to vote?
If you are not registered to vote where you live now and would like to apply to register to vote today please visit registertovote.ca.gov. Or, call 1-800-345-VOTE (8683).
32. What does self-employed mean?

People who are self-employed earn a living directly from their own business or services. They do not earn money from a company that pays them.
28. I just found out I am pregnant. Can I apply for health insurance that will cover me during my pregnancy?
Yes. Make sure to answer yes to the application question Are you pregnant? or tell the person helping you to fill out your application. You can apply for health insurance that can cover pre-natal care, labor and delivery, and postpartum care. Health insurance plans can no longer deny you health insurance if you are pregnant.
32. I am a federally recognized American Indian or an Alaska Native. How can Covered California help me?
If you are a federally recognized American Indian or an Alaska Native, you may be eligible for: Free or low-cost insurance Premium assistance Reduced out-of-pocket expenses Special monthly enrollment periods You can also get services from Indian Health Services funded tribal health programs orurban Indian health programs. Be sure to complete Attachment A and send it with your proof of Native American or Alaska Native heritage document. You may use the following documents to provide proof of your Native American Indian or Native Alaskan heritage: Tribal enrollment card or Certificate of degree of Indian blood (CDIB) from the Bureau of Indian Affairs
29. I just had a new baby. What should I do about health insurance?
If you did not have Medi-Cal or Access for Infants and Mothers (AIM) at the time of delivery, fill out this application for your newborn. If you did have Medi-Cal or AIM during your pregnancy, you do not need to fill out this application. Call your county social services office to make sure your baby is covered from birth, or fill out a newborn referral form. Print the form at www.dhcs.ca.gov/ formsandpubs/forms/Forms/mc330.pdf. If you had AIM, call 1-800-433-2611, or go to aim.ca.gov to register your baby.
33. What if I dont agree with the decision Covered California makes?
You can file an appeal. To appeal a decision you dont agree with, contact Covered California in one of these ways: Online: Visit CoveredCA.com. By phone: Call Covered California at 1-800-300-1506 (TTY: 1-888-889-4500). You can call Monday through Friday, 8 a.m. to 6 p.m. and Saturday, 8 a.m. to 5 p.m. The call is free! By fax: Fax the appeal to 1-888-329-3700. By mail: Mail the appeal to: Covered California Appeals P.O. Box 989725, West Sacramento, CA 95798-9725 In person: We have trained Certified Enrollment Counselors and Certified Insurance Agents who can help you. Or you can visit your county social services office. This help is free! For a list of Certified Enrollment Counselors and Certified Insurance Agents near where you live or work, or a list of county social services offices near you, visit CoveredCA.com or call 1-800-300-1506 (TTY: 1-888-889-4500).
30. Will I qualify for health insurance if I am not a citizen or do not have satisfactory immigration status?
Anyone who lives in California can apply for health insurance using this application. Only people who are applying must provide Social Security numbers or information about immigration status. But you may qualify for certain health insurance programs regardless of your immigration status and even if you do not have a Social Security number. We keep your information private and only share information with other government agencies to see which programs you qualify for.
Preguntas?
32
Extra help may be available

CalFresh
Do you need help buying food for you and your family? CalFresh may be able to help! In California, the federal Supplemental Nutrition Assistance Program (SNAP) is known as CalFresh. CalFresh helps you pay for nutritious fruits, vegetables, and other healthy foods. To see if you quality for CalFresh, call 1-877-847-3663 or visit www.calfresh.ca.gov, or apply online at benefitscal.org.
Welltopia by DHCS
Visit Welltopia by the Department of Health Care Services (DHCS), the place of wellness, on Facebook and Twitter! Youll find tips to lower stress, eat healthier food, enjoy physical activity, quit smoking, and more. Welltopia by DHCS has: Free, fun health apps Cool videos Links to: Tasty and easy recipes Farmers market locations CalFresh Fun places and activities for you and your kids Education, job placement, and other services to make your life a little easier
Like Welltopia by DHCS on Facebook! Go to: facebook.com/DHCSWelltopia Follow us! @WelltopiaDHCS
Earned Income Tax Credit (EITC)

EITC is a benefit for working people who have low to moderate income. This tax credit reduces the amount of tax you owe and may also result in a refund. irs.gov/eitc
Child Tax Credit

This tax credit that may be worth as much as $1,000 per qualifying child, depending on your income. irs.gov/Individuals/Child-Tax-Credit
Preguntas?
33
Getting help in other languages

You can get help with this application in other languages. Call 1-800-300-1506.
Podemos ayudarle en espaol a llenar esta solicitud. Llame al 1-800-300-0213.
SPANISH
1-800-778-7695.
1-800-996-1009. Qu v c th c tr gip v n ng k ny bng ting Vit. Hy gi 1-800-652-9528.

VIETNAMESE
1-800-738-9116.
Maaari kang kumuha ng tulong para sa aplikasyong ito sa Tagalog. Tumawag sa 1-800-983-8816.
TAGALOG
1-800-906-8528.
Koj txais tau kev pab nrog kev tso npe no ua lus Hmoob. Hu 1-800-771-2156.
HMONG
.1-800-826-6317
Like Covered California on Facebook! Go to: Facebook.com/CoveredCA
Follow us! @CoveredCA

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Application for Health Insurance

Your destination for affordable health insurance, including Medi-Cal

Application 219 Attachments AF Frequently Asked Questions 2027 2832

You can get this application in other languages

Ting Vit 1-800-652-9528 Tagalog

1-800-996-1009 1-800-921-8879 1-800-906-8528 1-800-771-2156 1-800-826-6317

Apply faster through Covered California at CoveredCA.com

STATE OF CALIFORNIA Health Insurance Application (09/13) | CCFRM604

Apply faster online When youre done

Get help with this application

Start application here (use blue or black ink only) Step 1:

Home Cell Work

Other phone number Number:

Home Cell Work

What language do you want us to speak to you in?

Email Email address: _____________________________________________________________________________________________________________________________________

Tell us about yourself and your family

You must include these people on this application:

Person 1 Tell us about yourself

Date of birth (month / day / year)

If yes, answer the questions below.

If no, go to the next page.

Person 1 continued on next page

Head of household Single Married filing jointly Married filing separately

This person is a parent without custody Yes No

Yes No Yes No Yes No No Yes No

Are you self-employed?

If yes, answer the questions below.

If no, go to other income on this page.

JOB 2: Are you self-employed? Type of work

If yes, answer the questions below.

If no, go to other income on this page.

If yes, answer the questions below.

If no, go to income change on this page. How much?

Where does this income come from?

How often do you get paid? (check one)

If yes, answer the questions below.

If no, go to the next page. How much?

Person 2 Tell us about the next person living in your home.

Home address City (home address)

Home Cell Work

Other phone number Number: (

Home Cell Work

Date of birth (month / day / year)

If yes, answer the questions below.

If no, SSN information is optional.

Social Security number (SSN)

If this person does not have an SSN, what is the reason?

 his person is a parent without custody who is not listed T

This person is a parent without custody

Person 2 continued on next page

Is this person 18 years old or younger?

Is this person temporarily living out of state?

Tell us about this person's race

White Black or African

Asian Indian Cambodian Chinese Filipino Hmong

If yes, answer the questions below.

If no, go to other income on this page.

Every two weeks

his person is a parent without custody who is not listed T

his person is a parent without custody who is not listed T

his person is a parent without custody who is not listed T