Application for
Health Insurance
TM
Your destination for affordable
health insurance, including Medi-Cal
See Inside
Application
The state of California created Covered California™ to help you
and your family get health insurance.
2–19
Attachments A–F
20–27
Frequently Asked
Questions
28–32
You can get this
application in
other languages
Español
1-800-300-0213
1-800-300-1533
1-800-652-9528
1-800-738-9116
Use this application to see what insurance choices you qualify for:
1-800-983-8816
Heccrbq
1-800-778-7695
1-800-996-1009
1-800-921-8879
1-800-906-8528
Hmoob
1-800-771-2156
1-800-826-6317
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.
STATE OF CALIFORNIA
|
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
results sooner!
CoveredCA.com
–
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 1-800-300-1506
In person:
CoveredCA.com or call 1-800-300-1506
office in person or call our Customer Service Center at 1-800-300-1506
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.
1
Start application here (use blue or black ink only)
Tell us about the adult who will be our main contact
for this application
Step 1:
First name
Middle name
Last name
Suffix (examples: Sr., Jr., III, IV)
Home
City (home address)
State
County
State
County
If it is not the same
Mailing address or P.O. Box
City
(
)
Mail
–
Home
Cell
Email
(
)
Home
–
Cell
____________________________________________________________________________________________________________________________________
Yes
If yes,
Yes
If yes,
If yes,
If no,
Yes
_____________________
______________________________________________________________________
__________________________________________________________
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
2
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
Male
Last name
Suffix (examples: Sr., Jr., III, IV)
Female
Self
Married
Divorced
Separated
Yes
If yes,
____________
______________________________________________________________________________________
Yes If yes,
No If no,
.
________________________________________________________
_ _ _ – _ _ – _ _ _ _
CoveredCA.com.
_________________________________________________________
1-800-300-1506
Person 1
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.
3
Step 2:
Person 1
Federal income tax information
Yes
benefit
If yes,
Yes
If yes,
______________________
Yes
If yes,
Yes
Yes
Yes
not
Yes To see if you have satisfactory status,
_________________________________________
___________________________________________________________________________
__________________________________________________________________
___________________________________________________________________
______________________________________________________________________________________________________________________________________
Yes
Yes
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
Tell us about your race
(Optional:
Japanese
If yes,
Korean
Laotian
Yes
Guamanian or
Samoan
Salvadoran
Filipino
Guatemalan
Puerto Rican
________________________________
______________________________
are a federally recognized
Person 1
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
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,
Where does this income come from?
No If no,
to
How often do you get paid? (check one)
How much?
_______________
$
___________________
One-time payment
_______________
$
___________________
One-time payment
Does your
Optional)
from month to month?
this
$
Optional)
$
next
Do you have deductions?
Yes If yes,
Type of deduction
No If no,
How often do you get or pay for this deduction? (check one)
How much?
_______________
Student loan interest
___________________
$
One-time payment
_______________
Student loan interest
___________________
$
One-time payment
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.
Person 2
Step 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
State
County
If it is not the same
Mailing address or P.O. Box
Home
(
)
Male
Cell
Home
(
–
)
Cell
–
Female
Married
Divorced
Separated
Yes
If yes,
_____________
_________________________________________________________________________________________
Yes If yes,
No If no,
________________________________________________________
_ _ _ – _ _ – _ _ _ _
_________________________________________________________
Federal income tax information
Yes
benefit
Yes
If yes,
If yes,
Dependent
______________________
Person 2
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
Step 2:
Person 2
Yes
If yes,
Yes
Yes
Yes
not
Yes To see if this person has satisfactory status,
__________________________________________________________________________
__________________________________________________________________________
___________________________________________________________________
__________________________________________________________________
______________________________________________________________________________________________________________________________________
Yes
Yes
Does
Did
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
Tell us about this person's race
(Optional:
Japanese
If yes,
Korean
Laotian
Yes
Guamanian or
Samoan
Salvadoran
Filipino
Guatemalan
Puerto Rican
____________________________
______________________________
a federally recognized
Person 2
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.
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,
Where does this income come from?
No If no,
to
How often does this person get paid? (check one)
How much?
_______________
$
___________________
One-time payment
_______________
$
___________________
One-time payment
Does this person's
this
Optional)
from month to month?
$
Optional)
$
next
Does this person have deductions?
Yes If yes,
Type of deduction
No If no,
How often does this person get this deduction? (check one)
How much?
_______________
Student loan interest
___________________
$
One-time payment
_______________
Student loan interest
___________________
$
One-time payment
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
8
Step 2:
Person 3
First name
the next person
Middle name
Last name
Suffix (examples: Sr., Jr., III, IV)
If it is not the same
Home
State
County
State
County
If it is not the same
Mailing address or P.O. Box
Home
(
)
Male
Cell
Home
(
–
)
Cell
–
Female
Married
Divorced
Separated
Yes
If yes,
_____________
_________________________________________________________________________________________
Yes If yes,
No If no,
________________________________________________________
_ _ _ – _ _ – _ _ _ _
_________________________________________________________
Federal income tax information
Yes
benefit
Yes
If yes,
If yes,
Dependent
______________________
Person 3
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.
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
Did
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
Tell us about this person's race
(Optional:
Japanese
If yes,
Korean
Laotian
Yes
Guamanian or
Samoan
Salvadoran
Filipino
Guatemalan
Puerto Rican
_____________________________
______________________________
a federally recognized
Person 3
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
10
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,
Where does this income come from?
No If no,
to
How often does this person get paid? (check one)
How much?
_______________
$
___________________
One-time payment
_______________
$
___________________
One-time payment
Does this person's
this
Optional)
from month to month?
$
Optional)
$
next
Does this person have deductions?
Yes If yes,
Type of deduction
No If no,
How often does this person get this deduction? (check one)
How much?
_______________
Student loan interest
___________________
$
One-time payment
_______________
Student loan interest
___________________
$
One-time payment
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.
11
Step 2:
Person 4
First name
the next person
Middle name
Last name
Suffix (examples: Sr., Jr., III, IV)
If it is not the same
Home
State
County
State
County
If it is not the same
Mailing address or P.O. Box
Home
(
)
Male
Cell
Home
(
–
)
Cell
–
Female
Married
Divorced
Separated
Yes
If yes,
_____________
_________________________________________________________________________________________
Yes If yes,
No If no,
________________________________________________________
_ _ _ – _ _ – _ _ _ _
_________________________________________________________
Federal income tax information
Yes
benefit
Yes
If yes,
If yes,
Dependent
______________________
Person 4
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
12
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
Did
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
If yes,
Yes
Yes
Yes
Tell us about this person's race
(Optional:
Japanese
If yes,
Korean
Laotian
Yes
Guamanian or
Samoan
Salvadoran
Filipino
Guatemalan
Puerto Rican
___________________________
______________________________
a federally recognized
Person 4
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.
13
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,
Where does this income come from?
No If no,
to
How often does this person get paid? (check one)
How much?
_______________
$
___________________
One-time payment
_______________
$
___________________
One-time payment
Does this person's
this
Optional)
from month to month?
$
Optional)
$
next
Does this person have deductions?
Yes If yes,
Type of deduction
No If no,
How often does this person get this deduction? (check one)
How much?
_______________
Student loan interest
___________________
$
One-time payment
_______________
Student loan interest
___________________
$
One-time payment
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
Step 3:
Please read and sign this application
You can choose an authorized representative
City
State
County
Date
Privacy statement
For more information or to see Covered California
Covered California
you provide on it is private and confidential. Covered
only
Department of Health Care Services
If you do not provide it,
Step 3
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.
Step 3:
Please read and sign this application
at 1-800-300-1506
Covered California at 1-800-300-1506
California at 1-800-300-1506
CoveredCA.com
office.
If someone on the application qualifies for Medi-Cal:
For parents whose child or children qualify for Medi-Cal:
1-916-440-7370
Your rights and responsibilities
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
Step 3:
Please read and sign this application
Your right to appeal:
Renewal of insurance
appeal means
to tell someone at
1-800-300-1506
decision.
3 years
2 years
1 year
OR
can explain my case to me.
1-800-300-1506
_____________________________________________________________________________________________________________________________________________________________
CoveredCA.com
__________________________________________________________
Step 3
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.
Step 3:
Please read and sign this application
Certified Enrollment Counselor
Certified Enrollment Entity
0B03017
Phillip Daigle
______________________________________________________________________________________
Step 4:
__________________________________________________
Mailing information and checklist
Mail your signed application to:
Did you remember to:
Covered California
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 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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
18
Step 4:
Mailing information and checklist
How did you hear about Covered California?
Radio ad
Email
Mailer
Friend or family
Certified Enrollment Counselor
Employer
Government Office
___________________________________________________
Need more information about other programs?
Or to apply
1-877-847-3663
CalFresh
www.calfresh.ca.gov
CalWORKs
Access for Infants and Mothers (AIM)
Family Planning, Access, Care, Treatment
(Family PACT)
Child Health and Disability Prevention (CHDP)
In-Home Supportive Services Program (IHSS)
Early and Periodic Screening, Diagnosis, and
Treatment (EPSDT)
Women, Infants, and Children (WIC)
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.
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 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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
20
Attachment A:
Person 3: First name
For federally recognized American Indians
or Alaska Natives
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 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.
21
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
What type?
Person 1:
Yes
Employer-sponsored insurance
Peace Corps
Person 2:
Yes
Employer-sponsored insurance
Peace Corps
Person 3:
Yes
Employer-sponsored insurance
Peace Corps
Person 4:
Yes
Employer-sponsored insurance
Peace Corps
Attachment B
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
22
Attachment B:
Tell us about your family's health insurance
Employer health insurance
only
Yes If yes,
No If no,
Name
Name
Employer name
This person:
How much does
this person
pay in monthly
premiums?
(for example, Jr., Sr., III, IV)
Does this health
plan meet
the minimum
value standard*?
Person 1:
Plans to enroll
____________________________
Yes
$
Person 2:
Plans to enroll
____________________________
Yes
$
Person 3:
Plans to enroll
____________________________
Yes
$
Person 4:
Plans to enroll
____________________________
Yes
$
$ _______________________
______________________________________
Quarterly
minimum value standard.*
Yearly
__________________________________
*Minimum value standard
Need help?
Go back to the application
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.
23
Attachment C:
Employer Insurance Form
TM
This form is only necessary for those who are applying for health insurance through a job.
1-800-300-1506
$ _______________________
______________________________________
Quarterly
minimum value standard.*
Yearly
__________________________________
Employee information
Employee: First name
Middle name
Last name
(Optional)
_ _ _ – _ _ – _ _ _ _
Employer information
Note for employer:
Employer name:
_ _ – _ _ _ _ _ _ _
Employer address
City
State
Email address
____________________________________________
minimum value
standard*
.
$ _________________
______________________________________
Quarterly
______________________________________________________________________________________________________________
Yearly
________________________________________
*Minimum value standard
¿Preguntas?
Go back to the application
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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
Attachment D:
Choose your health insurance plan
.
CoveredCA.com or call 1-800-300-1506
1-800-430-4263
Medi-Cal and Covered California plans
Name
(for example, Jr., Sr., III, IV)
Health plan name
Covered California plans Only
Metal tier
Metal number
Plan type
Person 1:
Platinum
Silver
Gold
EPO
HMO
PPO
Person 2:
Platinum
Silver
Gold
EPO
HMO
PPO
Person 3:
Platinum
Silver
Gold
EPO
HMO
PPO
Person 4:
Platinum
Silver
Gold
EPO
HMO
PPO
_____________________________________________________________________________________________________________________________________________________________
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.
Attachment E:
Step 2 references
Immigration status
Self-employment
Use this list for "Applying for health insurance"
Use this list for "Are you self-employed?"
qualify for health insurance
may
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
visa petition
Deductions
Use this list for "Do you have deductions?"
Certain self-employment expenses
Student loan interest deduction
Educator expenses
Domestic production activities deduction
Go back to the application
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
Attachment F:
Number of
people in your
household
Federal Poverty Guidelines
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.
1
2
3
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.
Frequently Asked Questions
Getting help through Covered
California
1. What is Covered California?
5. What health insurance is offered through
Covered California?
cover you
cannot refuse to
Covered California.
2. What is Medi-Cal?
3. What is Access for Infants and Mothers
(AIM)?
6. Can I get health insurance through Covered
California?
4. How can Covered California help me?
7. Can I get health insurance even if my
income is too high?
Frequently Asked Questions
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
28
Frequently Asked Questions
Getting help through Covered
California
10. Do I need health insurance now that health
reform has started?
8. How do I apply?
Online:
CoveredCA.com
or Medi-Cal.
and simple terms.
By phone: Call Covered California at 1-800-300-1506
By fax: Fax your application to 1-888-329-3700.
By mail:
Covered California
In person:
adjustment.
CoveredCA.com or call
1-800-300-1506
9. How much does it cost?
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?
CoveredCA.com
12. What if I already have health insurance?
insurance.
Frequently Asked Questions
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.
Frequently Asked Questions
Getting help through Covered
California
15. How can I choose a health insurance plan?
CoveredCA.com to easily
13. I don’t have all the information I need to
answer the questions on the application.
What should I do?
us at 1-800-300-1506
.
14. Can I get help with my application or with
choosing a plan?
need medical care.
Or,
Yes! Help is free. Certified Enrollment Counselors or
Care Options at 1-800-430-4263
.
16. What will happen after I apply?
Online:
CoveredCA.com
and simple terms.
By phone: Call Covered California at 1-800-300-1506
1-800-300-1506
Financial assistance
17. I don't make a lot of money. What
programs are available to help me get
health insurance?
In person:
A. Assitance with monthly premiums. Premium
1-800-300-1506
CoveredCA.com or call
.
less in taxes.
B. Medi-Cal:
meet certain requirements.
cost to you.
Frequently Asked Questions
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
30
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?
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?
amount of premium assistance and reduce your
insurance.
20. What if I didn’t file taxes last year?
25. Will I be able to use my new Covered
California health insurance plan right
away?
26. What do you mean by “disability”?
21. What if my income changes after I apply?
decisions.
daily activities.
Other questions
22. Does everyone on the application have
to be a U.S. citizen or U.S. national?
You do not
national.
Frequently Asked Questions
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.
31
Frequently Asked Questions
Other questions
27. I have a pre-existing condition or disability.
Can I get health insurance through
Covered California?
31. Where can I get information about
becoming registered to vote?
32. What does “self-employed” mean?
28. I just found out I am pregnant.
Can I apply for health insurance that will
cover me during my pregnancy?
32. I am a federally recognized American
Indian or an Alaska Native. How can
Covered California help me?
Premium assistance
29. I just had a new baby. What should I do
about health insurance?
formsandpubs/forms/Forms/mc330.pdf.
1-800-433-2611
30. Will I qualify for health insurance if I am
not a citizen or do not have satisfactory
immigration status?
33. What if I don’t agree with the decision
Covered California makes?
Online:
CoveredCA.com.
By phone: Call Covered California at 1-800-300-1506
By fax:
1-888-329-3700.
By mail:
In person:
For a list of Certified Enrollment Counselors and
CoveredCA.com or call 1-800-300-1506
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
32
Extra help may be available
CalFresh
or apply online at
.
1-877-847-3663 or visit
Welltopia by DHCS
Cool videos
•
•
•
“Like” Welltopia by DHCS on Facebook!
Go to: facebook.com/DHCSWelltopia
Follow us! @WelltopiaDHCS
Earned Income Tax Credit (EITC)
Child Tax Credit
¿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 sábados de 8 a.m. a 5 p.m.
O visite CoveredCA.com.
33
Getting help in other languages
You can get help with this application in other languages. Call 1-800-300-1506.
Podemos ayudarle en español a llenar
esta solicitud. Llame al 1-800-300-0213.
SPANISH
VIETNAMESE
TAGALOG
HMONG
“Like” Covered California on Facebook!
Go to: Facebook.com/CoveredCA
Follow us! @CoveredCA