Application for Health Insurance

Transcription

1 Application for Health Insurance TM Your destination for affordable health insurance, including Medi-Cal See Inside You can get this application in other languages Covered California is the place where individuals and families can The state of California created Covered California to help you and your family get health insurance. Español Use this application to see what insurance choices you qualify for: Heccrbq Hmoob Apply faster through Covered California at CoveredCA.com Or call: (TTY: ) You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. get this application in

2 Things to know What you need to know when you apply information We keep your information private and secure, as required by law. Apply faster online When you re done CoveredCA.com results sooner! Covered California If you don t have all the information we ask for, sign and send in your application anyway. Do not send your health insurance plan enrollment payment with this application. Get help with this application Call our Customer Service Center at or call person or call our Customer Service Center at Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. 1

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

4 Step 2: Tell us about yourself and your family Your spouse will need to file his or her own! for each Person 1 yourself. Suffix (examples: Sr., Jr., III, IV) Self Female Single Divorced Registered domestic partner Yes If yes, Yes If yes, No not No not Religious exemption Need help? Person 1 Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

5 Step 2: Person 1 Yes benefit Yes If yes, Head of household Single Yes If yes, on this application Yes If yes, Yes Yes Yes not Yes To see if you have satisfactory status, Yes Yes Yes If yes, Yes Yes Yes Yes Yes If yes, Yes Yes Yes Chinese Filipino Hmong Japanese Korean Laotian Vietnamese Guamanian or Chamorro Samoan ( Yes If yes, Salvadoran Guatemalan Person 1 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com. 4

6 Step 2: Person 1 Yes If yes, No If no, go to other income JOB 1: JOB 2: $ $ JOB 1: Yes If yes, No If no, go to other income How much $ JOB 2: Yes If yes, No If no, go to other income How much $ Yes If yes, No If no, go to income change Where does this income come from? How often do you get paid? (check one) How much? $ this $ next $ $ Yes If yes, No If no, go Type of deduction How often do you get or pay for this deduction? (check one) How much? Student loan interest $ $ Student loan interest Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

7 Step 2: Person 2 the next person If you have more than four people Suffix (examples: Sr., Jr., III, IV) If it is not the same Home (home address) State If it is not the same Mailing State Home Cell ( ) Home Cell ( ) Female Single Divorced Registered domestic partner Yes If yes, Yes If yes, No If no, Religious exemption Yes benefit Yes If yes, Head of household Single Dependent Yes If yes, on this application Person 2 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

8 Step 2: Person 2 Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does this person Yes Did this person Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Chinese Filipino Hmong Japanese Korean Laotian Vietnamese Guamanian or Chamorro Samoan ( Yes If yes, Salvadoran Guatemalan Person 2 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

9 Step 2: Person 2 Yes If yes, No If no, go to other income JOB 1: How does this JOB 2: How does this $ $ JOB 1: Yes If yes, No If no, go to other income How much $ JOB 2: Yes If yes, No If no, go to other income How much $ Yes If yes, No If no, go to income change Where does this income come from? How often does this person get paid? (check one) How much? $ this $ next $ $ Yes If yes, No If no, go Type of deduction How often does this person get or pay for this deduction? (check one) How much? Student loan interest $ $ Student loan interest Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

10 Step 2: Person 3 the next person Suffix (examples: Sr., Jr., III, IV) If it is not the same Home (home address) State If it is not the same Mailing State Home Cell ( ) Home Cell ( ) Female Single Divorced Registered domestic partner Yes If yes, Yes If yes, No If no, Religious exemption Yes benefit Yes If yes, Head of household Single Dependent Yes If yes, on this application Person 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. 9

11 Step 2: Person 3 Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does this person Yes Did this person Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Chinese Filipino Hmong Japanese Korean Laotian Vietnamese Guamanian or Chamorro Samoan ( Yes If yes, Salvadoran Guatemalan Person 3 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

12 Step 2: Person 3 Yes If yes, No If no, go to other income JOB 1: How does this JOB 2: How does this $ $ JOB 1: Yes If yes, No If no, go to other income How much $ JOB 2: Yes If yes, No If no, go to other income How much $ Yes If yes, No If no, go to income change Where does this income come from? How often does this person get paid? (check one) How much? $ this $ next $ $ Yes If yes, No If no, go Type of deduction How often does this person get or pay for this deduction? (check one) How much? Student loan interest $ $ Student loan interest Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. 11

13 Step 2: Person 4 the next person Suffix (examples: Sr., Jr., III, IV) If it is not the same Home (home address) State If it is not the same Mailing State Home Cell ( ) Home Cell ( ) Female Single Divorced Registered domestic partner Yes If yes, Yes If yes, No If no, Religious exemption Yes benefit Yes If yes, Head of household Single Dependent Yes If yes, on this application Person 4 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

14 Step 2: Person 4 Yes If yes, Yes Yes Yes not Yes To see if this person has satisfactory status, Yes Yes Does this person Yes Did this person Yes Yes If yes, Yes Yes Yes If yes, Yes Yes Yes Chinese Filipino Hmong Japanese Korean Laotian Vietnamese Guamanian or Chamorro Samoan ( Yes If yes, Salvadoran Guatemalan Person 4 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

15 Step 2: Person 4 Yes If yes, No If no, go to other income JOB 1: How does this JOB 2: How does this $ $ JOB 1: Yes If yes, No If no, go to other income How much $ JOB 2: Yes If yes, No If no, go to other income How much $ Yes If yes, No If no, go to income change Where does this income come from? How often does this person get paid? (check one) How much? $ this $ next $ $ Yes If yes, No If no, go Type of deduction How often does this person get or pay for this deduction? (check one) How much? Student loan interest $ $ Student loan interest Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com. 14

16 Step 3: Please read and sign this application State Your signature Date If you do not provide it, For more information or to see Covered California Covered California For the Department of Health Care Services Step 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

17 Step 3: Please read and sign this application at Covered California at California at visiting If someone on the application qualifies for Medi-Cal: health insurance or legal settlements related to that For parents whose child or children qualify for Medi-Cal: does not live with the child and does not send support Your rights and responsibilities Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

18 Step 3: Please read and sign this application Your right to appeal: Renewal of insurance OR Date Step 3 Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

19 Step 3: Please read and sign this application Certified Enrollment Counselor Date Step 4: Mailing information and checklist Mail your signed application to: Covered California Did you remember to: Sign this application on 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 Loss of health insurance Step 4 Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

20 Step 4: Mailing information and checklist How did you hear about Covered California? Radio ad Sign in retail store Certified Enrollment Counselor Church Government office Need more information about other programs? CalFresh CalWORKs Access for Infants and Mothers (AIM) Child Health and Disability Prevention (CHDP) Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) Family Planning, Access, Care, Treatment (Family PACT) In-Home Supportive Services Program (IHSS) Women, Infants, and Children (WIC) Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com. 19

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

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

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

24 Attachment B: Tell us about your family's health insurance only not are examples Yes If yes, No If no, Name (for example, Jr., Sr., III, IV) Employer name This person: How much does this person pay in monthly premiums? Does this health plan meet the minimum value standard*? Person 1: Person 2: Person 3: $ $ $ Yes Yes Yes Person 4: $ Yes the.* premiums for that plan $ Date of change * Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

25 TM Attachment C: Employer Insurance Form This form is only necessary for those who qualify for health insurance through a job Employee: Note for employer: Employer name: State address * * meets the * premiums for the $ premiums for that plan $ Date of change * Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

26 Attachment D: Choose your pediatric dental plan and your health insurance plan visit or call Name Child 1: Child 2: Child 3: Child 4: Pediatric dental plan name Coverage level High Low High Low High Low High Low Plan type Name (for example, Jr., Sr., III, IV) Health plan name Metal tier Covered California plans Metal number Plan type Person 1: Gold Silver Person 2: Gold Silver Person 3: Gold Silver Person 4: Gold Silver Attachment D Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

27 Attachment D: Choose your Covered California plans Agreement for Binding Arbitration CoveredCA.com all Signature of Person 1 Signature of Person 2 Signature of Person 3 Signature of Person 4 Date Date Date Date Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

28 Attachment E: Step 2 references Immigration status Use this list for "Applying for health insurance" may qualify for health insurance Refugee Deferred action status Granted withholding of deportation or withholding visa petition Self-employment Use this list for "Are you self-employed?" Depreciation Legal and professional services Repairs and maintenance Examples of other income Use this list for "Do you have other income?" Retirement or pension income Capital gains Farming or fishing income Court awards Deductions Use this list for "Do you have deductions?" Student loan interest deduction Educator expenses Health savings account deduction Domestic production activities deduction Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

29 Attachment F: Federal Poverty Guidelines 1 4 You may be eligilble for Medi-Cal. You may be eligible for insurance with financial help through Covered California. Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

30 Frequently Asked Questions (FAQ) Getting help through Covered California 1. What is Covered California? 2. What is Medi-Cal? 3. What is Access for Infants and Mothers (AIM)? 4. How can Covered California help me? 5. Can I get health insurance even if my income is too high? health insurance through Covered California regardless 6. What health insurance is offered through Covered California? cannot refuse to cover you Covered California offers four groups of private health and Can I get health insurance through Covered California? Covered California if he or she is a state resident and or for financial help that can lower the cost of premiums 8. How much does it cost? Frequently Asked Questions Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

31 Frequently Asked Questions Getting help through Covered California 9. Should I include my first premium payment with this application? 10. How do I apply? Online: Visit By phone: Call Covered California at By fax: By mail: Covered California In person: or call I am currently enrolled in Medi-Cal. Can I get health insurance through Covered California? 12. What if I already have health insurance? 13. Do I need health insurance now that health reform has started? office or Covered California 14. I don t have all the information I need to answer the questions on the application. What should I do? us at What will happen after I apply? Frequently Asked Questions Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

32 Frequently Asked Questions Getting help through Covered California 16. Can I get help with my application or with choosing a plan? Online: Visit By phone: Call Covered California at In person: or call How can I choose a health insurance plan? Covered California will offer choices of private health Or, Financial assistance 18. I don't make a lot of money. What programs are available to help me get health insurance? A. Assistance with monthly premiums. B. Medi-Cal: 19. If my income changes, will my premium assistance change immediately? 20. If my income changes, how will the change affect me when I file my taxes? California that affect the amount of premium Frequently Asked Questions Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

33 Frequently Asked Questions Financial assistance 21. What if I didn t file taxes last year? 22. What if my income changes after I apply? Other questions 23. Does everyone on the application have to be a U.S. citizen or U.S. national? 24. Will my family and I qualify for the same program? 25. This application asks for a lot of personal information. Will Covered California share my personal and financial information? 26. Will I be able to use my new Covered California health insurance plan right away? 27. What do you mean by disability? You do not 28. I have a pre-existing condition or disability. Can I get health insurance through Covered California? 29. I just found out I am pregnant. Can I apply for health insurance that will cover me during my pregnancy? Frequently Asked Questions Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

34 Frequently Asked Questions Other questions 30. I just had a new baby. What should I do about health insurance? Will I qualify for health insurance if I am not a citizen or do not have satisfactory immigration status? information with other government agencies to see 32. Were you in foster care on your 18th birthday? 33. What constitutes a one-time payment? 34. What does self-employed mean? 35. Where can I get information about becoming registered to vote? 36. I am an American Indian or an Alaska Native. How can Covered California help me? need to send 37. What if I don t agree with the decision Covered California makes? Online: Visit By phone: Call Covered California at By fax: Fax the appeal to By mail: In person: For a list of Certified Enrollment Counselors and or call Need help? Call Covered California at (TTY: ). The call is free. You can call Monday to Friday, 8 a.m. to 8 p.m., and Saturday, 8 a.m. to 6 p.m. Or visit CoveredCA.com.

35 Extra help may be available CalFresh to help! or visit Welltopia by DHCS Cool videos CalFresh Earned Income Tax Credit (EITC) Child Tax Credit Preguntas? Llame a Covered California al (TTY: ). La llamada es gratuita. Usted puede llamar de lunes a viernes de 8 a.m. a 8 p.m. y los sábados de 8 a.m. a 6 p.m. O visite CoveredCA.com.

36 Getting help in other languages You can get help with this application in other languages. Call