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, veteran's 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, veteran’s 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).

  • I understand that any changes in my information or information of any member(s) in the applicant’s household may affect the eligibility of other members of the household.

  • Except for purposes of applying for Medi-Cal, 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.

  • 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: ƒ

 

  • I know that if Medi-Cal pays for a medical expense, any money I or anyone on this application gets 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: ƒ

  • 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 right to appeal:

  • ƒIf 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.

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 won’t 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.

Declaration

I declare 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 in 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.

  • If I am selecting a health plan, and if I am determined eligible by Covered California to enroll in the plan I select, I give my Agent consent to enter me into a contract with the issuer of that plan.

  • ƒI am at least 18 years of age or I am an emancipated minor, and I am mentally competent to sign a contract.

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Updated July 13, 2019

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