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NUMBER OF PEOPLE IN YOUR HOUSEHOLD AND LISTED ON YOUR TAX RETURN
Important: select the full number of people in your household who are included on your tax return even if they are NOT enrolling. Each person who files their own taxes must complete their own application.
IMPORTANT: Select the full number of ALL people you include when you file your taxes even if those people are NOT enrolling. Do NOT include any people who are not included on your tax return. This allows us to process your application and to get you the maximum government assistance.
PERSON 1
For your privacy and security, your Social Security number is not required to complete the online application.
A naturalized citizen is someone who was not born in the U.S. but later became a citizen. If you were born in the U.S., the answer is "no".
NOTE: You may NOT submit this application
unless you have satisfactory immigration status
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly
SELF-EMPLOYMENT INCOME
Note: Net income means the profits left over after all expenses are paid.
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
How often means weekly, bi-weekly, twice a month, monthly or annually
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
PERSON 2
Please complete this section for your PERSON 2, even if he or she is not applying for coverage.
For your privacy and security, Social Security numbers are not required to complete the online application.
A naturalized citizen is someone who was not born in the U.S. but later became a citizen
NOTE: You may NOT submit this application
unless you have satisfactory immigration status
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly?
SELF-EMPLOYMENT INCOME
Note: Net income means the profits left over after all expenses are paid.
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
How often means weekly, bi-weekly, twice a month, monthly or annually
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
PERSON 3
Please complete this section for your PERSON 3, even if he or she is not applying for coverage.
For your privacy and security, social security numbers are not required to complete the online application.
"NOTE: You may NOT submit this application
unless you have satisfactory immigration status"
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly?
SELF-EMPLOYMENT INCOME
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
PERSON 4
Please complete this section for your PERSON 4, even if he or she is not applying for coverage.
For your privacy and security, Social Security numbers are not required to complete the online application process.
"NOTE: You may NOT submit this application
unless you have satisfactory immigration status"
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly?
SELF-EMPLOYMENT INCOME
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
PERSON 5
Please complete this section for your PERSON 5, even if he or she is not applying for coverage.
For your privacy and security Social Security numbers are not required to complete the online application.
"NOTE: You may NOT submit this application
unless you have satisfactory immigration status"
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly?
SELF-EMPLOYMENT INCOME
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
PERSON 6
Please complete this section for your PERSON 6, even if he or she is not applying for coverage.
"NOTE: You may NOT submit this application
unless you have satisfactory immigration status"
FEDERAL INCOME TAX INFORMATION
YOUR CURRENT EMPLOYMENT AND HOW YOU RECEIVE INCOME
All income you receive from work, self-employment, investments, etc. must be included below.
Regular income means from a job, self-employment, an investment, Social Security, unemployment, alimony, etc.
W-2 EMPLOYMENT INCOME
How often you get paid is weekly, bi-weekly, twice a month or monthly?
SELF-EMPLOYMENT INCOME
OTHER INCOME
Unemployment, Social Security, disability, retirement, etc.
DEDUCTIONS
Deductions include student loan interest, alimony paid, IRA or Health Savings account deduction, etc.
Note: Deduct business expenses from the profits of any self-employment income in the Self-Employment Income section.
HEALTH PLAN SELECTION
Let us help you find the perfect health plan. Tell us about what you're looking for.
If you do not know the health plan you would like to enroll in, select "not sure" and an Agent will assist you select a plan.
Dental and Vision Insurance
Covered California health plans do not include dental and vision coverage for adults 18 and older. Dental insurance is offered by Starmount and is a separate policy from your Covered California health insurance policy.
This plan has no waiting periods and no deductible for preventative services. The plan pays 100% for preventative services such as exams, cleanings, x-rays and 50% for basic services. Vision benefits include $15 co-pay for annual eye exams and $20 co-pays for lenses and frames.
This plan offers the highest annual benefit - $2,000 per covered person. There are no waiting periods for preventative and basic services and major services such as crowns, bridges, implants and root canals are covered at 12 months. Vision benefits include an annual eye exam for $15 and frames and lenses for $20.
Accident Medical Expense Coverage
Accident medical expense insurance from NEA pays a cash benefit to cover your out of pocket medical expenses, such as deductibles and co-pays, due to an accident or injury. Up to $5,000 of coverage per occurrence, per family member.
ADDITIONAL COMMENTS (if any)
CONSENT FOR VERIFICATION
Covered California checks other agencies' computer records to verify citizenship, satisfactory immigration status, tax information, and other information related only to eligibility to see if you and other people on this application qualify for health insurance.
Terms and Conditions Agreement
To submit your application, read the agreement here and enter your eSignature in the space below. When you enter your eSignature, it means you are sure about the health insurance plans you chose and have read all the terms and conditions.
- Terms and Conditions: 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, any contracted health care providers, administrators, or other associated parties, about the membership in the health plan, the coverage for, or the delivery of, services or items, 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, and agree to, the use of binding arbitration to resolve disputes or claims (except for Small Claims Court cases and claims that cannot be subject to binding arbitration under governing law) 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 plan’s coverage document.
Electronic Signature
Please read the information bellow. Then check the boxes and sign (Electronic Signature). Click "Submit" to send your completed application.
- Maintaining Your Verification
I understand that the Covered California will use my tax return at renewal time each year to see if I qualify for help paying for health coverage. I understand that I can change my answer later. -
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, 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.
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 Right to Appeal
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.
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 by clicking here. See DHCS' Notice of Privacy Practices by clicking here.
