Terms and Conditions Agreement of Covered California Health Insurance Premium assistance
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, and to give up my right to a trial by court except where regulations allow such exceptions. I understand that the full arbitration provision for each participating health plan, if they have one, is in the health plan’s coverage document which is available online at CoveredCA.com for my review, or I can call Covered California for more information.... On the first page you are signing your application for Covered California health insurance, Expert Auto Home Health Insurance Agency or employees are Covered CA Storefront an insurance agency licensed with the California Department insurance. By my signature I I do acknowledge that The Expert Insurance Agency or Shaw n Pirnia is your insurance agency of record and authorize Expert Auto Home Health insurance Agency or Shawn Pirnia or employees to act on your behalf, this agency employees have access to all my data and the personally identifiable information that you provide to complete the eligibility and enrollment process. For further information, please contact Expert Auto Home Health insurance Agency directly. Please do not sign if you do not like or authorize this agency, employees to be your agency of record and have access to personally identifying information that you provide to complete the eligibility and enrollment process. ” For additional information regarding enrollment Delegation or Covered California, please call 310-533-6001.
Medi-Cal Estate Recovery Alert
The Medi-Cal program must seek repayment from the estates of certain deceased Medi-Cal members for payments made, including managed care premiums, for nursing facility services, home and community-based services, and related hospital and prescription drug services provided to the deceased Medi-Cal member on or after the member's 55th birthday. If a deceased member does not leave an estate or owns nothing when they die, nothing will be owed. For more information you may visit the Estate Recovery website at http://dhcs.ca.gov/er
If you are found eligible for Covered California plans or for Medi-Cal, you must tell your agent for Covered California plans and Medi-Cal to county eligibility worker about any changes that may affect your eligibility for health insurance within 10 days of the change. These changes include, but are not limited to If you move, any income change, any household changes as you marry/divorce, become pregnant, or have a child(ren).
Voter Registration
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. I agree to Consent for 5 years Verification and I know I can change my answer later.
I know that if I am not truthful there may be a civil and/or criminal penalty for perjury (under California Penal Code Section 126, perjury is punishable by imprisonment for up to four years).
I understand that if I have received federal subsidy or advanced premium tax credits for health coverage through Covered California during any calendar year benefit year, I must file a federal income tax return for that benefit year.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
By entering my full name below, I agree that this digital signature shall have the same force and effect as if I signed this application by my own hand.
