LA Care Application Agreement
Privacy Information
This application is for healthcare coverage with L.A. Care Covered DirectTM provided through L.A. Care. The information you provide is personal and confidential. L.A. Care requires the information to process your application and to administer our program.
We are required by the Affordable Care Act to obtain your Social Security number to confirm with the IRS that you have health insurance so that you can avoid any penalty.
L.A. Care will use and share your information with others as allowed and required by law. For information on how L.A. Care may use or share your information and your rights regarding your information, please log on to lacarecovered.org and click “Privacy” located at the bottom of the page to review our Notice of Privacy Practices or call 1.855.222.4239 (TTY 711).
Authorizations Terms and Conditions
Please read the following terms and conditions carefully. Each applicant age 18 and older is required to review the completed application and provide his/her own authorization and signature. Please keep a copy of this application for your records.
Application for coverage: It is important to know that L.A. Care may decline your application for coverage if you do not meet the eligibility criteria. Your application must be approved by L.A. Care, and an effective date for coverage assigned, before coverage can become effective.
First month’s dues/premiums: L.A. Care requires payment of first month’s dues/premium for your coverage to become effective. L.A. Care will mail your first bill once your application is approved. Your first payment is due by the due date on your bill. To avoid cancellation of your application, you must make your first premium payment within one (1) month following your effective date of coverage. For example, if your effective date of coverage is January 1, you must make your first payment by February 1 to avoid cancellation of your application. If you do not pay your first full premium within one month following your effective date of coverage, your application will be canceled and you will be required to reapply for enrollment in L.A. Care Covered Direct™. If you miss your first month’s dues/premiums, your effective date of coverage will then begin the first of the following month of the receipt of payment. Your monthly premium rate may also increase based on any updated information. Your future monthly premium payments are due on the 26th day of the month. Refer to the “Billing and payment information” section on page one of this application. Please note that the processing of your first month’s payment does not constitute approval of your application with L.A. Care. If you do not qualify for coverage, the dues/premium you submit to L.A. Care will be returned.
Dues/premiums: Dues/premiums are to be paid in full by the due date. Coverage will be terminated for failure to pay dues/premiums in a timely manner as set forth in the health service agreement/policy and as allowed by law.
Effective date of coverage: If you qualify for coverage, L.A. Care will notify you of your effective date of coverage. If L.A. Care cannot honor your requested effective date, or is unable to issue coverage before your requested date, coverage will begin as soon as possible (coverage will begin on the first of the month after all requirements have been met). If additional dues/ premiums are owed, payment must be received before coverage becomes effective. Any charges incurred for services received prior to your effective date or after termination of coverage are not covered. Effective dates for a Special Enrollment period may be different than for an Open Enrollment period. These effective dates are assigned by L.A. Care and may be as early as the 1st of the month following the receipt of the Special Enrollment period, as required by regulation, or as early as the date of birth in the case of a newborn. For information on Special Enrollment period application effective dates, please see Step 7).
Acceptance of application: You understand that only L.A. Care can accept your application and issue coverage for an Individual and/or Family Plan requested on this application. Your agent or broker cannot enroll you for coverage or change any terms or conditions of coverage.
Parents/guardians: If you are the parent or legal guardian of an applicant who is a minor, please sign below on behalf of the applicant. As the parent or legal guardian, you are identified as the person who may make inquiries and act on behalf of the applicant regarding this coverage (as allowed by law). In addition, you are agreeing to assume all responsibility for payment of dues/ premiums and for following the terms and conditions for coverage. If you are not the parent of the applicant, please attach the court documents that appoint you as the guardian of this minor.
Authorization for spouse/domestic partner to make changes: If you are an applicant whose spouse/domestic partner is also applying for coverage, please specify if you authorize your spouse/domestic partner to make changes to the contract/policy on your behalf. You may discontinue this authorization at any time by sending a written request to L.A. Care.
Process to authorize L.A. Care to release personal protected health information to a third party: If you would like to authorize your spouse, domestic partner, or a third party to access your personal protected health information, please complete the form titled Authorization for Use and Disclosure of Protected Health Information to a Third Party. To obtain this form, contact us at 1.855.222.4239 (TTY 711).
Response to requested information: You agree to cooperate with L.A. Care by providing, or by providing access to, documents and other information requested (such as court orders to provide dependent coverage, etc.) to corroborate information provided in this application for coverage. You acknowledge and agree that failure or refusal to provide these documents or the information requested may be cause to rescind or cancel your coverage.
Authorization to receive materials and communications electronically: Check here if you agree to receive required benefit plan and coverage-related materials and communications via email (i.e. enrollment information, evidence of coverage and health service agreement/policy, explanation of benefits (EOB), annual privacy notice, etc) in place of mailed printed copies, unless required by law. I have reviewed all responses pertaining to me in this application.
I have read the Summary of Benefits and Coverage (SBC), and the terms and conditions of coverage and authorizations set forth above. With my own signature below, I represent that the information provided in this application is complete and accurate to the best of my knowledge, and I understand and agree to the terms and conditions of coverage and the authorizations I have provided. (Important: Each adult applicant must provide their own signature.) I understand that I must inform L.A. Care if anything changes or is different from what I listed on this application before my coverage with L.A. Care begins.