Covered California
You hereby authorize Stride Health, Inc. to act as your Agent of Record in connection with this Application, and you acknowledge and agree that Stride Health, Inc. may use your personally identifiable information in order to complete the eligibility and enrollment process on Covered California. By submitting your application, you agree to the Covered California Terms of Use and Privacy Policy. You also acknowledge and agree to the following:
####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 or call (916) 650-0590.
####Covered California Nondiscrimination Policy#### Covered California complies with applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex. Covered California does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.
Covered California provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats and other formats).
Covered California also provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages.
If you need these services, contact the Civil Rights Coordinator at (916) 228-8764 or by email at CivilRights@covered.ca.gov.
If you believe that Covered California has failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with the Civil Rights Coordinator.
You can file a grievance in person in any of the following ways:
Mail: Civil Rights Coordinator, P.O. Box 989725, West Sacramento, CA 95798-9725 Phone: (916) 228-8764 Fax: (916) 228-8909 Email: CivilRights@covered.ca.gov
You can also file a civil rights complaint with the Office for Civil Rights at the U.S. Department of Health and Human Services. Mail: U.S. Department of Health and Human Services, 200 Independence Ave. SW, Room 509F, HHH Building, Washington, DC 20201 Phone: (800) 868-1019 or TTY: (800) 537-7697 Online: Office for Civil Rights Complaint Portal at https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
Complaint forms are available on the U.S. Department of Health and Human Services Office for Civil Rights website.
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
If you are found eligible for Medi-Cal, you must tell your 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
If your income changes
If your household changes, for example, you marry/divorce, become pregnant, or have a child(ren)
If you become qualified for other health insurance
I have understood all the questions on this application and provided true and correct answers to such questions to the best of my knowledge. Where I do not have personal knowledge of an answer, I have made every reasonable attempt to verify (or confirm) the information with someone who has personal knowledge of the answer.
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 know that all information disclosed on this application will be used to determine eligibility of every person applying for health insurance on this application. The information will be kept private as required by federal and California law.
Cancellation Disclaimer:
Pursuant to the new healthcare reform laws, all individuals must maintain "minimum essential coverage" for themselves and their dependents beginning January 1, 2014. If an individual fails to meet the requirement of the individual mandate for one or more months, then the individual will face a tax penalty unless the individual is determined to be exempt from such requirements.
The term "minimum essential coverage" means any of the following:
(A) Coverage through government sponsored programs, such as Medicare, Medi-Cal or Health Families Program.
(B) Coverage under an eligible employer-sponsored plan.
(C) Coverage under a health plan offered in the individual market within a State, such as the Exchange.
(D) Coverage under a grandfathered health plan.
For detailed definition of "minimum essential coverage", including some example, or to find out if your coverage would qualify as "minimum essential coverage", please visit the Minimum Essential Coverage page.
To find whether you are "exempt" from this requirement, or how to apply for and obtain a Certificate of Exemption, please visit the Exemption page.