There are just a few legal points we need to cover before we submit your application to Covered California. You must agree to report any changes to the information in this application to Covered California or to the local county
office.

You are responsible for reporting changes to any information in your application. Some common changes are: moving,
adding or removing family members and changes in immigration status. If you are enrolled in Medi-Cal, you must report a change within 10 days. If you are enrolled in Covered California, you must report a change within 30 days.

  • You must report a change if you:

    Get married or divorced.
    • Have a child, adopt a child or place a child for adoption.
    • Have a change in income.
    • Get health coverage through a job or a program like Medicare or Medi-Cal.
    • Move.
    • Have a change in disability status.
    • Gain or lose a dependent.
    • Have a change in tax filing status.
    • Have a change in citizenship or immigration status.
    • Are incarcerated or released from incarceration.
    • Have a change in status as an American Indian or Alaska Native or change your tribal status.
    • Have a correction to your name, date of birth or Social Security number.
    • Experience any other changes that may affect your income and household size.

    Special note: Covered California does not require members to report a pregnancy. If you are an existing Covered
    California member, it is not necessary or recommended to report a pregnancy unless you are interested in other coverage
    options for pregnant women such as Medi-Cal or the Medi-Cal Access Program.

  • Special Enrollment

    You can apply for free or low cost health care through Medi-Cal or Covered California at any time of the year. To enroll in a
    health plan through Covered California, you must have a qualifying life event during the special enrollment period (outside of
    the Open Enrollment Period). If you are eligible for Medi-Cal you can enroll through the year. Please make sure your
    application is true and correct. If you provide false information, your coverage may be cancelled. The U.S. Department of
    Health and Human Services may also fine you for providing false information.
    • You may be fined up to $25,000 if you negligently or with intentional disregard for the rules provide false information
    in your application.
    • You may be fined up to $250,000 if you knowingly lie on your application

  • I certify under the penalty of perjury that I have read and agree to the above terms and condition. I also agree to hold Peace & Grace Insurance Service harmless of any liabilities resulting from this application or my client relationship with Covered California. I also understand that I may terminate my relationship with Peace & Grace Insurance Services by calling 1-800-300-1506.
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