Get ready to renew your application for <Next Benefit Year>!

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Covered California

P.O. Box 989725

West Sacramento, CA 95798-9725

{FIRST_NAME} {LAST_NAME}

{ADDRESS_LINE1}

{ADDRESS_LINE2}

{CITY}, {STATE_CD (FK)} {ZIPCODE}

<Notice Date> Case Number: <Case #>

Dear {FIRST_NAME} {LAST_NAME},

You are getting this letter because, in <previous benefit year>, you or members of your

household qualified to enroll in a Covered California health plan.

Covered California is reaching out to you to let you know you can renew your application

and pick health and dental plans. Renewal for your household is due by

<End_Renewal_Date>. When you renew and submit your application, you will be able to:

 Let Covered California know if your application information has changed

 Find out if you qualify for more or less financial help

 Find out if your monthly premiums have changed

 Pick the health and dental plans that best meet your needs

Note: If someone in your household has Medi-Cal, your local county social services office may

contact you to provide more information. To help them keep Medi-Cal, you will also need to

provide any information your local county social services office asked of you.

Get ready to renew your application for <Next Benefit Year>!

Your destination for quality

healthcare, including Medi-Cal

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You can go online to CoveredCA.com and renew your application. For more information

on how to renew and submit your application, read the “How do I enroll in my insurance

now?” section of this notice. It is important to renew your application to make sure you

get the correct amount of premium assistance. Premium assistance is a federal tax

credit that helps make health insurance more affordable. When you qualify for premium

assistance, there are three ways you can use it:

 Apply all of your tax credits in advance to lower the amount you pay each month,

 Take some of the tax credits each month and claim the rest on your federal

income tax return at tax time, or

 Wait until tax time and claim all of your tax credits on your federal income tax

return.

If you take some or all of your tax credits in advance (before you file your federal income

tax return), the tax credit is paid directly to your health insurance plan.

REMEMBER: If you receive more premium assistance in advance than the total credit

you qualify for, you may have to pay some or all of it back to the IRS at tax time. On the

other hand, you may qualify for more premium assistance at tax time in the form of tax

refund or tax credit if you did not get the full amount in advance.

The amount of premium assistance you can get depends on your family size, annual

household income and the price of health plans where you live.

Family Dental Plan Enrollment

If you are currently enrolled in a family dental plan, you can go online to CoveredCA.com and

log into your Covered California account to renew your current dental coverage or choose a new

dental plan. If you do not choose a new dental plan by December 15, <current year>, we will

keep you in your current dental plan if you remain eligible and your plan is still available.

Family Dental Plans offer optional coverage at an additional cost. Premium assistance is

not available for Family Dental Plans.

All Covered California health plans include pediatric (children’s) dental coverage. You do

not have to pay for a separate dental plan for your children.

What if I do not renew my insurance?

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If you do not renew your insurance, Covered California will automatically re-enroll you or

members of your household into your current health and dental plans by December 15,

<current year>, if you remain eligible and your plans are still available. We will renew

your insurance using the most recent household size and income information in your

application.

If your health or dental plan is not available in <next benefit year>, you may need to

choose a new plan by December 15, <current year>. If you do not choose a new plan by

December 15, <current year>, Covered California will enroll you into a similar plan with

your current carrier, if available. If not available, Covered California will enroll you into a

similar plan with a different carrier.

What will change for you next year?

The Amount of Premiums You Pay

The amount you pay for health coverage may change each year. If you pick a health plan

with Covered California in the fall, you will receive a letter from the health plan carrier you

chose. The letter will show your monthly premium amount for <next benefit year>. Make

sure to pay your premium directly to your health or dental plan carrier by the due date so

your coverage can start on January 1, <next benefit year>. Please do not send your

payment to Covered California.

The Amount of Premium Assistance You Receive

The amount of premium assistance you qualify for may be different than before. It is

important that you let us know if you moved or if your annual household income or family

size has changed.

The Level of Out-of-Pocket Savings You Qualify For

The level of cost sharing reduction you qualify for may be different too. Or, you may be newly

eligible for cost sharing reduction. Cost sharing reduction lowers the amount you have to pay

out-of-pocket when you use your health plan. You can only get these savings if your income

qualifies and you choose a silver health plan. With cost sharing reduction, you will save money

on co-pays and deductibles.

How do I enroll in my insurance now?

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To enroll in a health insurance plan for your household before <End_Renewal_Date>,

follow the steps below:

Step 1: Log in to your CoveredCA.com account

Step 2: Click the yellow “Apply Now” button

Step 3: Check your application information

Make sure your information is correct by <End_Renewal_Date> to get the coverage that’s

right for you.

If your application information has not changed, confirm your current information by clicking

“Continue” until you get to Step 4 (see below).

What if my information has changed?

If your application information has changed, you must report the changes to Covered California

within 30 days of the change. Click the “Edit” button next to the information you want to change.

Certain changes can affect the amount of premium assistance you receive through Covered

California or whether you qualify for free or low-cost Medi-Cal. Examples of changes that must

be reported to Covered California include:

 The number of people in your household went up or down during the year

 Your household income goes up or down

 Moving to a new place

 Qualifying for other coverage, such as, Medicare or coverage through an employer

You can report any changes when you log into your account at CoveredCA.com or by calling the

Service Center at 1-800-300-1506 (TTY: 1-888-889-4500).

Once you report your changes, your household may qualify for different programs or health

plans available through Covered California. If you agree with the decision that we made when

we processed your changes, you can choose your health and dental plans by

<End_Renewal_Date>. You will pay your premium directly to the health and dental plans

carriers. Pay by the due date so your coverage can start on January 1, <next benefit year>.

You may contact your health or dental plan carrier or wait for them to bill you. Please do not

send your payment to Covered California. To report changes, you can also call the Service

Center.

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Note: If you or someone in your household has Medi-Cal, report changes to your local

county social services office within 10 days.

Step 4: Shop and pick the best plan for you

Once you confirm your application information, you will be able to pick a health or dental

plan. Or, you can compare rates and shop for a new health plan or enroll in a dental plan.

You may want to check whether the plans you are looking at have your current doctors or

hospitals. At CoveredCA.com, there are links to each health plan provider directory.

There you can check to see which doctors are available.

If you do not choose a new health or dental plan by <End_Renewal_Date>, we will keep

you in your current health and dental plans if you remain eligible and your plans are still

available.

Covered California offers a range of choices of health and dental insurance plans. You

can choose the plan and level of coverage that best meets your needs and budget. You

can choose to pay a higher monthly cost (called a premium) so that you pay less out of

pocket when you need care. Or, you can choose to pay a lower monthly cost but pay

more out of pocket when you need care.

What if I do not renew my application and pick a health

plan by <End_Renewal_Date>?

If you do not choose a new plan by <End_Renewal_Date>, you can still enroll in

Covered California and pick a plan. The <next benefit year> Open Enrollment Period is

from <OE begin date> to <OE end date>. Open Enrollment Period allows you to:

 Change your health or dental plan for any reason

 Add new members to your coverage

 Enroll in a dental plan

Please remind your family and friends that the Open Enrollment Period is coming and

send them to CoveredCA.com.

For Open Enrollment, you can:

 Go online to CoveredCA.com and log in to your Covered California account.

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 Call our Customer Service Center at 1-800-300-1506 or (TTY: 1-888-889-4500).

Starting now and until the end of Open Enrollment, the Service Center has

extended hours.

 Get free help in person from trained Certified Enrollment Counselors and Certified

Insurance Agents who can help you. See “Do you need help?” below.

Do you need help?

A Covered California Certified Enrollment Counselor or Certified Insurance Agent can help you.

Use this snippet if the consumer did not have a counselor or agent

<Do you have an Enrollment Counselor or Agent? To find an Enrollment Counselor or Agent

close to your home, go to CoveredCA.com and click on Get Help. Or call the Covered California

Service Center. See “Do you have questions?” below for Service Center contact information.>

Use this snippet if the consumer already has a delegated counselor or agent for <previous

benefit year>

<Our records show that you were helped by a Covered California Certified Enrollment Counselor

or Agent from {Entity Name or Agent Name}.You may reach your Certified Enrollment Counselor

or Agent at:

{Entity Name or Agent Name}

{Entity/Agent Address Line 1}

{Entity/Agent Address Line 2}

{Entity/Agent City}, {Entity/Agent State} {Entity/Agent Zip Code}

{Entity/Agent 1Phone Number}

{Entity/Agent Email}>

Why is it important to keep your health insurance?

Health insurance helps make sure you get the care you need to keep your body healthy,

and it gives you peace of mind because you know you’ll have help when you need it.

The law requires that most consumers must have health insurance. This may be through

your employer, coverage you buy for yourself, Medicare, or Medi-Cal. Consumers who do

not have health insurance may have to pay a penalty called a “shared responsibility

payment” that increases each year up to a maximum amount.

For example, the chart below shows the penalty with the maximum for an uninsured

household of four:

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Year

How the fee is calculated

The maximum fee for an uninsured

household of 4 (2 adults and 2 children)

2015

2% of the annual household

income or $325 per adult

($162.50 per child under 18) up to

$975 for a family.

You will pay whichever of these

amounts is higher.

Household earning $40,000 could pay up to

$975

Household earning $50,000 could pay up to

$1,000

2016

2.5% of the annual household

income or $695 per adult.

($347.50 per child under 18) up to

$2,085 for a family.

You will pay whichever of these

amounts are higher.

Households earning both $40,000 and $50,000

could pay up to

$2,085

If you are uninsured for just part of the year, you pay 1/12 of the yearly penalty for each month

you are uninsured. You will have to pay the penalty when you file your federal income tax return

for that year. If you are uninsured for less than 3 months, you do not have to pay the penalty.

Remember: if you are uninsured, you also pay 100% of your medical costs.

Do you have questions?

 Visit the CoveredCA.com website for more details.

 If you have created a CoveredCA account, log on to your account at

CoveredCA.com; or

 Call the Covered California Service Center at 1-800-300-1506. You can call Monday

through Friday 8 a.m. to 6 p.m. During certain times of the year, the Service Center

may be available Saturdays 8 a.m. to 5 p.m. The call is free.

This letter is being sent to you in compliance with the Affordable Care Act:

45 CFR 155 § 335(c) Notice to enrollee and Cal. Code Regs., tit. 10, § 6498(e).