Covered California

PO Box 989725
West Sacramento, CA 95798-9725

Margie Flores Your destination for quality

1372 13th ST healthcare, including Medi-Cal
Apartment 1
Imperial Beach, CA 91932

Case Number: 5000438691

We need more information to confirm your eligibility!

You or a member of your household are conditionally eligible for Covered California. Please read the
following pages to learn about your eligibility and what documents we need. On the back of this page,
you’ll find a list of documents we accept.

Please send us this page with any documents or information we ask for. It is important to send us this
page with your documents so that we can quickly confirm your eligibility.

SEND THIS PAGE WITH YOUR DOCUMENTS!

Three ways to send your documents:

1. Upload through your account at CoveredCA.com. It’s fast and easy! Now available on your smart
device.

2. Fax: 1-888-329-3700 (1-888-FAX-3700)

3. Mail:

Covered California
P.O. Box 989725
West Sacramento, CA 95798-9725

Please put this page on top of any documents you are sending.

CCOE100 1
This is a partial list of the more common documents you can send. For a complete list of documents, visit:
CoveredCA.com/confirm.

Please read the letter to learn about your eligibility and what documents you should send with cover page (other side of
this page). REMEMBER: Only send documents we need.

DO NOT SEND ORIGINALS

If this letter says you need to prove your INCOME, here are some documents we accept:
If you earn income at a job: If you get Social Security:
• Most recent W‐2 or pay stub • Form SSA‐1099 Social Security Administration (SSA)
• A letter from your employer benefits statement
• A copy of a check paid to you as wages • SSA document showing your full name, the
amount, and how often you get it
If you are self-employed: If you get income from other sources:
• Most recent 1099-MISC • Statement of unemployment income
• Recent profit and loss statement • Veterans Benefit statement
• Bookkeeping records or ledger showing income
and deductible expenses

If this letter says you need to prove you DO NOT HAVE OTHER COVERAGE, send a copy of one
of these:
• Letter from employer or health plan or a government document with the names of persons who no longer
qualify, coverage type and end date of coverage or ineligibility to program.

If this letter says you need to prove U.S. CITIZENSHIP OR NATIONAL STATUS, send one of
these:
• A copy of your original or certified birth certificate • A copy of your Certificate of Naturalization or
• A copy of your U.S. Passport Certificate of Citizenship

If this letter says you need to prove LAWFUL PRESENCE, send a copy of one of these:
• Permanent Resident card (“Green Card” I-551) • Employment Authorization Document
• Reentry Permit (I-327) • Form I-94
• Refugee Travel Document (I-571) • Temporary I-551 Stamp (on passport or I-94)

If this letter says you need to prove you are NOT INCARCERATED, send one of these:
• Letter that you are not incarcerated (in jail or prison) or attestation form (visit website at top of page)
• A copy of inmate release or parole papers

If this letter says you need to prove a household member is NOT DECEASED, send us in writing:
• The full name of the person who was identified as being deceased,
• A statement that this person is not deceased, and
• The date and signature of the person who was identified as being deceased.

If this letter says you need to prove federally recognized AMERICAN INDIAN OR ALASKA
NATIVE heritage, send a copy of one of these:
• Document from a federally recognized Indian tribe showing you are a member or affiliated with the tribe
• Tribal enrollment ID or Certificate of Degree of Indian Blood from the Bureau of Indian Affairs

If this letter says you need to prove your SOCIAL SECURITY NUMBER (SSN):
• Call Covered California to verify your personal information.

CCOE100 2
 Covered California
PO Box 989725
West Sacramento, CA 95798-9725

Margie Flores
Your destination for affordable
1372 13th ST healthcare, including Medi-Cal
Apartment 1
Imperial Beach, CA 91932

Important news about your health benefits

11/21/2019 Case Number: 5000438691

Dear Margie Flores,

Thank you for choosing Covered California. Unless you told us not to, we checked to see if your
household members qualify for:

• Free or low-cost Medi-Cal

• A private health insurance plan through Covered California
• Financial help (premium tax credits and cost-sharing reductions)

If someone in your household qualifies for a private plan through Covered California, their coverage is
for benefit year 2019. Medi-Cal coverage may start sooner. Look for the person's name below to see
what they qualify for.

Margie Flores
We recently received updated information about your application. Based on this information, you and
your family qualify for the following health program(s):

Covered California Eligibility

You are conditionally eligible for Covered California health and dental plans with up to $513.81 per
month in premium assistance (a federal tax credit). This can be used to lower your household's health
plan premium (monthly cost). We based our decision on the household size and income you reported
($27,581.67 per year).

We need more information to confirm that you qualify. Look for the “We need proof” section below.

You have 60 days from the date of your life event to pick your plans.

Medi-Cal Eligibility
We checked to see if you can get Medi-Cal. You do not qualify for Medi-Cal because your income is
above the Medi-Cal limit of $1,437.00 per month. We based this decision on 45 CFR §155.305, 45 CFR
§155.505, 45 CFR §155.520, 42 CFR §435.911.

CCOE100 3
 We need proof by the due date!
Our records do not match the information on your application for one or more members of your
household. We need more information so we can see if you qualify. We must get each member’s
information by their due date.

If we don’t get the information we need, we may have to end the health or dental plan, or both, for the
people listed below. Or the financial help your household gets may change or end.

Records show Household member

Household income does not match our records. Please All household income (due 02/22/2020)
send proof.

Important: If your due date is in the past, send your proof now to avoid losing coverage.

How to send your information

Send your proof with the cover page (the first page of this letter). There is a list of documents we
accept as proof on the back of the cover page. If you need more time, please call.

Questions?
• Members who qualify for Covered California, call Covered California at 1-800-300-1506 (TTY:
888-889-4500).

What is financial help? Financial help is based on the income and family size you report. To qualify,
you must file income taxes, even if you do not usually file or have not filed in the past. Additionally, if
you are married and live with your spouse, you must file taxes as “Married Filing Jointly.” There are
different kinds of help:

• The federal Advance Premium Tax Credit (APTC) and the California Premium Subsidy lower the
premium (monthly cost) for your health plan.

• Cost-Sharing Reductions (CSR) can lower out-of-pocket costs, such as co-pays and deductibles
when you enroll in an enhanced silver plan.

Remember: If you get too much financial help during the year, you may have to pay some or all of it
back when you file taxes. At the end of the year, if you qualify for more financial help, you may get a
credit. For more information, visit: CoveredCA.com/financial.

What to do next
This letter says that you or someone in your household qualifies for Covered California. You need to
pick health and dental plans before your special enrollment period ends. Special enrollment ends 60
days after your qualifying life event date.

If you have not already picked the health plan that best fits your needs, please log into your account at
CoveredCA.com to pick a plan. You can also call Covered California at 1-800-300-1506 for help.

Your coverage will not start until you pick a plan and pay your first premium (monthly cost) directly to
the health and dental insurance companies. You should get a bill with your premium due date. You
can also contact the insurance companies directly.

CCOE100 4
If you do not pick a Covered California plan before your special enrollment period ends, you may have
to wait until the next open enrollment period. Or you may re-apply if you have a new qualifying life
event. Covered California can help if you don't know if a situation is a qualifying life event.

Note: If this letter says you or someone in your household may be eligible for Medi-Cal, then those
household members cannot pick a plan now. Please wait to hear from your County worker.

Report changes to Covered California within 30 days.

You must tell us if your household size or income changes or if you are eligible for other health
insurance. For a full list of changes you must report, visit: CoveredCA.com/RAC.
If you think we made a mistake or you disagree with a decision we made, you have the right to
appeal. Read the page titled “If you think we made a mistake.“

Questions?
• 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 notice is being sent to you in compliance with the Affordable Care Act:
45 CFR 155.305, 45 CFR 155.310, 26 USC 36B, 45 CFR 155.320, 45 CFR 155.315, 45 CFR 155.420(c), 45 CFR 155.420(d), 45 CFR 155.505, 42 CFR 435.911, 26
CFR 1.36B, 45 CFR 155.520

CCOE100 5
If you think we made a mistake
1. Call Covered California for help at 1-800-300-1506 (TTY: 1-888-889-4500). We are open Monday –
Friday 8 a.m. to 6 p.m.

2. If we cannot solve the problem, you can ask for an appeal. You must ask within 90 days of the
date on your eligibility notice. You can ask for an appeal in one of these ways:

• Online at www.cdss.ca.gov/Hearing-Requests
• Email SHDACAOperations@dss.ca.gov (do not email private information)
• Call the State Hearings Division at 1-855-795-0634
• Visit your local county office

You have the right to appeal any eligibility or enrollment decision. This includes, but is not limited
to:

• Your eligibility for Covered California or Medi-Cal

• The date your health plan coverage starts
• Your premium assistance amount or cost-sharing reduction level
• You have waited too long for a decision
• Your eligibility for an exemption

About appeals
You only have 90 days from the date of your eligibility notice to ask for an appeal. An appeal decision
could change eligibility, enrollment, premium (monthly cost) or cost-sharing reduction for you or other
household members.

Appeal hearings are by telephone, video conference or in person. You can speak for yourself or be
represented (have someone speak for you). For free, local help with your appeal, call the Health
Consumer Alliance at 1-888-804-3536.

If you need health services right away and a standard appeal could put your life or health in danger,
call 1-855-795-0634. Ask for an expedited (fast) appeal.

If you have a Covered California plan, you can ask for continued enrollment. This will let you keep
your health plan and premium assistance amount while you appeal. You must keep paying your
premium (monthly cost).

CCOE100 6
 Section 1557 of the Patient Protection and Affordable Care Act (ACA)
Covered California complies with applicable federal civil rights laws and does not discriminate on the
basis of race, color, national origin, age, disability, sex, gender identity or sexual orientation. Covered
California does not exclude people or treat them differently because of race, color, national origin, age,
disability, sex, gender identity or sexual orientation.
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 1-916-228-8764 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, sex, gender identity or sexual
orientation, you can file a grievance with the Civil Rights Coordinator.

You can file a grievance in the following ways:

Mail: Civil Rights Coordinator

P.O. Box 989725
West Sacramento, CA 95798-9725

Phone: 1-916-228-8764

Fax: 1-916-228-8909

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: 1-800-368-1019 or TTY: 1-800-537-7697

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.

CCOE100 7
 Getting Help in a Language Other than English
IMPORTANT: Can you read this letter? You can call
1-800-300-1506 and ask for this letter translated to your
language or in another format such as large print. For TTY
call 1-888-889-4500 where you can also request this letter
in alternate format.
Español IMPORTANTE: ¿Puede leer esta carta? Usted
puede llamar al 1-800-300-0213 y pedir esta carta
traducida en su idioma o en otro formato, como en letras
grandes. Para TTY, llame al 1-888-889-4500, donde
también puede pedir esta carta en algún formato diferente.
(Spanish)
中文/繁體字 重要事项：您能否阅读此信件？您可以致电
1-800-300-1533, 要求将此信件翻译为您的母语或者索要
其他格式（如，大字版本）的信件。如需 TTY 服务或者
索要其他格式的信件，请致电 1-888-889-4500。
(Chinese)
Tiếng Việt QUAN TRỌNG: Quý vị có thể đọc được bức thư
này không? Quý vị có thể gọi điện đến số 1-800-652-9528
và yêu cầu được dịch bức thư này sang ngôn ngữ của quý vị
hoặc chuyển sang định dạng khác như bản in khổ lớn.
Người dùng TTY, hãy gọi số 1-888-889-4500 quý vị cũng
có thể yêu cầu định dạng thay thế khác cho bức thư này.
(Vietnamese)
한국어 중요: 이 편지를 읽을 수 있나요? 1-800-738-9116
에 연락하셔서 번역되어 있거나 인쇄물 등 다른 포맷으로
되어 있는 편지를 요청해보세요. TTY 1-888-889-4500 에
서도 이 편지의 다른 포맷을 요청할 수도 있습니다.
(Korean)
Tagalog MAHALAGA: Makakabasa ka ba sa sulat na ito?
Maaari kang tumawag sa 1-800-983-8816 at humiling na
isalin ang sulat na ito sa iyong wika o sa iba pang format
katulad ng malalaking titik. Para sa TTY, tumawag sa
1-888-889-4500 kung saan maaari kang humiling ng
alternatibong format ng sulat na ito.
‫ ﻫﻞ ﻤﻳﻜﻨﻚ ﻗﺮاءة ﻫﺬا اﻟﺨﻄﺎب؟ ﻤﻳﻜﻨﻚ اﻻﺗﺼﺎل ﺑـ‬:‫اﻟﻌﺮﺑﻴﺔ ﻫﺎم‬
،‫ﻣﱰﺟﺎﻤ إﱃ ﻟﻐﺘﻚ أو ﺑﺼﻴﻐﺔ أﺧﺮى‬
ً ‫ وﻃﻠﺐ ﻫﺬا اﻟﺨﻄﺎب‬1-800-826-6317
ً‫ ﺣﻴﺚ ﻤﻳﻜﻨﻚ أﻳﻀﺎ‬1-888-889-4500 ‫ اﺗﺼﻞ ﺑـ‬،‫ ﻟﻠﺼﻢ واﻟﺒﻜﻢ‬.‫ﻣﺜﻼ‬
(Arabic) .‫أن ﺗﻄﻠﺐ ﻫﺬا اﻟﺨﻄﺎب ﺑﺼﻴﻐﺔ ﻣﺨﺘﻠﻔﺔ‬
հայերեն ԿԱՐԵՎՈՐ Է: Դուք կարո՞ղ եք կարդալ
այս նամակը: Դուք կարող եք զանգահարել
1-800-996-1009 և խնդրել, որ այս նամակը
թարգմանվի Ձեր լեզվով կամ Ձեզ տրվի մեկ այլ
ձևաչափով, օրինակ` խոշորատառ: TTY-ի համար
զանգահարեք 1-888-889-4500, որտեղ կարող եք
նաև այլընտրանքային ձևաչափով խնդրել այս
նամակը: (Armenian)
ភាសាែខ�រ សំខាន់៖ េតើេលោកអ�កអាចអានលិខិតេនះ�ានែដរឬេទ?
េលោកអ�កអាចទូរស័ព�មកេលខ 1-800-906-8528
និងេស�ើសុំឲ�េគបកែ�បលិខិតេនះជាភាសារបស់េលោកអ�ក
CCOE100
ឬជាទ�មង់មួយេផ�ងេទៀតដូចជាអក�រពុម�ធំៗ។ ស�មាប់ TTY
ទូរស័ព�មកេលខ 1-888-889-4500
ែដលេលោកអ�កក៏អាចេស�ើសុំលិខិតេនះ ជាទ�មង់េផ�ងេទៀត
�ានផងែដរ។ (Khmer)
Русский ВАЖНАЯ ИНФОРМАЦИЯ: Вы можете
прочитать это письмо? Вы можете позвонить по
телефону 1-800-778-7695 и запросить получение этого
письма, переведенного на Ваш родной язык, или
распечатанного крупным шрифтом. Лица со сниженным
слухом могут позвонить по телефону 1-888-889-4500,
чтобы запросить это письмо в ином формате. (Russian)
‫ آﯾﺎ ﻣﯽ ﺗﻮاﻧﯿﺪ اﯾﻦ ﻧﺎﻣﻪ را ﺑﺨﻮاﻧﯿﺪ؟ ﻣﯽ ﺗﻮاﻧﯿﺪ ﺑﺎ ﺷﺎﻤره‬:‫ﻓﺎرﺳﯽ ﻣﻬﻢ‬
‫ ﻤﺗﺎس ﺑﮕﯿﺮﯾﺪ و ﺗﻘﺎﺿﺎ ﮐﻨﯿﺪ ﮐﻪ اﯾﻦ ﻧﺎﻣﻪ ﺑﻪ زﺑﺎن ﺷﺎﻤ‬1-800-921-8879
‫ ﺑﺮای‬.‫ﺗﺮﺟﻤﻪ ﺷﻮد ﯾﺎ ﺑﻪ ﻓﺮﻣﺖ دﯾﮕﺮی ﻣﺎﻧﻨﺪ ﺣﺮوف درﺷﺖ ﺑﻪ ﺷﺎﻤ ارﺳﺎل ﺷﻮد‬
‫ ﻤﺗﺎس ﺑﮕﯿﺮﯾﺪ و از ﻃﺮﯾﻖ ﻫﺎﻤن ﺷﺎﻤره‬1-888-889-4500 ‫ ﺑﺎ ﺷﺎﻤره‬TTY
‫ﻫﻤﭽﻨﯿﻦ ﻣﯽ ﺗﻮاﻧﯿﺪ درﺧﻮاﺳﺖ ﮐﻨﯿﺪ ﮐﻪ اﯾﻦ ﻧﺎﻣﻪ ﺑﻪ ﻓﺮﻣﺖ دﯾﮕﺮی ﺑﻪ ﺷﺎﻤ ارﺳﺎل‬
(Farsi) .‫ﺷﻮد‬
Hmoob TSEEM CEEB: Koj nyeem puas tau tsab ntawv no?
Koj hu tau rau 1-800-771-2156 nug daim ntawv txais ua
yog koj cov lus los yog lwm hom xws lis tus ntawv loj. Hu
tau TTY ntawm 1-800-889-4500 ua koj thov hloov tau lwm
hom. (Hmong)
मह�वपूणर्: �ा आप यह पत्र पढ़ सकते ह�� इस पत्र को अपनी भाषा म�
अनुवाद करने के �लए या बड़े �प्रटं क� तरह िकसी अ�य प्रा�प म� प्रा�त करने
के �लए 1-800-300-1506 पर कॉल करके अनुरोध कर सकते ह�। TTY के
�लए 1-888-889-4500 पर कॉल कर� जहाँ आप इस पत्र को िकसी अ�य
प्रा�प म� प्रा�त करने का अनुरोध कर सकते ह�। (Hindi)
重要：この文書を読むことができますか？希望の言語に翻訳
された文書、または大きな文字など別の形式の文書をご希望
の場合、1-800-300-1506 までお電話ください。TTY の場
合、1-888-889-4500 にお電話いただければ、その他の形式
の文書をリクエストすることもできます。(Japanese)
ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁਸ� ਇਸ ਪੱਤਰ � ਪੜ ਸਕਦੇ ਹੋ ਤੁਸ�
1-800-300-1506 'ਤੇ ਕਾਲ ਕਰ ਸਕਦੇ ਹੋ ਅਤੇ ਇਸ ਪੱਤਰ � ਆਪਣੀ
ً ‫ﺑﺨﻂ ﻛﺒﺮﻴ‬ ਭਾਸ਼ਾ ਿਵਚ ਜਾਂ ਿਕਸੇ ਹੋਰ ਸਰੂਪ ਿਵਚ‚ ਿਜਵ� ਿਕ ਵੱਡੇ ਪਿਰੰਟ ਲਈ ਪੁੱਛ ਸਕਦੇ ਹੋ।
ਟੀਟੀਵਾਇ ਲਈ 1-888-889-4500 'ਤੇ ਕਲ ਕਰੋ ਿਜੱਥੇ ਿਕ ਤੁਸ� ਇਸ ਪੱਤਰ
ਦੇ ਿਵਕਲਪਕ ਰੂਪ ਿਵਚ ਸਰੂਪ ਲਈ ਬੇਨਤੀ ਵੀ ਕਰ ਸਕਦੇ ਹੋ। (Punjabi)
สําคัญ: คุณสามารถอ่านจดหมายฉบับนี � ได้หรือไม่? ถ้าคุณมีข้อสงสัย
คุณสามารถติดต่อได้ท�เี บอร์ 1-800-300-1506
เพื�อทําการพูดคุยกับเจ้าหน้ าที�ที� ใช้ภาษาของคุณ
นอกจากนี �คณ ุ ยังสามารถร้องขอให้แปลจดหมายฉบับนี �เป็ นภาษาที�คุ
ณต้อง การได้หรือเปลี�ยนแปลงรูปแบบตัวอักษรให้เป็ นรูปแบบอื�น
เช่น ตัวอักษรพิมพ์ ใหญ่หรือทําให้มีขนาดใหญ่ขน ึ � สําหรับระบบ TTY
�
คุณสามารถติดต่อได้ทเี บอร์ 1-888-889-4500
ซึ�งคุณสามารถขอจดหมายฉบับนี � ในรูปแบบอื�น ๆ
ได้ตามที�คณุ ต้องการ (Thai)
8