Agent Code of Conduct

Background

Covered California's mission is to increase the number of insured Californians, improve health care quality, lower costs, and reduce health disparities through an innovative and competitive marketplace that empowers consumers to choose the health plan that best meets their needs. Covered California contracts with licensed insurance agencies and agents to implement this mission and ensure consumers receive quality service and enrollment assistance.  

Covered California developed the Agent Code of Conduct to promote ethical sales practices in order to preserve the integrity of its mission and the trust of its consumers. Agencies and their Agents must comply with the below rules to maintain certification with Covered California.  

 
 

Failure to comply with the following rules constitutes a breach of the Agency or Non-Monetary Agent Agreement and may result in termination of the Agreement and revocation of certification pursuant to Section E of Exhibit C.

Rules

  1. Agency and Agent agrees to fairly and accurately promote Covered California health plans to consumers. 
  2. Agency and Agent will not charge any fee to consumers for performing any service under the Agency Agreement or Non-Monetary Agent Agreement.
  3. Agency and Agent will not charge consumers translation fees for services offered in connection with a Covered California enrollment.  These services must be provided free of charge.
  4. Agency and Agent agrees to assist consumers with finding the health plan that best meets the consumer’s needs.  Agency and Agent will make health plan enrollment recommendations based on the consumer’s best interests and not influence consumers to enroll in health plans based on financial compensation and incentives from health issuers.
  5. Agency and Agent will only sell Health Care Sharing Ministry (HCSM) products in accordance with the requirements as set forth in the Agency Agreement and this Code of Conduct.  For each consumer who signs up for a HCSM product, Agency and Agent must follow the below procedures:
    • Agency and its Agents must perform an eligibility determination as outlined in the Agency Agreement for any consumer interested in purchasing an HCSM product. Before enrolling a consumer in an HCSM product, Agency and its Agents must share the full results of the eligibility determination with the consumer and explain the benefits of enrolling in a Covered California plan. Agency and its Agents must disclose all financial assistance that the consumer may be eligible to receive and all insurance affordability programs that the consumer may be eligible to enroll in, such as Medi-Cal.
    • Agency and its Agents must require consumers to complete a Health Care Sharing Ministry Consumer Acknowledgement Form before enrolling them into an HCSM product. Agency must maintain hard or electronic copies of executed forms for a minimum of three (3) years. Agency must make these executed forms available to Covered California upon request.
    • Agency must ensure its Agents complete an attestation to confirm compliance with this section when completing any annual training requirements.
    • If requested by Covered California, Agency must disclose the total number of HCSM products that it sold in the previous plan year.
  6. Agency and Agent must not mislead consumers into purchasing supplemental products as a requirement to purchasing a Covered California plan. Agency and Agent will inform the consumer that the purchase of supplemental products is an optional purchase and is not required to obtain a Covered California plan. 
  7. Agency and Agent shall not unduly influence consumers to enroll in lower premium health plans if it is not in the best interest of the consumer to do so. Agency and Agent cannot steer consumers into plans with lower monthly premiums in order to facilitate supplemental product sales.    
  8. Agency and Agent shall not condition enrollment in Covered California plans on enrollment in other products unrelated to Covered California plans. Agency and Agent must assist with enrollment in a Covered California plan even when a consumer does not want to purchase a supplemental product.   
  9. When performing any service under the Agency Agreement that involves interacting with Covered California consumers, employees, Qualified Health Plan issuers, contractors, or other representatives acting on Covered California’s behalf, Agency and Agent shall not engage in abusive, intimidating, threatening, or any other detrimental behavior.
  10. Agency and Agent will ensure their Covered California-Approved Admin Staff are only designated as Authorized Representatives for those consumers who have expressly consented in writing to the designation as required by 10 CCR § 6508(b). Admin Staff who are designated as Authorized Representatives may only perform those duties as authorized in the Agency Agreement and may not enroll consumers into Covered California plans while acting on behalf of the Agency or Agent.  
  11. American Rescue Plan: When migrating an off-exchange consumer to a Covered California Qualified Health Plan (QHP) in order to maximize the premium subsidy under the American Rescue  Plan, Agency and Agent are not required to present all available enrollment options to the consumer. This limited exception only applies to enrollments from off-exchange to Covered California when a consumer can take advantage of enhanced subsidies under the American Rescue Plan. Agency and Agent must present all enrollment options if specifically requested by the consumer during the off-exchange transition and for all other enrollments. Agency and Agent must also track all off-exchange to Covered California enrollments. Covered California may request information related to those enrollments from Agency and Agent at any time.

 

Pursuant to Section C(23) of Exhibit A, this Code of Conduct is incorporated by reference into the Agency Agreement as well as the Non-Monetary Agent Agreement. Agencies and Agents are hereby mandated to comply with the rules as set forth in this document. Covered California reserves the right to modify or amend this Agent Code of Conduct at any time and without prior notice to Agency or Agent. Any changes shall be posted to http://www.coveredca.com/agents/become-an-agent/. In advance of amending the Code of Conduct, Covered California will communicate any such changes to Agencies and Agents via the appropriate communication channels. For any questions regarding the Code of Conduct, please contact AgentContracts@covered.ca.gov.

Rev. 2/2022           

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