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Covered California Q&A

Covered California and Obamacare related questions from consumers, employers and agents are answered by Phil Daigle with the best information available at the time. Archived entries may no longer be accurate as the Covered California and Obamacare knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Physician Balance Bill?

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Question: I have Anthem Blue Cross silver 94 PPO. I had to visit to ER in March and I verified the facility was in network. I received a balance bill from the Doctor demanding me to pay what anthem did not pay. Do I have to pay this bill?

Answer: You are not alone. A recent Consumers Union survey found that one-quarter of Californians who had hospital visits or surgery in the past two years were charged an out-of-network rate when they thought their provider was in-network.

Emergency physicians in California are barred from "surprise" balance billing. Health plans pay non-contracting physicians the plan's average contracted rate or 125% of the Medicare rate, whichever is greater. Your insurer, Anthem can tell you what portion of the doctor's bill you are required to pay under your plan of coverage.

A new California law goes into effect on July 1, 2017 that extends the "no surprises" balance billing restrictions to non-emergency medical services. The bill, passed by the California General Assembly after months of tough negotiations, also tightens requirements on health plans to offer adequate provider networks.

Question: I'm 17, I'll be having my baby late July. As a minor, how can I apply for health insurance for me and my kid? Im currently unemployed and wont be able to work until next year. I also wont be turning 18 until 7 months after my baby is born. Im under my moms health insurance at the moment.

Answer: You can stay on your Mom's insurance and your newborn can be insured independently for about $150/mo with any health insurance company in California. If that rate is unaffordable, Medi-Cal is free if you qualify. Click here for ways to apply for Medi-Cal.

Question: I work the the State of CA and my Wife works for the County. We both have covered HMO coverage, Kaiser, which is offered through our work. We filed our taxes and received a response from the IRS asking for a 1095-A. Why are we getting this and how do we get our taxes filed?

Answer: ​I​f you received coverage through a fully insured employer-sponsored health plan, you'll receive a Form 1095-B from the insurer​ (Kaiser)​. If you received coverage through a self-insured employer-sponsored health plan, your employer will complete Part III of Form 1095-C. You need to file the Form 1095-​B or 1095-C with your individual federal income tax return to prove compliance with the individual mandate.

Question: My daughter who is single, doing online college, living at home, and who is on her dad's company insurance is expecting a baby in July 2017. My insurance and my husbands insurance will not cover the baby. What do we do?

Answer: The baby will have his or her own policy. You can apply for an individual health insurance plan for the baby as soon as he or she is born. For a preview of available plans and rates click here. (Use today's date for date of birth.)

Republican Healthcare Plan?

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Question: What is the plan to replace Obamacare?

Answer: The House of Representatives is presenting their health plan today. Here are the highlights:

  • Eliminate insurance marketplaces 2018.
  • Eliminate insurance mandate and penalties 2018.
  • Eliminate some “essential” benefits 2018.
  • Eliminate taxes on $250K+ households, insurance companies, medical devices makers 2018.
  • Phase out consumer subsidies based on income 2018.
  • Provide consumer subsidies based on age 2018.
  • Phase out federal aid for Medicaid expansion 2020.
  • Provide block-grants to states for Medicaid funding 2020.

Question: Last year we had a Bronze HSA plan with Blue Shield. This year we have a Bronze HSA plan with Anthem. After several claims this year I have noticed that IDENTICAL procedures are being paid differently to providers by Anthem vs. Blue Shield (and not to our benefit). Why would plans which are considered the same metal (i.e., Bronze) pay differing amounts? I thought the only difference between insurers was the providers that accepted the plans? If that is not the case, how would it be possible to find out this information before selecting an insurer?

Answer: Each health insurance carrier negotiates payment rates with their own network providers. That's how Anthem and Blue Shield can pay the same provider different amounts for the same treatment. The contracted rates between carriers and providers are not available to the public, so a consumer cannot know in advance exactly what a carrier will pay the provider for any specific treatment of procedure.

Question: It is February now. We just found out a doctor that we have been seeing does not accept our plan this year. Can I change my plan to another carrier now?

Answer: If your insurance carrier listed your doctor within their provider network in error, then you are eligible for a Special Enrollment Period (SEP). That means you can choose another health insurance carrier that includes your doctor.

Question: We are married but filing separately. Do we apply Medi-Cal or Covered CA separately also? or must be together?

Answer: You must apply as a couple, but because you file taxes separately, you will not be eligible for premium assistance through Covered California. Your tax filing status will not matter if you are eligible for Medi-Cal coverage based on your income.

Adding Out-of-State Children?

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Question: My kids mother and I are divorced. I live in California and she lives in Tennessee. As part of our child support agreement she would like for me to add our kids to my covered California insurance even though they live with her for most of the year. I currently have Kaiser. Will it be possible to add them to my plan even though they live in another state?

Answer: No. (1) Your children are not California residents. (2) Kaiser Permanante has no doctors or facilities in Tennessee.

Need PPO Insurance?

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Question: I recently lost my disability income and therefore lost my subsidy for PPO. I was given Medical but they only cover 4 out of my 15 medications and my doctors are not in their network. How can I purchase a PPO insurance on my own? It has taken my doctors 3 years to get me stable, I can't go back to near death over insurance dilemmas. I need to get my medications and the cash cost is over $2k per month! Please help!

Answer: You can shop, compare, and buy California individual health insurance at http://www.cahba.com.

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