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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.


Question: I purchased a 2016 Anthem Silver 70 PPO plan offered by Covered California in large part because the brochures describing the plan said: "Our preferred provider organization (PPO and Tiered PPO) plans also include extra coverage for non-emergency care when they visit participating BlueCard providers in the U.S. or travel abroad. They can see any provider they wish, but they'll pay less out of pocket when they use BlueCard providers and hospitals." When I called Anthem about getting non-emergency services outside CA from a BlueCard provider, they told me I have no coverage outside CA (whether in-network or out-of-network) unless it is an emergency or for urgent care. I thought that changed with the 2016 policies? Am I missing something?

Answer: You got the wrong answer from Anthem Blue Cross. It happens. Here's how to use your BluCard. Let's say you are in New York City for a meeting. You have medical symptoms - not an emergency, but you want to see a doctor. Do a Google search for "Blue Cross Blue Shield New York City". Google will provide a link to the Empire Blue Cross Blue Shield website. You can use their online "Find a Doctor" feature or call them for names of in-network doctors nearby. As long as you use an in-network Empire Blue Cross Blue Shield provider, you'll be covered as if you were in California.


Coverage During Appeal?

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Question: I would like to appeal a Covered California decision that my plan was terminated due to non-payment. I understand that I may be eligible for continuing enrollment while the appeal is pending. If this is the case, how would my eligibility be affected in the scenario that the appeal is decided in my favor vs if it goes against me. When would coverage end in either scenario? If I lose the appeal, would coverage under “continuing enrollment” simply end on the day the appeal is decided or would it terminate on an earlier or later day? I guess I am asking if I am safe using health care while an appeal is pending or if I am at risk of incurring liability if the appeal goes against me. Thanks!

Answer: I asked my colleague, Max Herr, to answer this question as I was uncertain. Here’s what he had to say: “The question, ‘When would coverage end if I lose the appeal?’ is simple: Almost certainly on Day 1 of the original cancellation date (the first day of the month for which the first unpaid premium was due) — It should have terminated then, and it remains terminated as of that date. If premiums were paid in the interim, they may or may not be refundable, possibly even if claims are not paid (they would almost certain NOT be refunded to the extent that they offset any claims paid). Now, on the other hand, if the appeal determines that coverage was improperly terminated by the insurance company (which is highly unlikely, but could happen), the insured will still be responsible to pay any unpaid premiums that have accrued throughout the time it takes to get adjudication — three months or longer in most cases. And there will be a short deadline to make that payment, probably 20 days or less.” I would add that it is not “safe” to make claims against a policy that had been cancelled, even during the appeal process. You will most likely be left holding the bag for 100% of those claims.


HSA Eligibility?

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Question: I have an HSA and a high deductible plan, but found out that if you have any co-pays, you're not eligible to use them. I have copays for the first three office visits, but am not covered for anything else until the deductible is met. I cannot find an HSA compatible plan in California anymore. Am I not eligible for an HSA because of these three copays?

Answer: The high deductible plan you currently have is not HSA compatible. You will have to switch plans at the next open enrollment period in order to make contributions to your HSA starting in 2017. Here are 3 HSA compatible plan options: Anthem Bronze HSA PPO, Blue Shield Bronze 60 HSA PPO, and Kaiser Bronze 60 HSA HMO.


(email: jaynedoe13@yahoo.com)

Question: When I contact a doctor to see if they take our insurance and tell them we have Blue Shield PPO, they say yes. Once I give them my subscriber number they say, "Oh, we don't take Covered California plans." Since my understanding is that all plans on exchange mirror those off exchange, I have asked the insurance company why certain doctors refuse. They said they can't force doctors to take the plan. But, if the exchange plan pays exactly the same as the off exchange one, why would there be so many refusals (and trust me, there are a lot!). It has begun to feel like a plan purchased on exchange (without subsidy at this point) is like a welfare plan that no one wants to touch. Any ideas? Since we cannot switch to another plan at this point (no special circumstance) it has become quite irritating to be shoved off like we have the plague! Thanks!

Answer: When your doctor says they take Blue Shield PPO, that means they are included in the Blue Shield PPO networks for employer-based health plans for the most part. They get higher reimbursement rates from those plans. Covered California fosters competition between authorized carriers to yield the lowest premium rates possible in the current marketplace. In order to compete, the carriers lean on their providers (doctors and hospitals) to accept ever lower reimbursement rates. Many providers refuse to participate in Covered California carrier networks resulting in "narrow networks" with fewer provider choices. Because 90% of patients are covered either by employer-based health plans or Medicare, doctors can opt of out Covered California with minimal downside to their practice.


Question: I currently have individual health insurance with Covered California and receive a financial subsidy. I will be turning 65 in July 2016. I also have only 31 work credits with Social Security towards premium-free Medicare Part A. Accordingly, as I will not have the requisite 40 credits when I turn 65 this July for premium-free Medicare Part A, can I keep my existent Covered California plan and its financial subsidy?

Answer: No. The law makes no distinction between premium-free and premium-required Part A enrollment, so all persons age 65 and older are supposed to enroll in Medicare. Those with less than the requisite 40 credits for fully insured status must pay the premium for Part A. In 2016, the Part A premium is $411. Part B premiums are a minimum of $122 per month. If you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it.


Question: I estimated my wife's self employed income at 30 k but so far she has only made around 3k. She gets paid sporadically and it is very possible that she will end the year with the estimated income. If she does not, we would become eligible for premium assistance. If I do not report the change now in the hopes of her making that money, will There be some sort of penalty. Right now we are not eligible based on the estimate and have not taken any assistance. Also, is one required to take premium assistance even if one qualifies for it. My wife has her own private health insurance, and I have covered california which, even without assistance, is cheaper than what I had off the exchange. Can I say I do not want premium assistance and skip the hassles of reporting income change ges, proving income, etc. Or would I still be subject to all of that

Answer: If you enrolled through Covered California, you can receive premium assistance retroactively. For example, let's say your estimated you household income (both you and your wife) for the 2016 tax year above the amount that would make you eligible for premium assistance (subsidy). However, at the end of the year your actual income is lower than you estimated (there is no penalty for overestimating your income) and now your actual income makes you eligible for a subsidy. You will get that money as a lump sum tax credit on your 2016 tax return. However, there is a potential snag in your situation. You say, "My wife has her own private health insurance". I take that to mean that your wife has off-exchange health insurance. If that is the case, her portion of the premium assistance will be lost. She has to be enrolled through Covered California in order to be eligible for a subsidy now or later.


Question: I was on Covered California with a subsidy. When I reported to Covered California that I am now pregnant, I was switched to Medi-Cal. I don’t want Medi-Cal because my doctor doesn’t take it. Can I get back on Covered California?

Answer: Your problem is shared by thousands of other California women who reported their pregnancies to Covered California. It was triggered by a recent policy change in Medi-Cal eligibility. Covered California acknowledged the problem, blaming its computer system. That computer glitch will be fixed, but not until September. The computer system was immediately transitioning some low-income pregnant women into Medicaid. Usually, consumers are placed in either Covered California or Medi-Cal based on their income, with no choice in the matter, even though they can enroll in Medi-Cal via the Covered California website. But the rules are different for some pregnant women whose household income falls between 138 percent and 213 percent of the federal poverty level, or roughly $22,100 to $34,100 for a family of two. Under an October policy change, women who are pregnant at the time they apply for health coverage and fall into this income bracket will automatically be placed into Medi-Cal. Women in the income range who already have Covered California plans before they become pregnant are now supposed to be given the choice to remain in their subsidized plans — which have out-of-pocket costs such as co-pays and deductibles — or move to Medi-Cal, which is free. The idea is to allow them to keep their existing Covered California providers if they want. But the Covered California computer system wasn’t programmed to give them the choice, and some pregnant women were moved immediately into Medi-Cal. Covered California has trained its customer service reps to explain to pregnant consumers that reporting a pregnancy could trigger a switch to Medi-Cal. You can get your Covered California plan back, retroactive to the date you reported your pregnancy by calling Covered California’s customer service center at 800-300-1506.


Question: Im on Cov Ca now but my employer just offered all of us employees new coverage. They are going to pay for most of it but its not as good as the coverage from Cov Ca that I have now and it will actually cost me a little more because I have a large subsidy. I was told that if my employer offered me coverage I couldn;t have Cov Ca and that if I kept it it was possible that I might have to pay back some or all of the subsidy that the state gives my family. I'm confused...should I cancel the Cov Ca and get on my company plan? I don't want to have to pay the IRS anything next year.

Answer: Yes. You should cancel your Covered California coverage and sign up for your employer-based coverage. Once you have access to employer-based coverage, you are no longer eligible for a subsidy so you would have to pay back any premium assistance you received after that point.


Question: I had covered California with kaiser for 2014 i cancelled it in Dec of 2014 since beginning jan1 2015 my employer was going to be covering me also through Kaiser. I received a letter from the IRS saying they could not finish my return due to being given an advance tax premium through the exchange. I didn't have covered California at all in 2015 and i received my 1095c from my employer showing me covered for the entire year how do i fix this?

Question: Apparently. the IRS has received an erroneous 1095 from Covered California indicating that you received premium assistance in 2015. You need to respond to the IRS and tell them this. You also must contact Covered California and point out the error.


Question: Can a school district force its classified employees to take out health insurance? If so, can the employee get help from the State of California to pay the premiums? My instructional aide was told that she MUST sign up for health insurance through our district. She is having a hard time living on what is left of her paycheck after all the required deductions. She is a single mother with one child. She works 6 hours per day for 180 days per year. I believe she earns about $13 per hour.

Answer: This employee is eligible for Medi-Cal. Once she has Medi-Cal, she can opt out of her employer-based coverage. The school district must release her from their group coverage since she will have "minimum acceptable coverage" through another source.

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