Covered California and ACA 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 ACA and Covered California knowledge-base is evolving quickly. TO REQUEST A PERSONAL RESPONSE INCLUDE EMAIL ADDRESS.

Question: My two children are currently on medi-cal, but our income went up and they are no longer be eligible (annual review is pending, but I know they will be dropped). Will this be a triggering event for covered california just for the two of them or for the whole family? I ask because without the entire family enrolling, we don't qualify for premium assistance, so it becomes very expensive just to enroll them now separately. We are a family of 5 and made 92k last year. My husband has covered through work (self employed, but had to enroll himself to be able to get his employees covered), and myself and newborn daughter have private insurance. Thanks!

Answer: Yes. You and your children will be eligible for a Special Enrollment when they loose Medi-Cal coverage due to your income change. Your Covered California share of the net (after subsidy) premium for an adult and 3 children will be about $725 monthly for a Silver Plan. Interestingly, your husband could be added to your Covered California family plan at no additional cost. I suggest he re-examine the rationale behind participating in or even having a employer-based health plan for his business.

Out of Network Coverage?

By on | No Comments

Question: I have a Blue Shield of CA Platinum PPO purchased through Covered California. I am confused as to how much I would be responsible for if using a surgeon who is listed as in-network with Blue Shield not purchased through Covered California, but is not listed as in-network for Covered California policies. Would I be responsible for 50% of Blue Shield's contracted amount with the surgeon or 50% of the surgeons non-contracted fee? Also, how is the maximum out-of-pocket work when using in-network and out-of-network providers? I want to have an Anterior Approach total hip replacement, but none of the top surgeons who perform this approach are on my provider list.

Answer: One of our readers, who prefers to remain anonymous, provided the following answer. I believe the information is accurate.

You would be responsible for 50% of Blue Shield's typical contracted fee PLUS anything beyond what Blue Shield allows of the doctor's full bill. This is complicated, so let me explain. When it comes to out of network coverage, the devil is in the details, and the details of Blue Shield's implementation of out of network coverage is hell, where devils belong. Everyone is inevitably surprised by their paltry out of network coverage, because how it works is very obscure.

Blue Shield's policy states that they allow for an out of network doctor what they WOULD HAVE ALLOWED had the doctor been contracted. (This implies that there is just one single fee that they allow all doctors providing a particular service/region- and that is most certainly a fabrication but is another matter.)

Then too, Blue Shield allows its new "Exclusive Provider" network providers much less than it allows its older, full PPO network providers (the network which grandfathered individual plans, and corporate PPO plans, still use). So when Blue Shield says "What we would have paid had the doctor been in network," they mean "in YOUR network, which may be a network that pays doctors very little."

So: If an *in-network* surgeon charges $5,000, since you have Platinum there is no deductible. Let's say Blue Shield only allows $2000 for the surgeon fee. In a platinum plan they would pay 90%, or $1800, and you would pay 10% or $200. The surgeon would be contractually required to write-off (that is, ignore) the remaining $3000 that Blue Shield disallowed.

Out of network, they would allow a surgeon only that same amount - $2000, and would pay just 50% of that $2000, or $1000. You would owe the surgeon your half of the allowed amount, or $1000 - plus another $3000 for the rest of his $5000 bill. (That's the "balance billing" aspect of this.)

Adding insult to injury, what have you paid "out of pocket?" Just $1000, not $4000. Blue Shield - all insurers - ignore anything you pay that is beyond your share of the amount they allow.

FURTHER, if the facility is out of network and you have 1 or more overnight stays the cost is pretty ruinous, because of Blue Shield's extraordinarily stingy allowance for out of network facility charges. They allow no more than $500 per day for out of network hospital charges, and then pay 50% of that - or $250. Since an actual hospital facility can cost thousands of dollars per night, do the math! Stay out of out of network hospitals except for emergencies.

Policies state "out of network, your costs may be higher." That's a very lame warning and it's amazing regulators allow that wording. (Or maybe it's not so amazing - the regulators don't do much in California.) Your costs will not only absolutely be higher, they will absolutely be MASSIVELY higher. All of this is in the Summary of Benefits and Coverage and in the policy documents. I am not making up any of it, but have the Blue Shield plan documents for every word of it.

Question: My income dropped dramatically as a self employed realtor because my husband had a stroke and I became a full time care giver. My father in law took over our paying our monthly premium of $2,000 per month. He is running out of funds to help us out. Can I apply under special circumstances or do I have to wait for open enrollment. My insurance is through the California Association of Realtors group plan.

Answer: Covered California will recognize that your the group health insurance is unaffordable, i.e your monthly cost exceeds 9.5% of your income. Therefore, you are eligible for Covered California individual coverage with premium assistance. However, to enroll outside of the open enrollment period, you will have to claim that your income change occurred within 60 days of applying. Whether your father-in-law pays or not is not relevant your eligibility.

Question: What type of coverage is available if you can no longer pay your Cobra premiums and Covered California will not let you enroll with or without a subsidy because of having Cobra? My husband was laid of at the end of 2014 and accepted Cobra because the first 5 months were affordable at employee rates, but will increase to $2,300 a month which is not affordable (57% of our income). What can we do for the remaining 7 months of the year? There is no way to pay $2,300 a month until open enrollment.

Answer: According to the ACA, if you have COBRA coverage you can enroll in Covered California under the following circumstances: (1) during open enrollment or (2) when your COBRA coverage expires. You missed the open enrollment period and can't afford to pay for COBRA to expiration because your COBRA coverage is unaffordable by any measure at your current income. If you can enroll in Covered California, your net premium after applying the subsidized premium assistance would be less than $400/mo for a Silver Plan (2-person household @ $48k/yr). So how can we make that happen? A significant change of income can trigger a "Special Enrollment Period" giving you 60 days to enroll in Covered California after the income change. Your income change after your husband's layoff was probably more than 60 days ago, but your employer continued to pay a portion of your COBRA premium - a form of income - for 5 months. When your employer stopped funding the premium, you experienced another change of income, significant enough to make your coverage unaffordable. I believe you can be enrolled in Covered California now, but this is a case where you would be wise to use a Certified Agent to submit your application and advocate for you.

Question: I wish to open a health savings account with $5500 from a retirement fund. If I use pretax funds (which are fully tax deductible), must I report this as income to Covered CA, because if I must, then I would most certainly exceed the threshold for a subsidy. My actual question is this: Would I have to repay the entire subsidy for the year or only from the point at which my income exceeded the threshold (that is, December 2015, the month I intend to open the HSA)?

Answer: Your plan won't fly. You can only open a health savings account (HSA) if you have a HSA qualified high-deductible health plan. That would be a Covered California plan labeled "Bronze 60 HSA". If you do not already have such a plan, you will not be able to change for one until 1/1/16. Secondly, if you take a $5,500 withdrawal from a qualified retirement account, the income will be reflected in your AGI and, whether or not you report it to Covered California, the IRS will adjust your tax due to reflect the added income and some of your premium tax credits will have to be repaid. If your AGI is above the subsidy threshold (400% FPL), then you would repay all of the subsidy you received.

Question: I am under a Covered California Policy and turn 65 in August. Can I still keep my Covered California policy (and contribute to my HSA) for three months past my 65th birthday? Reason, I have reached my Deductible and Out of Pocket Maximum due to an unplanned surgery. Medicare allows me to enroll 3 months past my 65th birthday.

Answer: No. You cannot keep your Covered California coverage once you are eligible for Medicare - the month you turn 65 - even if you were to delay your Medicare enrollment. Also, you cannot make contributions to a Health Savings Account after age 65.

Question: I am self employed. after my adjustments for self employment and ira contribution, my agi is $18500. But, after that I take deductions for my real estate taxes and mortgage interest, and standard deduction, I am in a very low income tax bracket. Which figure should I use? the AGI or after real estate taxes mtg interest and standard deduction.

Answer: For most of us, MAGI is the same as AGI - Adjusted Gross Income found on line 37 of the 1040. But more precisely, MAGI is the adjusted gross income plus any amounts excluded from taxation by section 911 (the exclusion from gross income for citizens or residents living abroad), any tax-exempt interest received or accrued during the tax year, and any portion of the taxpayer's social security benefits that are excluded from gross income.

Do I Use 2014 Income?

By on | No Comments

Question: Next week I will be leaving my current job which provides health insurance. I am curious if covered california uses our income from 2014 to determine which plan we are eligible for or if they use an estimate for this year? I am returning to school and will make about 20,000.00 less than last year so I am a bit concerned?

Answer: When you apply for Covered California coverage use an estimate of your income for 2015.

How to Compute Estimated Income?

By on | 1 Comment

Question: Is my income based on what I would make in a year if I hadn't lost my job or do I prorate the number for the year? Example. I was making $60,000/year. I got laid off at the end of April. do I prorate the number to $15,000 because that is what I will make if i don't get another job this year.

Answer: If you did not receive another penny in taxable income for the rest of 2015, the amount you already earned - $15,000 in your example - would be your projected annual income. If you are eligible for unemployment income, estimate what you could collect for the rest of the year and add it to the income already earned for your 2015 estimate. If you were to get a job at some point, that income would be added to your annual projection. Any significant income change, such as you described, makes you eligible for a Special Enrollment Period (SEP) during which you can re-enroll and qualify for either Medi-Cal or Covered California coverage with premium assistance.

Question: I received my 1095-a from CoveredCA back in January and noticed that it was not accurate. It showed policy dates of 4/1 to 10/1 with subsides for said months. The problem is that it included a subsidy for the 10th month when in fact it should not have. I filed my dispute over 60 days ago... I never heard from them. That said, I have been calling and have been told that they see the error and that the IT department needs to change the end date to the last day of 9th month. I've not been given a time frame with any certainty as to when this will happen. I have been told that the corrected 1095-a can't be issued until it does. So... my question is: Is there anyway I can get this resolved quicker? Is there a way for me to contact a rep that can actually get it fixed?

Answer: Your don't need a corrected copy of the Form 1095-A to file your federal tax return. The Premium Tax Credit form used as part of your federal tax filing is the IRS Form 8962.pdf You know the correct amounts for total premium and premium tax credits from your monthly health insurance bill. Enter those amounts on the Form 8962 and get on with it.

Your Question

Click here to submit your question. But first you may want to use the search tool above because your question may have already been answered and you won't have to wait.

Ads

Email Subscription

Twitter Updates