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.

Cedars Doesn't Take My Insurance?

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Question: My son has a preexiting heart condition. He needs to continue with his cardiologist who as treated him his entire life. What can I do to get coverage that cedars will take?

Answer: You can change plans during the annual open enrollment period. This year it starts November 15th. Your change of coverage will not be effective until January 1 2015. Work with your agent to find coverage that includes Cedars Sinai.

Trouble Uploading File?

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Question: I have submitted numerous documents to covered ca since April2014. This is the second time I am trying to upload and it is saying file type not supported. I have sent it in jpeg,bmp,and tiff all in grayscale. All of my other documents submitted were in jpeg. Online chat said to try another browser. tried google chrome, no go. using internet explorer. the last time this happened, I just kept trying daily till it was excepted. here we go again! the problem is with the website. What a horrible website!

Answer: The preferred format is PDF. The image formats you have been using create much larger files than PDF. Scan and save your documents as PDF files. You should have no further problems.

EPO and HMO Coverage Out-of-State?

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Question: I have to be in another state for half the year but am a resident of CA. What I am seeing is all plans offered in my area for 2015 are going to be either EPO or HMO plans. In the past I had doctors in both states that I used that were in-network. What am I to do now for non emergency coverage when I am out of state?

Answer: You are correct. EPO and HMO plans will only cover emergency medical care in another state. This is only an issue if you are eligible for a subsidy and must buy your coverage through Covered California. Otherwise, there are PPO plans available off-exchange that can provide out-of-network benefits at your second home.

Close Covered California Account?

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Question: I signed up one family member with the incorrect DOB (typo is off by one day). I cannot get it resolved and it is now causing rejected claims and billing problems. DOB can only be changed at CC by an IT tech person. We’ve gone that route twice in the past 5 months and neither the CC account nor the Anthem account is updated. Some insurance sites advise closing the account and starting over. The family member is undergoing diagnostic services and treatment at this time so I do not want them to be without coverage. But having the wrong DOB is like being uninsured as the claims are not being paid. Can any agent please advise on best way to reach a resolution at CC (who will then update Anthem)? Or is canceling and starting over the only way? Thanks for your assistance.

Answer: Expert agent, Max Herr, says: DO NOT CANCEL THE ACCOUNT!! Doing this will terminate coverage and you won’t be able to get it back until January 1, 2015. You should be able to resolve this with a phone call to CoveredCA (800-300-1506). Although you will probably have to wait on hold for an hour or more, it should not take an act of Congress to get a CSR to make the change. Do you have a designated Certified Insurance Agent? If you did, that agent ought to be able to get the change made for you. I’ve been able to get similar changes made without difficulty.

Question: My Husband took out 20,000 from his IRA, I believe it raised our income to 47000 which normally be around 27,600 with half of his SS and my rental income. I did not report this chanage as I am confused on what is Income, if we do not count on that money yearly nor will we have it ever again, how do I calculate or preview plans that are based solely on our 'Income' and not extras, as not to over pay.

Answer: Yes.Based on what you've told me, your taxable income for 2014, will be about $47,000. Since you are collecting a monthly subsidy based on an estimated income of $27,000, your excess subsidy will be about $1,700 for 2014. What that means to you is, your tax bill for 2014 will increase by $1,700. I suggest save up the $1,700 to pay the additional taxes in April, but do not change your income with Covered California. That's because in 2015, your income will return to to about $27,000 and you'll be back on track will a minimum of complications.

Split Coverage and Subsidy?

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Question: If a spouse wants to stay on COBRA while the other spouse applies for Covered California during open enrollment, will the "household income" calculation still apply to both spouses' total income even though the coverage is for one?

Answer: Yes. The combined income of both spouses is used in the subsidy calculation even though only one spouse will require coverage through Covered California. Of course, the subsidy will be less for the one spouse enrolled than it would have been if both enrolled.

Medi-Cal Excess Charges?

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Question: I recently scheduled an appointment with a doctor for a physical. This was a new doctor under Medi-Cal Anthem Blue-Cross that I had never seen before. The doctor had me sign something saying that no matter what my insurance was I had to pay extra to the doctor for whatever the insurance didn't cover. I was surprised they had a medi-cal patient do this as I thought the doctors agreed to accept what medi-cal paid. Now I am afraid to go back as I know I will not be able to pay anything out of my own pocket. Is this even legal? BTW I waited 3 weeks to see the doctor and was given the doctors PA to talk to. Never even saw the doctor at all.

Answer: Since you are enrolled in a Medi-Cal Managed Care Plan through Anthem Blue Cross, you need not worry about the "excess billing" language in the standard Doctor/Patient Agreement. If your doctor orders a test or procedure that is not covered by Medi-Cal, he will tell you in advance. If you feel you have been taken advantage of, you can file a grievance against the physician with Anthem.

Waiting for Medi-Cal?

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Question: I called to cancel my Anthem plan because I lost my job and applied for Medi-Cal. I haven't heard much back from MediCal yet and Anthem is bugging me to pay the premiums. What do I do?

Answer: At this point, Medi-Cal still has a backlog of about 300,000 applications to process. Let's say your application is in that pile. Medi-Cal will cover you retroactively to the date of your application. So if you let your individual policy lapse and have unavoidable medical expenses in the coverage gap, you can eventually be reimbursed for some of the money you had to put out. But it won't be easy.

STILL RECEIVING BILLS?

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Question: WHY AM I NOW RECEIVING BILLS FROM COVERED CALIFORNIA? TODAY IS SEPT. 21ST 2014. I WAS APPROVED JANUARY 2014 AND TURNED 65 MAY 18TH I PAYED MY MONTHLY DUES NOW I AM BEING BILLED FOR SERVICES FROM MARCH 2014. I WAS ON HEALTH NET COVERED CALIFORNIA FOR THREE MONTHS UNTIL I WAS ELIGABLE FOR MEDICARE WHEN 65, NOW I AM GETTING ALL THESE BILLS ADDING TO OVER $1,0000 FROM COVERED CALIFORNIA. I AM SOOO VERY UPSET I COULD SCREAM!!! I HAVE HAD NOTHING BUT PROBLEMS FROM THE COVERED CALIFORNIA PLAN RIGHT FROM THE BEGINNING WHEN TRYING TO SIGN UP.. PLEASE-PLEASE HELP ME. THERE IS NO WAY I CAN AFFORD TO PAY THIS BILL!!!!!! THANK-YOU, DIANE

Answer: Diane, your caps lock key is stuck. Health Net needs to know you are now on Medicare. Call them and tell them. The number is on your insurance card. You will not have to pay premiums after May 1st.

Individual vs Agency Rights?

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Question: This question comes up quite a bit especially when there are several agents working under an agency, Can a certified covered ca agent write business under another certified agent log on, using their id and password and pin? Is is ok for the entity business owner to demand an agent to write under to log in so commission's are paid to the Entity? What liable affect can this have on the agent who is write's under the other agent? Especially when all agents signed a contract direct with coveredca?

Answer: If your employer has any sense at all, she told you before you accepted the job that you would not be paid commissions directly from the insurers, but according to some internal compensation plan for your agency. The issue of logging into another agent's Covered California account is not against any Covered California rules that I know of so in my opinion it can be done until someone tests it formally or perhaps legally. The contract you signed with Covered California is not a factor unless you enroll CC applicants through your own broker account.

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