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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.

Opting Out of Covered California?

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Question: I currently have a plan Blue Shield plan through Covered CA, but I want to change to a Kaiser Permanente plan OUTSIDE Covered California for 2016 since I don't qualify for any subsidy. If I do, do I have to notify Blue Shied so that they won't automatically renew my plan for 2016?

Answer: Yes. It is your responsibility to notify Blue Shield that you are cancelling your coverage effective 12/31/2015. You can apply directly through Kaiser Permanente for 2016 coverage. You can "terminate coverage" in your Covered California account effective 12/31/2015. I believe a better option is to keep your Covered California account open, select Kaiser for 2016, but opt out of premium assistance. This way, should your income drop again, you can easily opt back in for premium assistance.

Question; Do I include social security disability dependent benefits for my 2 minor children in the household income on the application?

Answer: No, the Social Security disability benefits that your children receive in your name is their income and only would be reportable as income by them if they had sufficient income that caused it to be taxable. Social Security disability benefits are never taxed to you as custodian.

Question: Can I buy coverage for my 19 year old son on the exchange. He is a student living at home and I am single, employed and have medical insurance at work, I make about 100,000 annually?

Answer: Yes. Your son can purchase coverage through Covered California. He will not be eligible for premium assistance.

Question: When trying to pick a dental plan on the CC website I am confused by the limited list of "benefits". There is a short list of services and their costs under each of 5 plans, such as fillings, root canal, pediatric filling, etc. However, it gives no costs for basic things like extractions and crowns. Is the list of services on the "Pick a Plan" page just for example? Is there someplace else to see the entire list of services covered and the cost?

Answer: More detailed dental plan lists of covered expenses can be found at the carriers' websites. For example, here is a detailed list of Benefits for the Access Dental HMO Plan. Access DHMO Benefit Details.pdf

Platinum Plan Rate Hike?

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Question: I have Blue Shield Platinum PPO that is $415 now and will increase to $521.99 in 2016. Why such a big hike? That seems unreasonable. I live in Santa Monica, CA. Have all plans done this under Obama Care? Where should I look for more reasonable coverage? I don't want to go down to Silver because sen generic drugs are $50 under it.

Answer: Platinum and Gold plan premiums went up more than Silver and Bronze plans on a percentage basis for 2016. The reason is "overutilization". That's insurance lingo meaning that there were more claims for those plans than anticipated in 2014 when the original rates were set. Platinum and Silver plans are usually purchased by people anticipating high medical expenses due to recommended surgeries or chronic medical conditions such as diabetes. Claims for these plans were higher than anticipated and the pricing had to be adjusted.

Question: I enrolled for medical insurance through my job. But now after doing more research, I realize I would've been better off going through covered California. Is it too late to change my mind and switch to medical insurance through Coveted California?

Answer: You are not eligible for premium assistance through Covered California coverage. It is for people who are not offered health insurance at work. However, You can purchase coverage on or off exchange without a subsidy.

Question: My employer is no longer covering family members. My husband and daughter will be out of coverage and I am trying to figure out my best option. My daughter is 3 years old and my husband is unemployed. I was told they could both receive medi-cal. Is this true?

Answer: If your employer does not offer coverage for spouses and dependents, they may be eligible for MediCal or Covered California coverage. If your household income is less than $27,000 per year, then both your husband and daughter will be eligible for Medi-Cal. If your household income is greater than $27,000 but less than $53,000, then your daughter will be eligible for Medi-Cal and your husband will be eligible for Covered California with premium assistance. If household income is over $53,000 but less than $80,000, both your husband and daughter are eligible for Covered California coverage with premium assistance. Over $80,000 per year, they can purchase health insurance without premium assistance.

What is an HSA Plan?

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Question: How does HSA insurance work? what are the advantages and disadvantages?

Answer: A health savings account (HSA) lets you save money for future health-related expenses. It's essentially like an IRA savings account for your health. And after you turn 65, it's even more similar to an IRA, because you can take out money for non-health expenses. You can use money from your HSA to pay for all tax-deductible medical expenses, from contact lenses to acupuncture. The money you put in the HSA is tax-deductible. Also, the money you withdraw isn't taxed by the IRS, as long as you spend it on approved, health-related stuff. The HSA's interest income isn't federally taxed, either. You can't use money from your HSA to pay for your health insurance premium -- unless you're unemployed. There are limits to how much you can save. For 2015, you can sock away $3,3500 if you are an individual or $6,650 for a family.

Out-of-Network Reimbursement Rate?

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Question: I am trying to find a plan that will cover out of network mental health treatment. I have been seeing a very costly therapist and am hoping that by enrolling in an expensive insurance plan, i can decrease that monthly amount by a bit. It is very hard to find information about out of network coverage on insurance websites- i mostly find a line that says "copay will be higher". I was looking at blue cross blue shield ppo plans. am i correct in assuming that if my therapist bill is 250 a session- they will cover only 50%? so, i would pay 125+ office visit (35 for higher plans)? Are there any better options?

Answer: Out-of-network benefits are reimbursed at a level much lower than 50% of the provider charges. The plan pays 50% of the carrier's allowable amount, not the provider's bill. For example: your therapist charges $250 per session. The insurance company's in-network allowable amount for this treatment could be as low as $75. Your benefit amount would be half of $75, not half of $250. In addition, out-of-network coverage has a separate deductible, usually 150% to 200% of the in-network deductible. Long story short, out of network coverage sucks. Better option? Find another therapist.

Question: Hi - I'm currently unemployed and am considering signing up for an Enhanced Silver Plan for 2016. If I start making more income either before 2016 or after the year begins, if I get removed from the Enhanced Silver Plan, what will my options be at that point? Will I get to choose a new plan, or will I be switched to the same plan in a non-enhanced version?

Answer: Covered California cost sharing reductions (CSR) are enhanced benefits such as lower copays and deductibles on silver plan benefits for those with income levels between 138% and 250% of federal poverty level (about $16,500 to $29,500 for a 1-person household). These enhanced plans come in three levels: Silver 94, Silver 87, Silver 73 - covering 94%, 87%, and 73% of covered medical expenses. Since the benefit is based on income, reporting an income change during the year may change one's level of benefits. If so, your coverage will automatically change to the appropriate CSR level or off enhanced benefits entirely to the Silver 70 level. A change of this nature does not trigger a Special Enrollment option so you cannot change plans either with the same or different insurance company. CSR benefits are not recoverable. Not reporting an income increase will probably result in an overpayment of premium assistance (subsidy) which may require payback to the IRS, but there's no payback for enhanced benefits.

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