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.

Eligibility is Conditional?

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Question: I have completed the process of applying online through Covered CA. My Eligibility Results page says: “Your eligibility is conditional. To receive the Advance Payment of Premium Tax Credit benefit, you must submit the following by January 31, 2014 (1) Proof of Income (1) Proof of Minimum Essential Coverage.” So my question is two fold. About the income verification, what will be required? And secondly, what is the Proof of Minimum Essential coverage about? Thank you for being literally the only resource I have found for this type of Q&A and shared information.

Answer: Covered California already knows that your income in 2012 was significantly lower than your 2014 estimate since they are connected to the IRS data hub. More than likely you will be asked to provide current income documents like pay stubs. The minimum essential coverage requirement is proof that you have ACA-compliant health insurance on January 1, 2014.

8 Comments

I received the same as everyone else upon submitting my application.

Re: Income Verification: My income, as a contract worker, is variable month to month and payments are not regular, and at times lumped together. I do not have a “pay stub” though I can get a copies/images of the checks received from my online bank account. Is that what they are looking for—all my checks received with explanations of what they refer to? Do they require bank statements?

Re: Proof of Minimum Essential Coverage: I’m still not clear what it is that I am to provide for this.

Thanks very much for an informative & helpful site.

At the end of the application process why are they asking for proof of minimum essential coverage when you are applying during the open enrollment period? Are you required to provide that documentation in order to complete your application?

I have the same question as Vanessa.

After completing the process it says that for the APTC and CSR my coverage is “conditionally eligible.” But it did not ask for any type of verification (not for ID, not for income, nothing). Further down the page is says three times, “Social Security number must be verified by the office of SSA.”

The system went ahead and let me enroll in a plan. On the enrollment page it just says, “As a reminder, your policy is not active until the initial payment (binder payment) has been made.”

It seems like I just have to wait to hear from the insurance company and pay the premium. Is that really it? Thanks for any help.

I also got the message: eligibility is conditional. So am I supposed to wait for someone to contact me regarding the submittal of proof of income? Or is there something I should be submitting now? Please help. I don’t want anything to screw up my chances to get health insurance. Thank you.

What if my family and I don’t have any of the documents listed for Proof of Minimum Essential Coverage? My daughter had Medi-Cal but aged out of it and doesn’t have proof of Notice of Action of discontinuance from Medi-Cal. My son and I have not had any insurance for a few years and have none of the proofs of discontinuance they are asking for. Thank you.

In response to the original question, I too am waiting to hear from Covered CA as to what constitutes proof of income. There are numerous instances where a single document like a pay stub won’t be sufficient. How do you document periodic layoffs, occasional reduction in hours, lower self-employment income due to increased costs, or reduced investment income due to lower interest rates or reduced dividend payouts? In each of these examples, the sheer volume of paperwork could become ridiculous. I suspect that what they will actually ask for is an explanation of your income estimate plus any documentation that you can provide.

Note that the actual California regulations appear less onerous, as they begin by stating that in these cases the exchange “Shall make a reasonable effort to identify and address the causes of such inconsistency, including through typographical or other clerical errors, by contacting the application filer to confirm the accuracy of the information submitted by the application filer”. This suggests that a detailed explanation of your estimate could be sufficient in those instances where a simple pay stub won’t cut it.

Michael, your first paragraph is correct. You can choose to get your subsidy for 2014 health insurance premiums when you file your 2014 tax return in early 2015 (in other words, you can receive your subsidy in a lump sum upon filing the 2014 tax return instead of receiving it during 2014 in the form of a reduced monthly premium).

The only catch is if you are under 250% FPL, then you are also entitled to reduced cost-sharing if you choose a Silver plan on the exchange. But you can only get that reduced cost-sharing (e.g. lower co-pays and out-of-pocket limits) by providing your estimated income in advance. If you choose to wait until the filing of your tax return to get your subsidy, and you find that you were actually under 250% FPL, you cannot receive any retroactive adjustment for the cost-sharing that you paid during 2014.

Question: If someone or a family enrolls in a Covered California health plan yet initially provides no financial information as if not ‘going for’ a subsidy, yet when they file their taxes at the end of the year and find they indeed were subsidy eligible based upon their annual earnings under 400% of FPL, will they still be able to obtain the tax credit subsidy?

Or per the response from Covered California as posted in this original question, will all financial docs to substantiate subsidy eligibility need to be submitted no later than the end of January (Jan 31st) of the same year in order to qualify for a tax credit subsidy in the first place?

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