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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.


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Question: I filed my 2015 federal income tax return but didn’t realize I needed to include Form 8962. Can I still receive premium subsidies in 2017?

Answer: If you received advance premium tax credits in 2015, you must reconcile your tax credit amount 2016 year in order to continue receiving advance tax credits next year. Remember, the subsidy you received in 2015 was based on your estimated income for that year. The law requires you to file a tax return at year end and reconcile your estimated income with your actual income. If you had under-estimated your 2015 income, you might have repay some of the 2015 tax credits that you received. If you had over-estimated your 2015 income, you could claim additional tax credit when you filed your return. Either way, the IRS requires this annual reconciliation. People who fail to reconcile the premium assistance they received last year will not be allowed to continue receiving advanced premium tax credits next year.

To continue receiving APTC in 2017, if you haven’t yet filed a 2015 return with a completed Form 8962, you should do so as soon as possible. To do this, you will also need Form 1095-A, which should have been sent to you by Covered California in January with information about your 2015 APTC. If you don’t have form 1095-A, you should call the Covered California Call Center at 800-300-1506 to obtain a copy. As soon as you file your 2015 tax return and completed Form 8962, contact Covered California to update your account to reflect this change.


Social Security Income and MAGI?

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Question: Are annual social security benefits counted towards MAGI, including the untaxed portion (as far as CC is concerned)? Sometimes, depending on income only a portion of my wife's SS is considered taxable.

Answer: MAGI (modified adjusted gross income) includes your adjusted gross income, tax-exempt interest income and half of your Social Security benefits. Some people who get Social Security benefits must pay federal income taxes on up to 85% of their Social Security benefits. If your income is less than $25,000 for individual tax filers or less than $32,000 for joint income tax filers, you pay no tax on your Social Security benefits. If you are married and file a separate return, you probably will have to pay taxes on your benefits.


Question: My projected income was over 400 percent of the fpl. However, it will wind up being lower. When I initially signed up last year, I think I chose to get a subsidy in one lump sum. Obviously, I have not gotten anything, because my projected income is high 83k.Is there a way to look at the website and see what I chose. I WOULD RATHER NOT CALL THEM, FOR FEAR THEY WOULD ASK ME ABOUT INCOME CHANGE. Do I need to worry about what I chose, since my projected income disqualifies me for aptc. Would I have been given a subsidy option with my income that High? I can't remember exactly what I did when signing up. Plus, I did call to report an income change, and the person on the phone asked me to break Down my income from various sources by month, so I am not sure if something might have been changed. My projected income was still higher than the 400 percent. Should I just not call them and leave it for reconciliation at tax time next year.

Answer: If you opted for premium assistance in one lump sum, you are in good shape. If you qualify for a subsidy, you'll get it when you file your taxes. if you were not due any premium assistance, there's nothing to repay. Logon to your Covered California online account, from the homepage select "Summary" and then select "Change Premium Assistance Amount" and the next page you see will explain which payment option you have - monthly or lump-sum. If it's not what you want, you can change it.


Question: I will be applying to Medi-Cal in September of 2016. I do not know if I should provide ONLY my information in the application or my parents information AND my information in the application. I was claimed as a dependent when they filed taxes on Feb. 2016 and when they file taxes on Feb. 2017 I will NOT be claimed as a dependent. In other words, I will be independent.

Answer: Apply through Covered California even though you know you are eligible for Medi-Cal. The online application process at CC is much easier than applying at Medi-Cal. Since your parents will not be claiming you as dependent for the 2016 tax year, apply as an individual. You will not provide any information regarding your parents or their income.


Question: If I wish to cancel my covered ca. Plan at the end of the year, can I do it easily on the website or do I have to call them. Is it as easy as clicking a cancel membership button and indicating the desired date of cancellation?

Answer: To cancel coverage online, logon to your Covered California account and find the link that reads "Terminate Plan". If you are uncertain, contact the Covered California service center for assistance at 800-300-1506.


Question: My Anthem Blue Cross PPO plan through Covered California won’t be offered again in 2017. Now what do I do? * Answer*: During Open Enrollment, you can shop for a different plan either with Anthem or any other insurance company available through Covered California. Or you can do nothing and Anthem will automatically enroll you in another plan it offers that is similar to what you had this year. You will receive a notice from AQnthem that describes that alternative plan and how it differs from your current plan.


Question: I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?

Answer: Yes. Leaving your job and losing eligibility for employer-based health coverage will trigger a special enrollment period (SEP) that lasts for 60 days. You can apply for Covered California health plans and (depending on your income) for premium tax credits (subsidy)and cost sharing reductions during that period. However, if you enroll in COBRA coverage through your former employer beyond the 60-day SEP opportunity, you will need to wait for the next Open Enrollment period to voluntarily cancel COBRA and enroll in a Covered California plan.


What are Catastrophic Plans?

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Question: I just lost my job and I’m buying Covered California. I notice “Catastrophic Plans” that look even cheaper. What are those and can I buy one if I want?

Answer: Catastrophic plans have the highest cost sharing - deductible and coinsurance. Not everybody is allowed to buy catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Covered California policy that costs less than 8.13 percent of their income. In 2016, Catastrophic plans have an annual deductible of $6,850 ($13,700 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $6,850 out of pocket; after that your plan will pay 100 percent of covered services for the rest of the year.


Question: I don’t have a green card yet. Can I buy a California Cover health plan?

Answer: If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan through Covered California. However, you can shop for health insurance and buy insurance directly from one of the health insurance companies offering off-exchange plans. Insurers outside of the Covered California are prohibited from turning you down based on your health status or your immigration status and must follow generally the same rules as plans in Covered California.


Question: I am moving to California next month. Will I qualify for a Special Enrollment Period of 60-days after I move?

Answer: The feds just passed a new rule affecting permanent moves. Starting July 11, 2016, if you move to another state, you will be eligible for a special enrollment period only if you had previously had been enrolled in other coverage. The new rule is that you have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day in the 60 days preceding the date of the permanent move in order to qualify for the permanent move special enrollment period.


Should I Buy in CA or NV?

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Question: I live in California, but drive across the border every day to work in Nevada. What state should buy coverage?

Answer: Generally, you should buy coverage in California, the state where you live.


Question: I just moved from Arizona to California. I am staying with a friend until I find a job and can get settled, but I need health insurance right away. How can I establish residency in CA?

Answer: The fact that you don’t have a permanent home should not affect your eligibility in California as long as you are currently residing here and intend to remain here. Covered California will accept an applicant’s statement regarding their state of residence without other verification. In situations where other information available to Covered California suggests that the applicant may live in a different state, it may ask for verification. This could happen in your case if records available to Covered California show your prior address in Arizona. You will need to provide a statement or other documentation showing that you have moved and now intend to reside in California. Also note that, starting July 11, 2016, to qualify for a special enrollment due to a permanent move, you must also have had been enrolled for at least one day, during the 60 days leading up to your move, under other minimum essential coverage, such as under a job-based health plan, another Marketplace plan, or Medicaid.


When Does My Coverage Renew?

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Question: I signed up for a Covered California health plan in April after I lost my job. Does my coverage get renewed in January or at the anniversary date next April?

Answer: All Covered California health plans provide coverage based on a calendar year. Coverage under your current plan continues through December. Open Enrollment (November 1, 2016 through January 31, 2017) is the time to renew coverage. You can return to the Covered California website or call Covered California to renew coverage yourself so that it continues in 2016. If you don’t act to renew your coverage by December 15, 2016, they will automatically renew coverage for you. If your coverage is automatically renewed, but you would still like to change plans, you can still do so until the last day of Open Enrollment, January 31, 2017.


Question: How do I prove that I had coverage?

Answer: You should receive a form 1095-B from your health plan or insurance company indicating the months in 2016 when you were covered under the plan. If you were enrolled in family coverage, Form 1095-B will indicate the names of all family members who were covered with you under the plan. A copy of this form will also be reported to the Internal Revenue Service.When you file your tax return for this calendar year, you will have to enter information about your coverage on the return.


Question: Do I need to be on the same plan as my spouse?

Answer: No. There is no requirement in the Affordable Care Act that spouses be on the same plan. But if you want to qualify for a premium tax credit, or subsidy, to lower the cost of your insurance, be aware that subsidies are based on your total household income level. So even though your spouse will not be covered by the subsidized insurance plan, his or her income will be included when determining the level of subsidy you are eligible for.


Question: I can barely pay my Anthem Blue Cross monthly bill now and that’s with a subsidy. I need the health insurance since I have diabetes.

Answer: If your current plan becomes unaffordable after the 2017 rate increase, you have a couple of options available to you without losing your health insurance, but both options involve trade-offs.

  1. If you have a Silver or higher tier plan, you can downgrade, for example from Silver to Bronze. If you stay with the same insurance carrier, Anthem Blue Cross in your case, you will stay in the same provider network of doctors and hospitals. The trade-off is higher out of pocket medical expenses because of higher deductibles and copays.
  2. Shop a cheaper Silver Plan with one of Anthem Blue Cross’s competitors. For example, you may find that you can change to an 2017 Oscar Health Silver EPO plan at the same rate as you had for Anthem Blue Cross Silver PPO plan in 2016. However, you will have to check carefully to make sure your doctors and other providers are in the Oscar health network. The trade-offs in this example are loss of out-of-network coverage in switching from PPO to EPO plans as well as the network considerations.

If you do not already have a Certified Health Insurance Agent now is the time to get one. Your agent can help clarify your options, guide you through the application process, and if subsidies are involved, make sure you get the best outcome possible.


Question: Will I be able to keep the same plan in 2017 that I have this year?

Answer: Probably. It depends on where you live. United HealthCare, after just one year of limited participation in Covered California, is pulling out in 2017. Other plans, including Oscar, Molina and Kaiser Permanente, are expanding into some regions. But even if you can keep your plan, a rate hike could put it out of your financial reach. To find a better price, more Covered California enrollees will have to switch plans, which means they could lose their current doctors. According to Covered California, about 80% of consumers will be able to pay less than they do now or cap their rate increases at 5% if they shop around and buy the lowest-cost plan at their current benefit level. Now more than ever, California health care consumers will benefit from the assistance of a Certified Insurance Agent to help them find a plan they can afford that includes access to their doctors and other health care providers.


Question: If I am getting premium assistance and the premium on my plan rises by 20% next year, does that mean I’m going to have to pay 20% more out of my pocket than I did this year?

Answer: Not necessarily. As premiums rise, so do tax credits, which means that, all things being equal, the premium assistance will absorb at least some of the rate hike. But you won’t be able to research your specific situation until early October. Because the Covered California online shopping tool won’t be updated for 2017 rates until then. If you already have a Covered California plan, you will receive a notice from Covered California in October explaining how much your current plan’s premium will change and what your tax credits — if any — will be for next year. You can keep the same plan at the new rate or switch plans during open enrollment.


Medicare Mandatory at 65?

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Question: I am currently insured with Blue Shield thru Covered California. I will be 65 in December. Must I choose Medicare and give up my current plan? I am retired and receiving social security benefits.

Answer: If you do not sign up for Medicare when it is offered (age 65 birthday month), you will no longer be eligible for a subsidy through Covered California. Unless you have money to burn, sign up for Medicare.


Question: I recently quit my job. I enrolled in a Covered California plan with premium assistance. My old company offered me COBRA coverage but it’s much more expensive. Does an offer of COBRA coverage someone from receiving a premium tax credit?

Answer: An offer of COBRA coverage does not prevent you from being eligible for premium tax credits. You could not receive premium tax credits if the you had actually enrolled in COBRA, then dropped it in favor of Covered California coverage. If a former employee actually enrolls in the COBRA plan, it is considered minimum essential coverage and becomes a barrier to receiving premium tax credits. People who are enrolled in COBRA coverage generally must wait until the marketplace open enrollment period to drop that coverage and enroll in a Covered California health plan with premium tax credits.


Question: I was offered health insurance by my employer, but missed the open enrollment period. Can I still keep my Covered California coverage with a subsidy?

Answer: Probably not. If the coverage offered by the employer was “affordable” and met minimum value, that employer offer still counts as an offer of minimum essential coverage that prevents a person from being eligible for premium tax credits. A person in this position may enroll in marketplace coverage, but will be ineligible for financial help.


Self-Employed Subsidy?

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Question: Can someone who is self-employed qualify for subsidized coverage?

Answer: Yes. A person who is self-employed can enroll in coverage through Covered California and potentially qualify for premium tax credits.


Question: My company gives employees a certain amount each month for coverage instead of providing health insurance. Ami I still eligible for a subsidy?

Answer: Yes. Some employers offer a cash “stipend” instead of offering health insurance. This cash stipend is taxable income, similar to a bonus or a pay raise, and cannot be conditioned on the purchase of health insurance. If the employee uses the stipend to purchase a marketplace plan, the payments will be made on an after-tax basis and will not be made through payroll deductions. This type of employer assistance does not disqualify a person from receiving premium tax credits. Employers cannot reimburse employees for the cost of their marketplace premiums using pre-tax dollars.


Question: I have just started a new job and was looking forward to having a company health plan, but what they are offering me is not a good deal. I can’t afford it. Can I stay with my Covered California plan?

Answer: Employee-only coverage is considered to be affordable if it costs less than 9.66 percent of household income in 2016. If employee-only coverage is affordable, then any offer of coverage for dependents is automatically considered affordable as well. This means that coverage offered by an employer to dependents may cost more than 9.66 percent of income and still be deemed affordable as long as the employee-only coverage costs less than 9.66 percent of income. In such cases, the dependents are not eligible for a premium tax credit because they are considered to have affordable employer-sponsored coverage.


Question: My wife and I currently both have the Blue Cross Enhanced Silver 87 plan that we pay $129 a month for based on 2016 projected earnings of $30,130. What is the penalty for us if our earnings would be say $33,000 for 2016? If we exceed by $100 is the penalty the same as if we exceed by $1000?

Answer: First of all, there is no "penalty" for unexpected fluctuations in annual income. If you received more premium assistance than you were entitled to based on your income, the IRS will make the adjustment retroactively on your tax return for that year. The premium assistance due for an income of $33,000 versus $30,130 would be about $400 less for the year. You would pay that back through an additional $400 in federal income tax.


Question: I am eligible for a subsidy but would rather not take it. The amount would be small and not worth the time, trouble and stress getting paperwork together. Can I choose not to take it, and, if so, how do I do that?

Answer: To avoid receiving premium assistance on a monthly basis ask Covered California to change your payment type to a "lump sum" at the end of the year. That way, you'll get any subsidy you may be due when you file your tax return and if you are not due any subsidy, you will not have to pay anything back.


How to Cancel COBRA?

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Question: I want to cancel my COBRA and enroll in a Covered California plan. How much lag time should I expect from time of application to activation of the new coverage?

Answer: Applicants who are eligible for a Special Enrollment Period (SEP) due to loss of coverage can apply right down to the last day within a 60 day window of loss of coverage and the new Covered California coverage is effective the first of the following month. However, in your case you do not qualify for a SEP until the expiration of your COBRA coverage. You can voluntarily cancel your COBRA during the annual Open Enrollment Period (Nov-Dec). During open enrollment, applications received on or before 12/15/2016 will be effective 1/1/2017.


Question: HI! I'VE ENTERED THE 4 HOUSEHOLD MEMBERS AND CLICKED CONTINUE ON THE APPLICATION, BUT IT KEEPS RE-ROUTING BACK TO YOU MUST FILL IN ALL THE INFORMATION FOR AN ADDITIONAL MEMBER, THERE ARE NO MORE. NO MATTER WHAT I'VE TRIED, IT'S NOT LETTING ME CONTINUE PAST THAT PORTION! HELP!!! THANKS!

Answer: It sounds like you may have accidentally clicked 5 instead of 4 household members at the beginning of app. If that's the case, you should go back to the beginning and fix that. The next place to check is the household relationship page and make sure that the parent/child, husband/wife section is accurate. Are you aware that a Certified Insurance Agent can help you with this at no cost to you. In addition to getting you over the land mines in the application, a knowledgeable agent can be a big help in selecting the right plan and making sure your doctor in in the network for the plan you select. (BTW check your keyboard. Your caps lock key appears to be stuck :)


Question: I read that California now limits what Medi-Cal can recover from beneficiaries estates?

Answer: Like the majority of Californians, I have long opposed California’s right to the seizure of assets, after death, of people who had received health insurance coverage through the state’s Medi-Cal program. While seldom enforced, it was a cloud over California’s 11 million Medi-Cal beneficiaries. Now, California’s $122 billion general fund budget includes money to dramatically limit the practice to recover money only for nursing home care.


Question: I heard the my Blue Shield grandfathered health plan is being cancelled. How will that work?

Answer: Starting this week, Blue Shield will begin sending notices to 2,062 grandfathered plan subscribers to inform them that their current Blue Shield of California health plan will no longer be available after December 31, 2016. The plans affected include Active Start, Vital Shield, and Shield Spectrum Plans. Blue Shield will automatically enroll these subscribers into an ACA-compliant plan on January 1, 2017. It is important that subscribers check to see if their current doctors are in the PPO network for the new plan. Subscribers who find that the new plan is unacceptable can select a different plan during the open enrollment period. Those who fail to do so, will have a Special Enrollment Period that extends from January 1, 2017 to March 31, 2017 to select another ACA compliant plan for 2017.


Question: My husband and I are now legally separated - he does not have insurance but I do under my employer who does not provide for family ins. Does my husband still have to include my salary to get his own insurance now that we are legally separated?

Answer: If you are legally separated under a final decree of legal separation you are considered single by the IRS and California state law. Therefore, your husband can apply for Covered California based on his income alone. You must both file your 2016 tax return as either single or head of household - not married filing jointly.


Question: I did not know that I was signing my husband up for the HSA PPO, I thought I was signing up for a regular Bronze PPO with covered ca. It's June, and I haven't opened a special HSA account at the bank, but he hasn't used his insurance yet either. What am I supposed to be doing?


Answer: It is not required that you open an HSA account just because you have purchased an HSA compatible health plan. But if you want to enjoy savings and tax benefits you should open an account now. Most banks offer HSA accounts. It's no more trouble than opening a checking or savings account. If you can open your account by July 1st, you will accrue 6 months of eligibility for the 2016 tax year. The annual contribution limit for an individual is $3,350 and for a family: $6,750. You can add another $1,000 annually as a "catch-up" benefit if you are over 55 yours old. Again, for 2016 your maximum contribution is one half of the annual limit. You can make contributions monthly or wait until the end of the year. Actually you have until April 15, 2017 to make your 2016 contribution. If you are interested in learning more about HSAs, google "health savings accounts".


What is the Grace Period?

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Question: I thought Obamacare made the grace period 90 days? I have been fighting with Blue Shield after they cancelled my coverage for non-payment. I was well within 90-days. Is that legal?

Answer: The ACA law requires a 90-day grace period for on-exchange members receiving subsidies for their health plan. For off-exchange members not receiving subsidies, the grace period is 30 days. If you are on a 90-day grace period and do not pay 100% of your total premium due, the grace period does not start over. Example: Let's say you owe $600.00 for March and April. In April, you pay one month's premium for the month of March. In this scenario, you are still in the 90-day grace period with 30 days left until you are cancelled. The 90-day grace period will start over once you have paid 100% of the amount due.


Question: I made more money than I estimated, so I will have to pay back some of the subsidy I received. My question is about the cost-sharing benefits I received with my Silver 87 plan. Will they charge me for that too.?

Answer: Covered California enrollees at the lower end of the income spectrum receive cost-sharing reductions (CSR) in addition to premium assistance. CSR benefits include lower deductibles for medical and prescriptions drugs and lower out-of-pocket maximums. Currently the IRS can recover premium assistance overpayments, but not CSR payments. That may be changing. We recently noticed that some Covered California accounts are beginning to show a CSR monthly dollar amount - see CSR Amount Sample.pdf. Once a dollar amount is established, can recoverability be far behind?


Question: When I purchased my health insurance through Covered California I did not apply for financial assistance. However I think I do qualify, how can I find out and how do I apply for past months.

Answer: You can find out if you qualify for premium assistance by using Covered California's Shop and Compare Calculator. If you discover that you are eligible for a subsidy, you may qualify for a Special Enrollment Period which would allow you to apply for assistance right now. You cannot recover assistance for past months when you did not request it. This is not a change you can make online. You will have to call Covered California at 800-300-1506.


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 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.


Marriage Causes Payback?

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Question: I just got married in december 28 2015, my husband has his own insurance thru his employer, in 2016 i am covered by my husband, why am i being charged in our joint tax filing in 2015?

Answer: You changed your tax status from single to married filing jointly for the 2015 tax year. As a 1-person household, you were eligible for premium assistance based on your income alone. Now your assistance is calculated on a 2-person household (even though your husband has employer-based coverage) and your joint income. You are paying extra tax to recover some or all of the premium assistance for which you are no longer eligible.


Payback Entire Subsidy?

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Question: I haven't filed my taxes yet because when I attempted to do so, I was told that I had underestimated my annual income, which meant that I owe an additional $750. It turns out that I was deemed eligible for Medi-Cal for the entire year of 2015. My caseworker and her supervisor found the mistake. Am I still going to be held accountable for paying back the IRS?

Answer: If your actual 2015 income qualified you for Medi-Cal, you may have to repay a maximum of $300 for any premium assistance you received through Covered California.


Can I Opt Out of the Subsidy?

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Question: Can I opt out of the subsidy even if I qualify now or later? If I did, would I still have to prove income, report changes, etc. Does covered california provide such an option?

Answer: There are a number of ways to apply through Covered California and opt out of premium assistance. (1) The very first question on the Covered California online application is: "Do you want to see if you qualify for free or low-cost Medi-Cal or tax credits with Covered CA?". If you respond "No" to this question, your income will not be considered and you will be ineligible for premium assistance. (2) If you respond "Yes" to this question, you can receive premium assistance if your income drops below the 400% FPL threshold. Most people should take this option, because they retain the option to receive premium assistance should your income drop. If you don't want to deal with having to repay premium assistance, report income changes, provide proof of income etc., here's what I recommend. When applying you can select and Annual Premium Assistance as opposed to the default, "Monthly Premium Assistance". The annual premium assistance option will credit any premium assistance due for the year on your tax return. That way you are not leaving any potential benefits on the table while minimizing income fluctuation reporting hassles.


Unexpected Tax Consequences?

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Question: We are husband and wife with $66,776 AGI. We are covered by Chinese Community health Insurance with monthly premiums of $1,629.79 and have a monthly advance payment premium tax credit totaling to $14,800. Now, this is what we owe the IRS. How are we being helped if at the end of the year we owe the IRS this much. Please help.

Answer: ​With an AGI of $66,776 for a 2-person household, you are not eligible for any premium assistance. That is why you have to repay all the the advance premium tax credits you received for the year. Apparently you claimed a lower income on your Covered California application in the first place. To correct this, you must notify Covered California of your actual income.


Back Payment to Medi-Cal?

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Question: I am single with no dependents. I have been covered by Medi-Cal since March 2015. I had a surgery in October 2015. My AGI for 2015 would be around $19,000. Will I be subject to back payment of healthcare expenses? If so, how much?

Answer: There is no penalty or repayment required for your previous Medi-Cal benefits. At $19,000 single-person household income, you are no longer eligible for Medi-Cal. You need to notify Medi-Cal of your higher income. They must release you before you can be eligible for Covered California coverage. You will be eligible for premium assistance and cost sharing reductions under Covered California​.


Question: We have a family coverage that's through my employer. It's a PPO. Can we still have a covered CA insurance just for our son? There are certain therapy he needs that's not covered by my insurance.

Answer: Your son cannot have a second health insurance plan, either Covered California or off-exchange, if he is already covered by your employer-based insurance plan. There is no option to make a change in his coverage at this time. Even if you were willing to pay full-price for health plan for your son, you would have to first voluntarily cancel his coverage under your group plan, but that would make him ineligible for a Special Enrollment in 2016. You will have to wait until Jan 1, 2017 to make that change.


Question: Where can I find the 1095 form for my son who was covered under medi cal 2015?

Answer: Each person who is or was enrolled in Medi-Cal will get his or her own Form 1095-B. Therefore, a household with more than one person covered by Medi-Cal may get a Form 1095-B for each person that had coverage. The 1095-B form will be mailed to you by March 31, 2016.


Change Coverage Now?

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Question: I chose Molina when I enrolled not knowing that Kaiser was available to me. I want to know how I can change from Molina to Kaiser. Is there a number I can call?

Answer: You can only change plans during open enrollment. Your next opportunity to change you health insurance plan will begin in November 2016.


Can My Son Go on Medi-Cal?

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Question: I'm 52. My wife is 49. We make 60 thousand a year. My son is 19 and he live in our basement but is never home. He files his own taxes and claims himself. He works full time but would be on medical if our income was not added to covered cal. Does he have to pay for insurance or can he file medical by himself.

Answer: ​Yes. He can apply for Medi-Cal by himself. Be aware that once you drop him from your Covered California account you become a 2-person household and your subsidy will be less than it was as a 3-person household given the income is the same.


Question: I'm in an odd situation where I stopped working around August of last year to return to school, BUT I do try to get some work in during breaks. Since then it's been a non-stop cycle of "submit proof of income">submit last pay stub>"welcome back". What triggers these requests?

Answer: Submitting your last pay stub doesn't really satisfy Covered California (even though they list it as an acceptable form of proof of income). They'll keep requesting proof of income until they get an easily verifiable form of proof such as your last tax return, W2 income, unemployment insurance, or disability income. Self employed income and "other" income such as rental, stocks, 401k etc almost always trigger the proof request. In addition, Covered California has access to IRS records, so if your income estimate for 2015 was more that 10% higher or lower than your 2015 tax return AGI (line 37 of 1040), you will be required to provide proof of current income again.


Question: I provide more than 50% support for my friend/roomate, which means I can now claim her as a dependent on my taxes. We dont want her to loose her insurance, she cant afford her own. If I claim her as a dependent on my taxes would she then have to include me on the household number and my income information for her Covered CA health insurance application?

Answer: Your friend can file a tax return, but not take a personal exemption (Line 6A for IRS Form 1040). That way you can claim a dependent exemption for her on your tax form without affecting her eligibility. She must complete her Covered California enrollment application as a single person household using her income only.


Question: What is the penalty for not having any health insurance?

Answer: In 2016, the penalty is $695 per adult and $347 per child up to a family cap of $2,500 or 2.5% of household income, whichever is greater. In 2015, it was $325 for adults, with a $975 maximum or 2% of household income. Kaiser Family Foundation predicts that in 2016, average penalties will increase, on average, from $1,177 to $1,450 per household. According to Peter Lee of Covered California, “The bigger penalty could be showing up in the emergency room and walking out with a bill in the tens of thousands of dollars,”.


Question: I started Covered CA enrollment on 1/27/16, but got hung up on credit freeze, or submitting Documentation. Will finish ASAP, but need a few more days to finish. Can I get a few more days to finish?

Answer: You have until midnight Sunday January 31st to finish your Covered California application yourself. But even if you get stuck and can't get it done by then, We'll get it done for you in overtime. That's right, you can have until midnight Saturday February 6th to finish it provided you use a Certified Insurance Agent or a Covered California Representative to complete it for you.


Question: Can I apply by myself for Covered CA even if my parents claimed me as a Dependent? I am 21 and do not live at home with my parents, yet I did not make enough to be independent.

Answer: Yes. Apply as a 1-person household and use your own income projection for 2016. You will have to file a tax return for the 2016 tax year, but you must waive the personal exemption. That way your parents can continue to claim your dependent exemption on their return.


Question: Our medical insurance has been through my husband's work, and he is retiring April 1 (with no retirement benefits). He is over 65, but I am 59, giving me 6 years before Medicare. I've run the numbers, and we won't be eligible for subsidies. It seems I should purchase insurance on the open market through an insurance company's individual plan. Am I missing something; should I consider going through Covered California? I thought the only reason was to get financial help with the monthly premiums, and can't see a reason otherwise. If I should go through Covered California anyway, please explain why.

Question: If you are not within the income range for a subsidy, there is no compelling reason to apply for coverage through Covered California. Some might argue that you may as well apply through CC now just in case you are eligible for a subsidy later. That way you could simply adjust your income in your online CC account and become eligible for subsidies immediately. However you could complete your CC application at that point where you income drops. It would take just a few more minutes to do it then. Purchasing an off-exchange plan directly from the insurer also offers some plan designs not available on Covered California. Finally, you don't have to disclose your personal IRS history to the insurer in a direct purchase as you would with Covered California.


How Can I Get My Form 1095-A?

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Question: How can I get my 1095-A form to do my taxes.

Answer: During the month of January 2016, Covered California mails out the IRS Form 1095-A to all who received premium assistance in 2015. Covered California also makes the 1095-A forms available for download from the insured’s online account. If you know how to log on to your California account, do so. Then, from the home page, click on the Summary box. Then from the left margin menu, select Documents and Correspondence. If your 1095-A is available now, you’ll see it listed as CalNOD62AIRSForm1095A. Click on view and print or save the form. If you’ve given it time, (let’s say it’s February 15th and you have not received it) and you have no idea how to log on to your CC online account, and you don’t have a certified agent to help you, you’re going to have to call CC at 800-300-1506 and click on I’m feeling lucky.


Question: My 28 year-old daughter lives with me. She is unemployed, no unemployment benefits, currently zero income. I have employer-based insurance for myself, and my income is over the thresholds for ACA subsidies. If my daughter earns nothing for the whole of 2016 (or less than $4,000) she is my "dependent relative". My question is, does that necessarily make us both part of one household, and therefore disqualify her for Medi-Cal because of my income? What happens if I choose to NOT claim her, even though I could?

Answer: Your daughter should apply for Medi-Cal directly through your county office. Medi-Cal is only interested in your daughter's income and assets. That way you can continue to claim her as a "dependent relative" on your tax return.


Question: My employer offered me, my spouse and my children a employer sponsored minimum essential coverage effective 01/01/2016. If my spouse and my children decline the employer sponsored minimum essential coverage offer, are my spouse and my children eligible for Covered California subsidy when my household income is greater than 266% of Federal Poverty Level?

Answer: No. The fact that your spouse and children have been offered employer-sponsored health insurance makes them ineligible for premium assistance in Covered California even if household income is between 128% and 400% FPL.


Question: My mom, a new green card holder, has an income less than $4000 from my home country. I have sponsored her green card, and signed the affidavit of support (I-846). I am not claiming her as a tax dependent. I've read that for certain federal and states benefits (including non-emergency medi-cal--see source below) my income would be counted as her income to assess her eligibility under "immigrant deeming rules". I have a high enough income that if added to hers, makes her ineligible for medical or discounts on CoveredCA market place. The medi-cal staff did not seem to know much about this and they say they are trained to count the IRS household income to assess eligibility, which means my income does not matter. Which one is correct? Is she eligible for medi-cal? If she is not eligible under medi-cal, does CoveredCA also deem my income as hers? The staff seem to be clueless. My research on this seems to go nowhere. I appreciate your help.

Answer: You can apply for health insurance for you mom through Covered California. Since you do not claim your mother as a dependent, her income alone is considered for eligibility. Since her taxable income is far less than the Covered California minimum, she will be deemed eligible for Medi-Cal. She can "buy into" Medicare once she has been in the US for 5 years.


File Your Own 1095-A?

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Question: Our 1095-A for 2015 is nearly completely wrong. I went to Medicare in may but my wife was and still is on the same Covered California Kaiser policy, Because of this I expected some problems, but the form only has her coverage for the first 4 months, nothing for my coverage in that period, and does not show her continued coverage for the last 8 months. I believe it is because it took a great deal of effort to get them to continue her coverage. They had me listed as primary and first dropped her coverage and then reinstated it, I assume with her as primary. I think this is the problem now, but it shows wildly wrong numbers and will cost me dearly if I cannot get it corrected. How do I do that when they have no way for me to communicate with them? They give no email addresses, the message board will not accept replies, and the chat people don’t have any idea what to do, other then assure me she has coverage. I don’t have any confidence that they will get me a corrected form so that I can file.

Answer: If you cannot get an accurate 1095-A before the tax deadline, you can file your own 1095-A. Here is what to do:

Download a blank 1905-A form at https://www.irs.gov/pub/irs-pdf/f1095a.pdf Now collect the following pieces of information for PART III - Household Information:

  • The months you, your spouse, and dependents had coverage.
  • Your total premiums paid for you, your spouse, and dependents.
  • The cost of the Second Lowest Cost Silver Plan in your Marketplace at https://www.coveredca.com/shopandcompare/2015/
  • The total amount of Advanced Premium Tax Credit that was paid on your behalf. (Your insurer will have this information too) NOTE: You can compare what you actually paid to the full price of the plan, the difference is your Advance Payment of Premium Tax Credit.
  • If you are married then you’ll also need “Policy Number (Form 1095-A, line 2)”. So it’s a smart move to get the policy number from the Covered California or your insurer. You only need to enter the LAST 15 digits of the policy number (that’s all that show on a 1095-A sent to you as well).

Now that you have all of that information, add the total amount in for each column.


Affidavit as Proof of income?

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Question: I have just opened up a new law office. I worked for an attorney for 13 years and would Gross over $200,000 per year. The practice is Social Security Disability appeals. The covered California said I cannot prove my income and must go on Medi-Cal. I do not want to do that. They gave me 90 days to appeal Any suggestions would be much appreciated. I do have three cases that are scheduled for hearing. I believe I will make $20,000.00 net after my first year as a solo practitioner. Thank you in advance for any help you can offer me.

Answer: While you are getting your business started, the common forms of proof-of-income may not available to you. You can submit an Affidavit - a signed and dated statement with the word "Affidavit" on top - explaining how much income you can expect to make and how you will earn it 2016.


Question: I read that sponsors of immigrants who sign the enforceable affidavit of support (Form I-864) may be required to repay the government for "means-tested" benefits used by the immigrant after he or she becomes a lawful permanent resident." and that "non-emergency medi-cal is a means-tested benefit". That says that if sponsored immigrants get on medi-cal, the sponsor should repay. Is that correct?

Answer: Yes. The sponsor is legally liable. The enforceable affidavit of support (Form I-864) states: "If a Federal, State or local agency, or a private agency provides any covered means-tested public benefit to the person who becomes a permanent resident based on the Form I-864 that you signed, the agency may ask you to reimburse them for the amount of the benefits they provided. If you do not make the reimbursement, the agency may sue you for the amount that the agency believes you owe." However, it is very rare for the sponsor to be sued. States are not required to go after sponsors, and to our knowledge, no government agency in California has sought reimbursement from a sponsor up to now.


Question: Can our sister, who is our financial dependent for IRS, federal taxes, also get benefits from California medi-cal and federal Medicare as her retirement income is insufficient to cover food, board and medical needs?

Answer: Your sister is eligible for Medi-Cal if she meets residence and income guidelines. She should apply directly through her county Medi-Cal office, not Covered California. Here's a link for MediCal contact info: https://www.medi-cal.ca.gov/contact.asp


Question: Does a new green card holder who stays in the US for 6 months a year only have to be covered by an ACA compliant plan? If yes, does it have to be for the entire year or just the duration of the stay in the US?

Answer: Yes. You must buy health insurance or pay the IRS penalty. You can cancel your coverage when you leave the country and reapply under Special Enrollment provisions when you return.


Can I Change My Health Plan Now?

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Question: Please help me figure out if I can change my health plan right now. I'd like to change from Heath Net to Blue Cross, because the doctor I need only takes Blue Cross.

Answer: Yes. You can change your plan selection any time before the current open enrollment period ends on Jan 30, 2016. The effective date of the new coverage will be February 1st, if you make the change by January 15th, or March 1st if you change between January 15th and 31st.


Question: Our family of four, husband Wife and two kids, with yearly income of $48000 qualify for premium assistance and cost sharing (Silver 87 Plan) according to Covered California’s shop and compare tool. However, when we applied, Covered California qualified kids for Medi-Cal. Pregnant wife also qualified for Medi-Cal. Now Covered California says the husband does not qualify for any premium assistance and cost of sharing plan because it will not consider Medi-Cal eligible members in the household size for covered California. Medi-Cal eligible members reduced the family size to one member for Covered California.Does Covered California not include Medi-Cal eligible members in the family size while determining eligibility? Does Medi-Cal not include Covered California eligible member in the family size while determining eligibility? Are Covered California and Medi-Cal programs mutually exclusive or inclusive or overlapping?

Answer: (1) Your 4-person household will receive premium assistance and cost-sharing (Silver 87) benefits based on your $48k annual income. The fact that your kids are eligible for Medi-Cal does not reduce the subsidy or cost-sharing (still calculated based on 4-person household, not a 2-person household). (2) Your wife’s pregnancy provides additional choices. When you apply through the Covered California enrollment portal you will be enrolled in Covered California coverage and your application will also be sent to Medi-Cal in your county. In your family’s case, your wife is eligible both the Medi-Cal Access Program and Covered California during her pregnancy and immediate postpartum. You cannot have the Medi-Cal Access Program and Covered California at the same time; you must make a choice. (3) If your wife chooses to enroll in Medi-Cal Access until after the baby is born, the husband’s Covered California eligibility will still be based in a 4-person household, but with only one person enrolling. He is still eligible for a subsidy and cost-sharing reductions, but the net Covered California premium for the husband alone would be higher than the net premium for both spouses in enrolling Covered California.


Over 65, Never Paid into Medicare?

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Question: I have a special needs brother who just turned 65. He has been getting medical insurance through Medi-Cal, but was told that now he is 65 he can no longer be covered unless he gives up all but $2,000 of his assets. He never paid into social security or medicare. Could you please provide some information on eligibility for those over 65?

Answer: Your brother is eligible for Medicare even though he never paid Medicare taxes. People with less than the requisite 40 credits​ ​must pay the premium for Part A​ - $411/mo​ for those with less than 30 credits. Part B premiums are $122 per month for most people.​ Go to medicare.gov for more infomation.


Obamacare Deadline?

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Question: My fiancé was unable to apply by the deadline yesterday because the computer gave an error message when he tried to submit online. He doesn't want to get hit with the penalty, and he wants health insurance. Is there anything he can do?

Answer: The Obamacare deadline for coverage effective 1/1/2016 has been extended two days - through midnight December 17th.


Question: What is the advantage of signing up directly with Blue Shield PPO, as opposed to signing up through Covered California?

Answer: Covered California is the only place to enroll for health insurance coverage if your household income makes you eligible for premium assistance. When you apply through Covered California you agree to file taxes each year and to allow Covered California to access your tax records through the IRS. When you apply directly through a California health insurance carrier like Blue Shield - referred to as an off-exchange enrollment - you are not asked to provide any income related information whatsoever. Off-exchange, you will find plans that mirror the covered California plans exactly in benefits and rates, but, you'll find plans that are unique to the off-exchange-market as well.


Premium Assistance Now or Later?

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Question: Will the premium assistance lower my monthly cost or simply give me a tax credit at the end of the year?

Answer: Most people who receive premium assistance take it each month to reduce the net premium they have to pay. But that's not the only way to do it. You can also take a lesser amount monthly or none at all. In the later case, you will receive the remainder of the premium assistance you are due when you file your tax return for that tax year.


Best Out-of-Network Coverage?

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Question: I make about 18,000 annually and live in the 90021 zip code. I am looking for a plan that will give me the most out of network benefits, because I need a spinal surgery, and my surgeon is not part of any networks. Personal pay and medicare only. Can you tell me of any plan options that include out of network benefits?

Answer: To receive out-of network benefits you must select a PPO plan. In your zipcode, there are two carriers offering PPO plans, Anthem Blue Cross and Blue Shield of California. Their out-of-network benefits are identical. Your income makes you eligible for a Silver 87 Plan with enhanced benefits, so here's how your surgery would be paid for. For all in-network costs - like hospital, drugs, and physical therapy - your in-network maximum-out-of-pocket expense will be $2,250 (Silver 87 plan). The out-of-network cost for you surgeon will probably meet the separate out-of pocket maximum of $9,250. Your total cost for this surgery will run $11,500. If you can find an surgeon in-network with whom you are equally comfortable, your total cost would be $2,250.


Covered California and SIMNSA?

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Question: My present insurance coverage is under Covered California through Health Net. My husband is the primary owner to this account but at this time he is unemployed. My employer is offering me a SIMNSA Insurance which has an office in Chula Vista California. The provider services are based in Tijuana, Mexico. I do not speak the language nor familiar in the Tijuana area. Crossing the border from U.S. to Mexico is a nightmare (the minimum is 2 hours going and 2 hours coming back in the U.S. This makes me uncomfortable since I don't speak Spanish. My question is can I legally reject/decline to the offered insurance? What will be the consequence in my part if I do reject this offer? (Note: SIMNSA is the only insurance company offered by the employer.) Will I lose my Health Net insurance since this is subsidized.

Answer: SIMNSA plans offered in the US are ACA compliant and meet the meet the minimum value and provide essential health benefits. Most services require no co-payment at the time of treatment. Some select services require a $5 to $10 co-pay, after which all services are covered at 100%. Unfortunately. you have to cross the border into Mexico to see a provider (except for emergency coverage in the US). You can opt out of the SIMNSA offer from your employer, but you will no longer be eligible for premium assistance (subsidy) through Covered California because you have access to employer-based coverage. Assuming your employer pays all or most of your monthly premium, I advise you enroll yourself and your husband in SIMNSA and plan on using it for any major medical expenses that may arise. If you prefer, you can pay cash to see medical providers in the US side for routine care. That expense would be much less than carrying an additional health insurance policy without premium assistance.


Must Dependent File Taxes?

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Question: My family of four is covered under Covered California with premium assistance for 2015. Our 21 yr old daughter did not complete enough school to be considered a full time student, so we cannot claim her for our 2015 tax return. She did work, and earned about $9000.00. Will we be penalized because she should have had her own health care plan (MediCal). Should she enroll for 2016 for her own plan before I take her off ours?

Answer: Single dependents must file a federal income tax return if their earned income is more than $6,100. So your daughter must file a tax return for 2015. She needs to create a Covered California application for her own 1-person household. Her income makes her eligible for Medi-Cal in 2016. You will need to update your Covered California account by removing her from your household. There are no penalties for either your daughter or yourself. If you received more premium assistance in 2015 than you were entitled to, you will pay some of it back to the IRS when you file your tax return for 2015.


File Taxes with $0 Income?

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Question: When I re-enrolled last November for Covered California I estimated my income about $1500/month (based on my income for the past 10 years). In January 2015, I became unemployed. I forgot to report my income change and been receiving premium assistance and been paying my adjusted premium. Since I had no income in 2015 do I have to file for taxes? Is there a penalty I have to pay since I forgot to report my income change and been receiving premium assistance? Thanks!

Answer: For starters, because you enrolled through Covered California you have to file a tax return for 2015, even if you had no income. With no income in 2015, you were eligible for Medi-Cal, not Covered California. But, since you made no money, there is no taxable income from which the IRS can recover the premium assistance your were given. So you get to skate by this time - no penalty, no tax recovery. Your Covered California coverage will end at the end of 2015 and your Medi-Cal coverage will start January 1st, 2016.


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.


Question: The Covered California online renewal process was convoluted and did not provide me with an acknowledgement that I have renewed successfully. How do I know if I have renewed my coverage? FYI, I worked for 30 years as a Computer Scientist and still struggled with the Covered California web site.

Answer: Here is how your Covered California homepage looks if you have completed your renewal Sample CC Home Page.pdf. Notice that all of the sections are checked, including Enrollment. If you click on the Summary checkbox, then from the next page, select Current Enrollment, you get a detailed summary of your coverage. Your 30-years of experience in Computer Science did not include government work apparently. It's a "different" world.


Question: My employer offers dependent coverage that I can't afford for my dependents. What are my options on covered ca.

Answer: You can enroll your dependents in Covered California coverage. However, they will not be eligible for premium assistance. If your income is low enough (for example: less than $27,000 annually for a 3-person household), you can enroll your children in Medi-Cal coverage rather than your employer-based coverage.


Question: Can I decline my employers medical coverage and get covered California at a reduced premium rate?

Answer: Generally, you cannot receive premium assistance with Covered California coverage if you opt-out of your employer's group health plan. Only if the employer-based coverage fails the "affordability test" can you be eligible for premium assistance through Covered California. To be considered "affordable" by IRS standards, the employee-only share of the cost has to be less than 9.5% of the employee's income.


HSA Compatible Plans?

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Question: I am currently enrolled in a high deductible plan with CCA. Can I start an HSA? If so how do I do this? And what expenses are eligible.

Answer: You may have to change your high deductible Bronze plan to one specifically labeled HSA eligible. Once you have done that, you can open an HSA account at the financial institution of your choice.​ Any medical, dental, or vision expense that the IRS recognizes as deductible can be paid with pre-tax dollars from your HSA funds.


Payback Cost Sharing Reductions?

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Question: My wife and I plan to quit our jobs effective 12/31/15 and enroll in Covered California. I have done compare and shop and we will qualify for the Enhanced Silver Plan, probably the Silver 87. What happens if part way into 2016 I find a way to make income. If the increase in income puts me in a more expensive plan I can pay back difference in premiums, but what happens if I had medical care on the Silver 87 in say March 2016 but I later have medical care when I qualify for say the Silver 70 like in October 2016. Would I owe reimbursement for services rendered early in the year at rates later in year if income changes?

Answer: I’m glad to put your mind at ease: there is no recovery of any cost sharing benefits​ you may receive. Only the premium assistance (subsidy) has to be repaid if an increase in income warrants. Since you will be making income adjustments to your Covered California account during the year, you would be well served to have a Certified Covered California agent to handle your initial enrollment and those income changes for you.


Re-apply to Medi-Cal for Kids?

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Question: My kids are already covered by Medi-Cal, they received their ID cards in the last 2-3 months. I am starting a new job without an employer health plan, so my wife and I will buy our own insurance through the state exchange. Do we have to re-apply for our children to be covered by Medi-Cal when my wife and I buy a plan through the exchange

Answer: Getting a new job usually results in an income change. Since your kids' eligibility for Medi-Cal is based on your household income, they may or may not still be Medi-Cal eligible. In any case, the Covered California online application will include Medi-Cal eligibility information for your children once you complete the application for your entire household. If the children continue to be Medi-Cal eligible, you do not have to reapply with Medi-Cal. If they are no longer eligible, Medi-Cal will drop them automatically (at some point) and your children will be included under your Covered California coverage.


Lost Subsidy. Why?

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Question: According to the website I will be losing premium assistance in 2016. I received around 180 dollars of assistance per month last year and I make almost exactly the same as I did before. Why did I lose my subsidy?

Answer: Probably because your 2014 tax return had an adjusted gross income higher than the estimated income you first entered. Covered California did not receive this information from the IRS until mid-2015, so the income adjustment was applied to the 2016 tax year.


Question: Hi, I and my wife are new immigrants sponsored by my son in CA and our age is > 65. Our combined income is 3k. I have few questions. Can we file tax as "married filing jointly" as income 3K. If so, can we apply for tax credit/subsidy in coveredca for the premium and for cost sharing(deductible/out of pocket cost)vWe are 81 and 77, household size is 2. If our income is about 10K/year, what will be our premium and out of pocket costs, even if its an approximation?

Answer: Medicare would be your first choice, but I assume because you did not mention it that you do not meet the 5-year residency requirement. Based on your income ($3,000 to $10,000 annual), you are eligible for MediCal (not Covered California). Medi-Cal requires only that you reside in California legally.


Question: If I am receiving a Subsidy and become newly employed with an Employer that offers and Affordable Minimum Essential Coverage and continue being enrolled on Covered California for myself with or without my dependents, will I have to repay the subsidy?

Answer: Yes. If you continue Covered California coverage after becoming eligible for employer-based group coverage, you will have to repay any subsidy received after that point. Even without a subsidy, dual coverage is not allowed. It is your obligation to notify Covered California once your employer-based coverage becomes effective.


Are All Bronze Plans HSA Eligible?

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Question: By definition it seems that ALL Bronze plans are considered HDHP. So, I’m confused by the fact that only certain plans offered actually say “HSA.” If I select a plan not specified as HSA but it is actually a high deductible plan, will I still be able to utilize an HSA account?

Answer: No. All Bronze plans are not HSA compatible. Only those labeled as HSA qualified will work with the IRS. If you select a plan not specified as HSA, you will not be able to utilize the tax benefits of an HSA account?


Find Medical Providers in My Area?

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Question: How can I determine which Covered CA health provider plans will accept the particular medical group and doctor that I want? I also have difficulty because of the restrictions on the area in which I live. Will a PPO plan help resolve this issue?

Answer: You will have to do an online search of providers - doctors and hospitals - at the website of each carrier you are considering. I have provided a list of links to some carrier provider directories below. If you are uncomfortable using the internet, you should contact a Certified Agent to help you locate the best plan including your provider preferences. In 2016, all counties in California will offer a choice of at least 3 different Covered California carriers: Blue Shield and Anthem Blue Cross PPO plans (no more EPO) are available in every county statewide. New this year, United Healthcare will offer a third PPO choice in even the most rural counties.


2016 Rate Increase?

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Question: I just received a mailing that states that our Anthem Blue Cross premium is going from $670 to $870 for 2016. We've reported no changes in income or family size (nor made any claims this year). As expected, the plan's deductibles, copays and OOP maximums have all increased. This is not the reasonable expected premium increases I've read about in the Covered CA press releases. We receive a subsidy. Our income for 2015 will be the same as for 2014 year. Is it safe to assume that the subsidy will not increase substantially to cover such a large premium hike? Hence our premium will now be an additional $200 out of pocket monthly?

Answer: If you are eligible for a subsidy, the net amount you pay after subsidy is set as a percentage of your income, so if your income is the same as 2015, your subsidy will increase to cover most if not all of the 2016 health plan rate increase. While the average 2016 rate increase for Covered California coverage statewide is 4%, there are anomalies. For example if you have a Blue Shield PPO plan in Monterey, San Benito or Santa Cruz county your rate could increase as much as 44%. This year both Blue Shield and Anthem Blue Cross offer PPO plans in all California counties, so don't renew your coverage without shopping all other plans in your area.


Question: Before I purchased my Covered California plan with Anthem last year, I carefully checked Anthem’s online provider directory (Covered California does not appear to have one) to confirm that my doctor, my wife’s doctors, and our preferred hospital were all in-network. When we visited our doctors a few months later, both of our doctors told us they do not take Covered California. This cost us significant out of pocket expenses. Is there any I can get reimbursed for their mistake? Is it any better now?

Answer: Today’s provider directories are somewhat better than a year ago, but are still inaccurate. (For a complete picture on why this situation continues 2 years after ACA implementation read: Provider Directory Study 9-2015.pdf. Accurate provider directories won’t happen any time soon. We need the Department of Insurance and the Department of Healthcare Services to “grow a pair” and start aggressively enforcing existing standards with sanctions and fines for the carriers. Covered California should add an SEP trigger to include consumers that can show that they chose a plan based on inaccurate provider directories. That way at least, the consumer could switch plans and minimize the added cost and inconvenience caused by errors or misrepresentations in provider directories.


Employee Dependents Opt Out?

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Question: A new employee wants to negotiate a stipend for not enrolling his family members on our company health insurance plan. He says his covered calif plan for them is cheaper than the cost would be for the company plan (we have kaiser and pay for 50% of dependent coverage). I don't know if we can (as an employer) pay the employee a stipend if he opts out of our coverage for his family.

Answer: Unfortunately for this employee, his dependents are not eligible for premium assistance at Covered California, because they are "offered" employer-based coverage. Should his dependents opt out of the group coverage, they can enroll in Covered California coverage but without a subsidy, making the Covered California cost much higher that 50% of the group coverage cost. To enable your employees to do what was requested here, your group plan would have to stipulate that no dependents will be offered coverage going forward.


File Taxes with Zero Income?

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Question: When I enrolled in Covered California a year ago, I was making about $1400 a month and received premium assistance. I became unemployed in January and did not report the change, but still paid the adjusted premium. Do I still have to file a tax return with almost zero income? Will there be a penalty or tax consequences for this at the end of the year?

Answer: Yes. You must file a tax return even if your income is zero. You agreed to do so as part of your Covered California application. Get a form 1040EZ and you can easily fill it out and submit it yourself. The amount you have to pay back is limited to $300 in your scenario. If you did not file a 2014 Federal Income Tax Return, you are not eligible for a subsidy in 2016.


Bronze HSA Better Than Platinum ?

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Question: My wife and I are self-employed and have a family of 4. We don’t qualify for subsidy in Covered California. Can you help us understand why one shouldn’t always go Bronze with HSA vs. a lower co-pay plan e.g. Platinum? Doesn’t the tax benefit of an HSA and the lower OOP costs of Bronze always mean a lower maximum, after tax health care spend? Under what circumstances does it make sense to purchase the Platinum plan?

Answer: People with chronic health conditions buy the platinum plan. For example, 40% of platinum plan users are diabetic. They know they will have significant medical expenses and they’d rather pay the higher insurance premiums than the out of pocket expenses. The out-of pocket maximum for platinum plans in 2016 is $4,000.

Healthy, more affluent people, see the Bronze HSA compatible plan, as a better option. For these people the $4,500 deductible (2016) is not a deal breaker because they have the money, if necessary. Because they are healthy, their out-of-pocket costs should be very low most years. Then of course, there’s the tax benefits and lower premiums. The out-of pocket maximum for platinum plans in 2016 is $6,500.


Will I have to Repay the Subsidy?

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Question:nMy partner and I are not married, but we live together and we have three children together. In March, I lost my job and with it, our health insurance. Without my income, we qualified for premium assistance subsidies because we had a low estimated annual income. I just took and job (August). I immediately reported our income change to my Covered CA agent. My fear is that at the end of the year our annual income will put us over the limit for qualifying for subsidies and we will be penalized for the five months that we received them. Is that how the system works?

Answer: If your 2015 adjusted gross income exceeds the premium assistance threshold of 400% of the federal poverty level (FPL) ($114,000 for a family of 5), you would end up repaying the IRS for all the subsidy you received for the year. Assuming your income was less than that, you will still repay a portion of what you were have been overpaid. Here’s the repayment schedule:

  • Less than 200% FPL ($57k in your case), the amount of the repayment is limited to one-half of $600
  • At least 200% but less than 300% ($85k in your case), the amount of the repayment is limited to one-half of $1,500
  • At least 300% but less than 400% (114K in your case), the amount of the repayment is limited to one-half of $2,500

You did the right thing by reporting your income change to Covered California as soon as possible to limit the overpayment amount.


Add Recently Immigrated Spouse?

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Question: My wife just immigrated. Since immigration is a circumstance that allows enrollment outside the normal enrollment period, can I add her to my existing plan?

Answer: Yes, if your spouse is "lawfully present" in the eyes of Covered California you can add her to your Covered California coverage. Lawfully present immigrants include:

  • U.S. citizens and U.S. nationals.
  • Lawful permanent residents or ("green card holders").
  • Lawful temporary residents.
  • Persons fleeing persecution, including refugees and asylees.
  • Other humanitarian immigrants, including those granted temporary protected status.
  • Non-immigrant Status holders (including worker visas and student visas).

Individuals who are not lawfully present are exempt from the requirement to have health insurance. They must apply for an exemption directly with the Internal Revenue Service (IRS) on their federal income tax return.


Question: If you withdraw $10,000 from an IRA, is that added to income amount to be calculated for Covered California.

Answer: Yes. Withdrawals from traditional IRAs (not Roth), 401Ks, and company pensions are taxed as income and will add to your Adjusted Gross Income (AGI on line 37 of 1040 tax return) which is the number on which Covered California bases its premium assistance calculations.


Question: We lost our employer coverage June 1 but were out of the country from early May until mid August. Are we just out of luck as far as buying insurance through Covered California until the next open enrollment?

Answer: You are entitled to a special enrollment period of up to 60 days following the termination date of your employer-based coverage. Your SEP expired on August 1st. Your should be able to get covered however. I suggest you contact a Covered California certified agent. The agent will help you request an enrollment "exception" due to the fact that you were out of the country during your SEP.


Question: I will need to buy health insurance due to job loss. I am going to be completely self-employed. I understand there is a regular Bronze plan and a HSA Bronze plan. Which is better for a healthy couple who expect little medical care? Please consider that self-employed deduct medical insurance paid on their income taxes.

Answer: ​Yes. I recommend the HSA compatible Bronze plan for healthy self-employed people because you can take advantage of the added tax benefits. Your premium payments are tax deductible to the business and any money you contribute to your HSA account is also pre-tax - up to $6,750 per year for a couple. You can use your HSA savings to pay for out of pocket medical expenses - copays and deductible - with pre-tax dollars.


Question: I have heard of the limit to tier 4 drugs. Can you elaborate on this as well any other changes like deductibles, co pays, coverage e passion etc?

Answer: In 2016, all metal-tier plans will now have a maximum monthly out-of-pocket cost on specialty drugs (once the pharmacy deductible is met). For the Bronze Plans there is a $500 monthly maximum and for Silver, Gold, and Platinum the monthly out-of-pocket maximum is $250 after the pharmacy deductible is met. The other significant change in benefits for 2016 affects the Bronze Plan. The first cumulative three visits will not be subject to a deductible and can include a specialist visit in addition to primary care, mental health and urgent care visits. In addition, laboratory work is not subject to the deductible.


Question: My daughter got Medi-Cal, as she was unemployed last year. She found a new, though, low paying, job about 6 months ago, but forgot to report the income change. Will this effect her ability to get Covered Ca in a timely fashion? She needs about 6 different prescriptions, and can't afford to be without her medicines. She also can't afford to buy insurance with any help. What should she do?


Answer: If your daughter is making less than $1,350 per month, she is still eligible for Medi-Cal and doesn't need to make any changes. If she is making somewhat more, but not a lot more, she can wait for open enrollment to make her income change and next year she will be on Covered California with premium assistance. There will be no financial penalty for underestimating her income in 2015.


Question: I put in incorrect information on my application which affects my eligibility for Medi-Cal. How and where can I change this? I don't see that option on the Covered California website.

Answer: To amend a Covered California application, login to your online Covered California account. From your home page select "Report a Change. This illustration (Report Change.pdf) will help. Then select the section you want to change, for example "Household" or "Income" and update.


Private Insurance for my Child?

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Question: I am self employed. Acceptance by physicians for Covered CA plans are different for me and for my 8-year-old child: my child's physicians do NOT accept ANY Covered CA plans, while mine do. Can I stay on my Covered CA plan and purchase an off-exchange plan for just my child? We don't qualify for a subsidy.

Answer: Yes. You can do that during open enrollment - November 1, 2015 through January 30, 2016 - when you may update your Covered California account to indicate that your daughter, though part of your household, is not requesting coverage. Then you can apply for coverage for her directly with an insurance carrier effective January 1, 2016.


Question: what is the penalty if any for someone who claims more income than they actually achieve? If someone earns a income that qualifies them for Medi-Cal but they inaccurately predict a income that would qualify for a substantial subsidy, then what is the practical outcome of this error? What is the maximum that someone would be penalized for after overstating their income? I doubt that there would be any practical penalty. Prove me wrong.

Answer: In the scenario you describe, you would be liable to repay no more than $300 for the year. The following is a more complete answer to the "clawback" question provided here in October 2013:

The consumer is liable for repayment of any excess tax credit received in the calendar year. However the amount of the "clawback" provision is limited by the household income according to the ACA law. If the household income (expressed as a percent of poverty line) is :

    Less than 200% FPL, the amount of the clawback is limited to one-half of $600
    At least 200% FPL but less than 300% FPL, the amount of the clawback is limited to one-half of $1,500
    At least 300% FPL but less than 400% FPL, the amount of the clawback is limited to one-half of $2,500.

Question: Husband on Medicare. Wife on CovCA. Income forecasts show we will be over the CovCA limit. Want to drop the Blue Shield plan (via Cov CA) and purchase new independent individual plan as wife's employer does not provide insurance. Can we do this? How? When? I assume deductibles won't be carried over (except for another Blue Shield plan maybe?)

Answer: Your question highlights a couple of common misconceptions about Covered California coverage. The fact is that you can keep your Blue Shield coverage through Covered California even though you are no longer eligible for premium assistance. Just change your income with CC so that your subsidy gets turned off. During open enrollment, November 1, 2015 through January 30, 2016, you can drop your CC coverage and apply directly with an insurance carrier, like Blue Shield. However, there is no real benefit in doing so, as the rates and plans are the same when you go directly to the carrier. Additionally, should your income drop again, you would have to reapply with Covered California to get subsidized.


Big Income Change?

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Question: We're a household of 3, husband at 55, wife at 46 & son at 14. My husband is quitting his job by the end of Sept 2015. YTD income at that point is $250K+ but the last quarter will be zero. Because he's starting something on his own, he will have zero income in the coming year or so while starting something from scratch. We probably opt out of using COBRA (too expensive). Here are my questions: 1. Given we have high income for 3/4 of the year but zero for the last 1/4, will we qualify for Cvered CA? If not, any other option? 2. If we can apply for the last 1/4 of the year for Covered CA, will we get premium assistance now that we are at zero income level? 3. For next year 2016, my husband will continue having zero income while I will try to get "part-time" job. Do we need to report any new income in mid-year once I find a part-time job? Basically, how it works when our income change during the year? Thanks for your advise in advance.

Answer: When your employer-based health plan terminates - let's say September 30, 2015 - you can sign up for individual health insurance through Covered California even though you will not be eligible for a subsidy in 2015. Then, sometime before December 15th, you will adjust your household income at Covered California to estimate your 2016 income. If that estimate falls within the premium assistance range ($28K to $80K for a 3-person household), you can receive a subsidy to help pay your premium until your income is once again beyond subsidy range. Your 2016 estimate does not have to be accurate, any excess subsidy you may receive will be returned when you pay your 2016 taxes and vice versa. In this case, you could really use a good agent to help you with the application process and subsequent changes as proper timing is key to maximizing your benefits and avoiding any gaps in coverage, not to mention a potential nightmare of governmental proportions if you do things incorrectly.


Dropping COBRA?

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Question: My wife's company is going to pay the COBRA premium for six months as part of termination agreement which is very expensive. Can I apply for individual coverage once they stop making our COBRA payments?

Answer: You would not be eligible for a Special Enrollment Period simply because your employer stops paying your COBRA premium. However, you can apply for individual coverage either through Covered California or directly with an insurance carrier during open enrollment starting November 1, 2015 through January 30, 2016. As luck would have it, you should be able to take advantage of the former employer's largess for most, if not all of the 6 months before open enrollment closes.


Question: My employer mandates insurance to all employees, however I am already covered by TRICARE when I retired from the military. I don't want my employers insurance and want my health and welfare portion to go into my retirement account. This adds up to over $8,300 a year which I feel I am entitled too. Can you please advise me.

Answer: You can opt-out of your employer-based coverage option in favor of your Tricare coverage, however your employer is under no obligation to pay you the unused premium.


Application for Dependent Only?

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Question: My son recent lost his eligibility for medi-cal Now I need to enroll him in a plan. Can I get him enrolled in a plan without also enrolling me and my husband? When I go to my account, I only get options for family enrollment plans.

Answer: When you enroll through Covered California, you will enter information about your husband and yourself as well as your son and any other household members. Further in the application process, you will indicate that only your son wants coverage. His eligibility for premium assistance is based on your household income.


Question: What will my maximum Out of Pocket expense be for a knee replacement surgery? I am 64 years old. I have Covered CA Blue Shield Silver Level health insurance. My deductible is $5,000.00 I look forward to your answer. thank you.

Answer: You can figure about $6,400, which is the maximum-out-of-pocket expense. Once you have paid out $6,400, your covered medical expenses are 100% paid by the plan. One thing to watch out for is extra charges for durable medical devices. In the case of a knee replacement, you are advised to go home with a device that flexes the repaired knee automatically. Make sure that the device you choose is covered by your plan.


Change Insurance Plan Now?

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Question: I am not happy with my Blue Shield of CA Platinum PPO insurance plan and I want to change to a less expensive plan and/or a different insurance company. I signed up for my plan directly with BlueSheild of CA not through the Covered California website (because it wasn't letting me due to computer glitches). I know you can terminate your plan through Covered California, but I'm not sure how to do it if I'm outside that system? Also, if I'm allowed to terminate my coverage with BlueSheild can I do so outside of the open enrollment period(now), and can I then enroll in some kind of other insurance through covered CA (also outside of open enrollment). Thanks so much for your help!

Answer: If you were to cancel your Blue Shield coverage you would notify Blue Shield (customer service number on your insurance card) since you bought directly from them. But you cannot get replacement coverage until open enrollment, so you are pretty much stuck with what you've got until January 1, 2016.


Question: Is income between 138-150% of FPL is the only condition? Would there be a problem that the person is 68 years old and does not qualify for Medicare? How is the 138% calculated ? Is it based on raw income or after tax income or else?

Answer: If the person in question is not eligible for Medicare at age 68 and has legal status, then this individual is eligible for Covered California coverage. The income calculation is an estimate of 2015 adjusted gross income (AGI) (see line 37 of last 1040 tax form to help estimation). If the estimated AGI is over 138% federal poverty level (FPL) and less than 400% FPL, this individual could be eligible for premium assistance. Whether, he or she can buy coverage now or wait for open enrollment is dependent on other factors.


Question: If my employer offers health ins without hospitalization can I still buy into the market place? I have a new job that gives Health Ins with no Hospitalization coverage. They meet the min requirements because they cover preventive care. But the min value part that covers hospitalization is not covered. You can purchase the plan and will not have to pay the penalty for not having insurance because they cover preventive care. But my concern is I will not be able to purchase health care on the market place because I am offered this by my employer.

Answer: Apparently, your employer has a limited-benefit minimum essential coverage (MEC) employer-based health plan - a loophole to avoid penalties for not offering required health insurance - and it protects you the employee from individual mandate penalties. However, you are still eligible for enrollment in Covered California and you may qualify for premium assistance if you meet residence and income guidelines. If you enroll in Covered California, your employer may be fined $3,000.


Question: If employer drops health insurance when can you apply for covered California?

Answer: The law says that you have a 60 days from the date your employer-based coverageends to apply for individual health insurance coverage. In order to avoid a gap in coverage, you can apply for Covered California coverage up to 45 days prior to the date your employer-based coverage ends. For example, if your coverage were to end July 30th, you could apply as early as June 16th for an August 1st effective date.


Insuring My 19 Year-old?

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Question: My daughter is 19, a full time student, and lives at home. Do I have to cover her under my plan at work, or can she apply for covered California on her own? Thank you.

Answer: Yes, you are generally required to cover your dependents with your employer-based coverage. There are alternatives for some people: (1) If your household income is low enough (for example, less than $42,000/year for a two-person household), your children would be eligible for Medi-Cal and she can enroll without considering the availability of group coverage through your work. (2) She can also waive coverage on your group plan and enroll in a Covered California, but that would be without premium assistance. (3) Student health plans are viewed as minimum acceptable coverage by the ACA so that could work too.


Question: My wife recently learned that her employer will be offering coverage for her (50% employer contribution) and spouse coverage with no subsidy. It is a Silver plan and the premiums are going to be higher than if I just stayed with my Bronze plan on the exchange. We do not receive any premium assistance. Am I allowed under ACA to keep my Bronze plan through the Exchange, or do I have to accept the employer-offered spouse coverage Silver plan the my wife's employer?

Answer: It is your responsibility to notify Covered California that your spouse has been offered employer-based health insurance. However, since you are not receiving premium assistance, there is no penalty for not reporting the change. You can remove your wife from your Covered California plan and continue on your own, if that works better for you. Know that you will be ineligible for premium assistance through Covered California, regardless of your household income, as long as your spouse is offered employer-based health insurance.


Question: I Just received a corrected Form 1095-A from Covered California with the result that I received too much subsidy in 2014. What do I do now? Do I have to refile my tax return?

Answer: No. You don’t have to file an amended return for 2014. The IRS says you don’t need to do anything if you already filed your 2014 tax return. Covered California says that this corrected Form 1095-A is “only for your own records”.


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?

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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?

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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.


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.


Sign-up an Unborn Infant?

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Question: My independent 24 yr old daughter has Anthem insurance coverage through her father's workplace (Univ. of So Cal). My daughter is low income and it was our plan to enroll the infant in Medi-Cal through CC. We were under the impression that the infant would be covered by my daughter's plan for the first 30 days. Marin General, the hospital where her doctor delivers, has contacted her to let her know that because she is not the policy holder, the infant has no coverage at birth. They let her know that the infant will incur charges from the minute she is delivered and advised her to get coverage. We can't figure out how to sign up just the baby before birth without a social security number.

Answer: You can't get Medi-Cal coverage for the newborn infant until after the child is born, but the baby's coverage will take effect retroactively to the date of birth. That means Medi-Cal will cover all of the newborn's expenses. Once the baby is born, the mother must apply on behalf of the baby using the Covered California online application even though you know the baby will be eligible for Medi-Cal.


Married Filing Separatey?

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Question: I filed married filing jointly in 2013. My husband moved out after Christmas 2013, & we have been separated. I qualified for assistance using our joint return 2013 for CoveredCA assistance for 2014. We filed married filing separately for 2014. I was accepted for coverage for 2014, but what will happen now? Will I still be covered? My income for 2015 will be less, as it was in 2014, but I am being given a penalty due to filing separately for 2014.

Answer: Had you listed your tax filing status as "married filing separately​" on your Covered California application, you would not have been eligible for a subsidy. So it seems to me that you have disqualified yourself from the advance premium tax credits you received in 2014. If so, you are still covered and your premium assistance will continue until you notify CC of your tax status change. In order to continue getting premium assistance (assuming you still qualify based on income) you will have to change your tax status to single or married filing jointly.


Question: If you have already been getting the credit, is the 4/15 2014 tax filing deadline firm that covered ca makes you agree to, or is an extension allowed until 10/15/15? what is the final consensus? thanks

Answer: You must pay your 2014 taxes by 4/15/15 along with your application for an extension. In other words, even though you are filing for an extension, you still have to pay your taxes on April 15th.


APTC over 65?

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Question: Can a person over 65 receive APTC?

Answer: Usually not, because most Californians over age 65 are covered by Medicare wich is considered Minimum Essential Coverage (MEC). Applicants who are eligible for MEC are not eligible for financial assistance unless they fall in this exception: If an applicant is eligible for Medicare part A coverage requiring payment of premiums, but is NOT enrolled in the program at the same time he or she enrolls in a Covered California plan (i.e., no dual coverage) will be eligible for financial assistance.


Address Change?

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Question: If I changed my address with Blue Shield and at my doctor’s office, will that the change also be updated at Covered California?

Answer: No. You must change your address in Covered California account. If you don’t, you may not receive correspondence from Covered California - IRS Form 1095-A, important notices, renewal information, etc.


Paying Back The Subsidy?

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Question: I enrolled in Covered CA and opted to take all of the subsidy now rather than at tax filing time. Starting April, I will have a new job that provides insurance. When I file taxes next year, my income will be too high to receive a subsidy. Will I have to make up the difference for the full premium for the 3 months of Covered CA insurance?

Answer: Yes, you will pay, but not that way. The subsidy paid to you in 2015 will be taxed as income based on the scenario you described.


Question: If I enrolled in Covered California and received a premium subsidy, but recently got a new job with an employer whose coverage meets the requirements for affordable care, can I keep my Covered California insurance?

Answer: No. You are no longer eligible for Covered California coverage because you have been offered employer-based coverage. You need to notify Covered California to cancel your coverage to coincide with the start of your group coverage.


IRA Distributions as Income?

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Question: I am going off my work insurance at the end of the month and am on Cal SDI from an injury as my only current income. Should I withdraw at least $16100 from my IRA to qualify for Covered California? I do not qualify for Medical. I anticipate my AGI to be about $20,000 this year, including IRA withdrawals. Is it OK to withdraw it as a lump sum and is it OK to convert to ROTH?

Answer: Yes. If you withdraw money from your IRA it as taxed as income. That income will be included in your AGI. At $20k, for a one-person household, you will be eligible for Silver 87 coverage and cost-sharing reductions. Using some of that IRA income to fund a Roth IRA would be very smart if you don't need the money otherwise.


Question: I own a company with 9 employees. They buy their own coverage through Obamacare. I started an HRA (Health Reimbursement Arrangement) four years ago to reimburse them for their out of pocket expenses, including their net premiums. Now i’m hearing that you can’t do that anymore. What’s the truth?

Answer: What you are describing is referred to a standalone HRA - designed to work with individual insurance coverage. The IRS says, a standalone HRA cannot be used to reimburse employee premiums. The most recent guidance from the IRS - IRS Notice 2015-17.pdf provides additional clarity, but it provides no wiggle room for to those software vendors or third party administrators (think Zane Benefits) who continue to imagine ways to get around the standalone HRA rules. Employers with standalone HRAs have been giver until June 30, 2015 to get rid of them. Only HRA plans that are attached to a conforming group plan can be used going forward. Agents and brokers need to be very careful that they aren’t the ones left accountable for bad advice.


Question: Does an employer document that spouses are excluded, may not enroll in group health plan, through the ERISA documents?

Answer: The group health insurance agreement between the employer and the insurance company providing the coverage typically does not give the employer the option NOT to offer to insure spouses and dependent children or to put it another way - to offer "employee only" coverage. In California, the only 2 exceptions currently are SHOP and Kaiser Permanente.


Question: My husband has employer group benefits offered to employee and family. However, his open enrollment period was Jan and we missed the cutoff to enroll family. Am I and my children eligible for tax credits?

Answer: No. You were offered group health insurance by your employer, making you ineligible for tax credits. Whether you deliberately opted-out or forgot to enroll in your group plan does not matter.


Medi-Cal Renewal Form?

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Question: The Medi-Cal renewal form says "every member of your household who is living with you or is listed on your tax return". I am married filing separately (for a few years now) and qualified for medi-cal for myself and 2 kids last year through Covered California. At that time i was not living with my husband. My questions is should i list my husband or not? We live with him now, but file taxes separately and do not have medi-cal with him.

Answer: Yes. His income is now a factor in your mutual eligibility, so if your household income is above $33k for 4-person household you and your spouse are no longer eligible for Medi-Cal and now eligible for Covered California coverage. But since you file taxes as "married filing separately", you are not eligible for premium assistance.


Question: We are a family of 4 however my daughter, age 23,who I covered under the Covered California family plan. She files her own taxes. Do I have to claim her and her income on my taxes?

Answer: No. If your 23 yr-old daughter files her own federal income taxes in 2015, she cannot be included as part of your household for CC eligibility. If she files fed income taxes for 2014 and you included her in your 2014 Covered California coverage, there is no penalty. However, you probably received excess advanced premium tax credits in 2014 which will be reconciled when you file your 2014 return. As for 2015, you have to remove her from your Covered California account and she needs to create a CC account of her own. She will be eligible for either Covered California coverage or MediCal based on her own income.


Question: My mother came in May 2013. Up to today, she has lived in the U.S. for 1.5 years. She just got her green card couple weeks ago. Can she qualify for Medicare as she never works in US or lives in US for 5 years? If she can't qualify for Medicare, can she get any healthcare plan with good medical coverage (> $1million)

Answer: Yes. You can enroll your 80-year-old mother in health insurance through Covered California even though she never worked in the US as long as she has legal residency in California. In fact, the only way to get her covered right now is through Covered Ca. She may be eligible for premium assistance otherwise the monthly cost will be pretty high as she will pay the monthly rate of a 64-year-old, the highest rate. Mom will be eligible for Medicare in 3.5 years, so she can use the Covered California coverage in the meantime. Longer term, she should apply for Medicare as soon as possible. Start at medicare.gov. She will have to pay for Medicare and cancel her Covered california coverage at that time.


Replace COBRA Now or Later?

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Question: If my COBRA coverage ends in July, do I have to enroll now or may I enroll in July?

Answer: You can enroll in Covered California by 2/15/15 and drop your COBRA effective 3/1/15 if it is advantageous for you. Otherwise, you can keep your COBRA coverage until it expires and apply for Covered California coverage then as you will be eligible for a special enrollment period at that time..


Kids in Medi-Cal Automatically?

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Question: I was told that if I have Covered CA health plan, my child is automatically enrolled in Medi-Cal. Is that true?

Answer: Not necessarily. It depends on the family income. If the household income is over 138% Federal Poverty Level (FPL) (approx. $33K for family of 4), but below 265% FPL (approx. $63K for family of 4), the children age 18 and younger are automatically enrolled in Medi-Cal. If the income is below 139% FPL, the parents are eligible for Medi-Cal as well. With income above 265% (and less than 400%) FPL, both the adults and children are eligible for Covered California coverage with premium assistance. If you or your children are eligible for Medi-Cal you can choose not to enroll, but you will not receive premium assistance.


Question: When I initially applied for Obamacare through Covered California is was found eligible for Medi-Cal. Three weeks passed before I could correct the income figures in my application. At that time I was approved for Anthem coverage with premium assistance through Covered California which I recently removed. Now, over a year later, Medi-Cal started sending me enrollment questions. They still think I’m enrolling in MediCal! How do I put a stop to this?

Answer: According to, Cathy Senderling-McDonald, Deputy Executive Director of the County Welfare Directors Association of California, county eligibility workers are unable to delete duplicate applications or remove applications upon a consumer’s request. Senderling-McDonald said, “Our county eligibility workers need to be able to tell the system, ‘This person is not eligible,’ or, ‘We need to withdraw this application,’” adding, “The computer can start that process, but our workers can’t and that was a huge oversight in the programming.” So I suggest trying to get your Medi-Cal enrollment cancelled by calling Covered California at 800-300-1506 and ask them to cancel the enrollment from their end.


Question: Hi, I want to download my 1095-A as a PDF. I don't want to have to chase down the paper copy. Is it available online? Please make it easy and obvious to find once I log in.

Answer: The Form 1095-A's have already been posted online. You will have to login to your Covered California online account. You may find the form in your Secure Mailbox (iffy) or more reliably on your Documents and Correspondence page. To get there, click on the Summary checkbox on the home screen and next click the Documents and Correspondence link, select and download the 1095-A document as PDF.


Question: Will an immigration sponsor be responsible for Medi-Cal bills of the immigrant who is holding a permanent green card?

Answer: No. To our knowledge, no government agency in California has sought reimbursement from a sponsor up to now.


Debt Cancellation Distorts AGI?

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Question: In 2013 and 2014 we had a debt cancellation (credit card settlements) since we were in financial hardship and weren't able to pay the credit card payments. We settled with creditors and paid off our debt but creditors have sent us 1099C forms and the amounts of cancelled debts were added to our income in 2013 and will be added in 2014 as well. This has raised our AGI tremendously for both years. Based on our actual income ,we are qualified but considering this phantom income (cancelled debt) seems like we won't be able to qualify. What do you suggest we should do? we need to send the 2013 tax return as proof of income. Can we to deduct the amount of 1099Cs from our AGI and report that amount? Please advise.

Answer: In addition to submitting a copy of your 2013 federal income tax return, you will want to explain to Covered California that your 2013 Income Tax form includes an exceptional one-time lump-sum credit which distorts your adjusted gross income (AGI). Download a free online affidavit form and use it to explain your debt cancellation issue. Otherwise, I would leave your Covered California account as it is for now.


Final Version of Form 8962?

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Question: Phil, you posted a draft version of the IRS Form 8962 a while back. Do you have a download for the final version?

Answer: Yes. Download IRS Form 8962.

When you file your federal taxes, you or your tax preparer will use the information on Form 1095-A to complete IRS Form 8962. You will use Form 8962 to tell the IRS how much premium assistance was paid to your health plan on your behalf in 2014. Using the form you will:

  1. Calculate the total amount of premium tax credit that you are allowed to claim based on your coverage, income and family size.
  2. Compare the amount of premium assistance that was paid in advance on your behalf to the premium tax credit.
  3. Determine the amount by which the premium tax credit exceeds the amount of premium assistance received, if any. And, claim it as the net premium tax credit on your federal income tax return.
  4. Determine the amount by which your premium assistance received exceeds your premium tax credit, if any, and report it on your federal income tax return. You will have to repay some or all of this excess amount.

How to Get IRS Form 1095-A?

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Question: How do I get my 1095A form?

Answer: You don’t need to do anything. Covered California will mail the IRS Form 1095-A to all consumers who got insurance through Covered California in 2014. They also send a copy to the IRS. The Form 1095-A has the information you or your tax preparer will need to file your tax returns. This form has information you gave about your family. The form also tells you:

  • How many months you had health insurance
  • How much you paid in monthly premiums
  • How much premium assistance was paid to your health plan on your behalf (if any)
  • Who was enrolled in your health plan

Unemployed Adult Child?

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Question: Adult non-disabled dependent is long-term unemployed. Parents are retired, on Medicare and income over $100,000. Is the dependent eligible for Medi-Cal if the parents do not claim the adult as a dependent on 2014 tax return?

Answer: Yes. In this case, the parent's income is not a factor in the Medi-Cal eligibility determination. The unemployed adult-child is not a dependent for tax purposes, so he or she is considered a single-person household with no income for Medi-Cal eligibility determination.


Question: I currently have private health insurance. I am looking at my options if I retire in 2015. My retirement AGI would be low enough to qualify for a subsidy under Covered Ca, and this may reduce my premiums by more than 50%. If I understand correctly, a low enough AGI might make me ineligible for this subsidy since I would qualify for Medi-Cal. Is this correct? What are the AGI thresholds for a single person in 2015? There seem to be many retirees in this same situation. They can afford to pay the subsidized plans, and they would rather not switch to Medi-Cal since it may not be accepted by their current doctor. Their options seem to be to either pay the full cost plan, or switch to Medi-Cal. Your thoughts?

Answer: Since many retirees can control their income through investment withdrawals etc, it make sense to know what the Medi-Cal income benchmark is. The Medi-Cal threshold is set at $138% of Federal Poverty Level (FPL). In 2015, that's $16,105.


Group Insurance or Medi-Cal?

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Question: I have a family of 4 with gross income of $28k. My employer offers me affordable insurance for myself but no contributions to my dependents. Can I and my family go on Medi-Cal? Joe

Answer: Medi-Cal eligibility rules do not conform to the ACA and IRS guidelines regarding access to affordable employer-based coverage. Your $28k income for a 4-person household makes you and your dependents eligible for Medi-Cal. You may opt out of your employer-sponsored coverage and apply for Medi-Cal.


Question: I will become Medicare eligible 7/1/2015 and elect a Medicare Supplement or Adv plan. My wife has another year before Medicare Eligibilty. When/how should I notify CovCA and /or Blue Shield that I am going off but wife needs to stay on plan. I have heard of others who had both spouses cancelled and huge headache to get straightened out. Do not need that hastle! Thanks.

Answer: You will need to cancel your Covered California coverage by June 15, 2015. You can remove yourself from coverage, leaving your spouse's coverage unchanged, through your Covered California online account. If you are not comfortable with the online method, your agent can handle it for you or you can call Covered California at 800-300-1506.


VA vs Employer Coverage?

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Question: I have had no medical insurance for 2014 except for how I am covered at the VA. The job I have for 2015 now offers insurance. Will I be penalized for using the VA and not acquiring CC insurance for 2014?

Answer: VA health coverage is recognized by the ACA aa meeting the "minimum acceptable coverage" requirement, so you are not subject to penalty if you opt out of your employer-based coverage. If you take the employer's coverage and keep the VA coverage, your benefits will be coordinated with the employer coverage used first and the VA covering the gaps.


Medi-Cal Managed Care Options ?

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Question: Hi, I received a Medi-cal card, but no information on where to go, who to see!! It has been weeks, not sure who to contact. I had Kaiser prior which my parents were paying but it became too expensive. I would like to continue with Kaiser since i already have MDs there I am comfortable with. Is this a possibility?

Answer: When you first qualify for Medi-Cal, you are covered under Medi-Cal Fee-for-Service. However, you must choose a managed-care health plan within 30 days. Managed-care plans like Health Net or Anthem come with their own provider networks. What that means to you is you don't have to struggle trying to find doctors that are accepting Medi-Cal patients. If you do not choose a plan within 30 days, the State will choose a plan for you. The county in which you live will determine your choice of Medi-Cal managed-care plans. For example, if you live in Los Angeles county you can choose between LA Care or Health Net while next door in Orange County you have one choice - CalOptima. Click here for a list of Medi-Cal managed care plans available in your county. If you find only one health plan, the county has chosen this plan for you. Please wait for your health plan information mailer in the mail. If you find multiple health plans listed, please explore each plan and choose the one that suits you and your family's needs. Remember, if you do not pick a plan within 30 days of receiving your health plan information mailer, Medi-Cal will pick a plan for you. However, you may also choose to stay in Fee-For-Service Medi-Cal.


Should Have Been on Medi-Cal?

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Question: I had a six figure income in 2013 and a 2 thousand dollar income in 2014. I work freelance and some years are very dry. I projected $29,000 in income when I applied for Covered CA. It didn't happen, but I left it as is because I thought one of the jobs would come through. So, I guess I should have been on Medi-Cal, though. What do I do now? And, will there be an issue since I received premium assistance in 2014? Thank you.


Answer: You are obligated to notify Covered California of your change of income which would make you eligible for Medi-Cal, but there is no penalty for not doing so. If your 2014 income was under 100% FPL ($11,670), any excess tax due to over-payment of advance premium tax credit is limited to $0 for the year. For 1-person househol with income over 100%FPL but less than 200% FPL ($23,400), any excess tax due to over-payment of advance premium tax credit is limited to $300 for the year. Any cost-sharing reductions received through Covered California during the year are not recoverable. Covered California will receive your 2014 tax return data in the summer of 2015 and at some point after that, CC will require you to verify your claimed income if your 2014 AGI was more than 10% higher or lower the income you claimed.


Switching from Cobra?

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Question: If I end my health insurance with Cobra on 1/31/15 because it is to expensive and sign up for Covered CA when will the insurance start?

Answer: If you apply through Covered California by January 15th, your new coverage will be effective on February 1st, 2015.


Can I Get Private Insurance Subsidy?

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Answer: I am fortunate to live with a daughter who has paid for my entire monthly insurance plan out of her pocket (she didn't claim me as dependent, so she also doesn't get any tax credit). For upcoming 2015 year, we feel that it is putting a lot of strain for her to pay close to $9000. Though Medical is an option for me, we both would prefer to stay with private insurance. I don't have any income. I live with my daughter who provides me with everything. If I can get CC subsidy, I wouldn't mind filing a tax return. My question is: is there any way I can go through CC and opt out of medical? My daughter is willing to pay me for housework, etc. Wondering if that's something I can report to IRS, thus I can become eligible for CC subsidized plans.

Answer: You are eligible for Medi-Cal, but you don't have to take it. You can choose private coverage instead, but will not be eligible for a subsidy. Your daughter can pay you a salary, but you would have to earn over $16,500 per year for you to qualify for a subsidized private coverage rather than Medi-Cal.


Change Plans after Dec 15th?

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Question: Can I switch plans in 2015 if I decide to do so?

Answer: Yes. The open enrollment period ends February 15, 2015. You can make changes until that date.


How Long Does it Take?

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Question: I signed up with KP and made the initial payment on CC over the weekend. I called KP today and it said it does not have the application nor the payment yet and may take 4 weeks for the info to show up in its system. Does it really take that long?

Answer: No. This business of putting you off for 4 weeks is just lazy or incompetent, probably both. Call Covered California and confirm that your enrollment is correct in their system. When it is, ask them to resend the enrollment to Kaiser and get an incident number from CC. Wait a couple of days and call Kaiser back with the incident number. If you get the 4-week BS again, demand to speak to a supervisor.


Deadline Extension?

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Question: Does the recent extension for enrollment by Dec 21st ( vs Dec 15th) for 1/1/15 effective dates apply only to applications already started by Dec 15th? Or can agents/CIAs assist any New Individuals with applications/enrollments by then?

Answer: Covered California has extended the deadline for January 1, effective date to midnight Sunday, December 21 for all applicants, agents and consumers.


Children Forced into Medi-Cal?

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Question: Why am I only being given the option for Medi-Cal for my children (age 5) on our CoveredCa application? We want them on our chosen plan (a Blue Shield PPO) but Covered Ca is not allowing that option. Our income is far above the Medi-cal limits for a family of 4.

Answer: For a 3-person household, your income would have to be $50,000 or more for the children to be eligible for subsidized private insurance while it only has to be $20,000 or more for the adults to be eligible. Why is that? It's a lot cheaper to cover people on Medi-Cal than to subsidize them with private insurance. Ultimately, it costs the taxpayers less and reduces the overall cost of healthcare.


Find Providers for Anthem Blue Cross?

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Question: How do I find providers for anthem blue cross under covered california?

Answer: To view a list of in-network doctors for your Anthem individual health plan:

1. Go to www.anthem.com/ca.
2. Under Useful Tools on the right, select Find a Doctor.
3. Under Search by selecting a plan/network, go to Select a state.
You can enter the name of your state or select it from the
drop-down list.
4.Under Select a plan/network, you can enter the name of your
plan/network or select it from the drop-down list then choose
Select and Continue.
5. Using the drop-down boxes, select what type of doctor and the
location you're looking for, then select Search.
6. For more info about a provider (like skills and training), just select
that name in the directory.


Question: CC qualification is based on income only while Medi-Cal is based on both income and assets. So if a person with no income but has more than $2,000 in the bank would not qualify for neither CC nor Medi-cal?

Answer: No. Qualifying for Medi-Cal no longer considers assets if one applies through the Covered California. So, no, a "low-income" applicant cannot be found ineligible for both. On the other hand, if one applies for Medi-Cal directly through the DHCS, assets are still considered. Go figure!


Question: If an employer offers “affordable” coverage for the employee, but the family cannot afford the dependent coverage and the family income is below the Medi-Cal eligibility threshold, is the family still eligible for Medi-Cal? Is the employee disqualified from Medi-Cal by the “affordable” employer plan? If so, are the wife and kids eligible for Medi-Cal?

Answer: Under the ACA, qualification for Medi-Cal is completely separate from subsidy-eligibility rules. Employees, will not be disqualified from Medi-Cal if their employer provides benefits, whether or not those benefits meet affordability guidelines. (This answer was provided by expert agent, Anne Kelley.)


Reporting Border-Line Income?

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Question: My income puts me on the border line of me getting premium assistance or Medi-Cal. It fluctuates greatly from month to month. Would I get switch back and forth between CoveredCA and Medi-Cal?

Answer: If you estimate your income for 2015 to eligible for Covered California premium assistance, you will not be switched to Medi-Cal during the year unless you notify Covered California that your income makes you eligible for Medi-Cal. Conversely, if you start the year in Medi-Cal, you won't be switched to CC unless you report higher income to Covered California.


How to Send Verification Documents?

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Question: Where do I send covered ca requested verification documents?

Answer: Send your documents in one of these three ways:
• Online using your account at www.CoveredCA.com
• By fax to 1-888-329-3700 (1-888-FAX-3700)
• By mail to:

Covered California
PO BOX 989725
West Sacramento, CA 95798-9725


Do You Need Financial Assistance?

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Question: One of the first questions asked in Cover California website is that "Do you need financial assistance?". If I answer "no" for now and it turns out that I'm qualify for assistance when I do my 2015 tax a year from now. Would I still be able to get premium tax credit?

Answer: Yes. If you answer no th the question, "Do You Need Financial Assistance?", your Covered California account still include your tax information and you will be able to claim a tax credit later. However, if you enroll off-exchange, you cannot later claim tax credits.


Current or Future Income?

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Question: I'm 24 and living in my parents' home. I'm currently unemployed (since Nov '14) and have $0 current income. I will be starting a contractor position in January. Should I keep my current $0 income and make changes later or must my current application somehow reflect changes that will come about in 2015?

Answer: In estimating your 2015 income, you would be more accurate to use your income from the contractor position as if it would continue for the year. You can change your income later, if you have a significant income change one way or the other.


A Bird in the Hand?

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Question: My income fluctuate from month to month. I prefer to pay the premium first then get the premium in tax credit, if any, in one lump sum after I do my tax for 2015. Can I do that? If so, what happens to the case if my AGI qualifies me for medi-cal? Would I still be able to get any tax credit in that case?

Answer: Yes you can opt to take your tax credit at the end of the year. However, if your income makes you eligible for Medi-Cal you will receive no tax credit. On the other hand, should you take your tax credit as an advance and later be found eligible for Medi-Cal, your income tax liability will be much lower than the tax credits you received and your payback will be limited to a fraction of what you got. I'm not recommending gaming the system, but at least for now, that is the way it is.


Tax Credit Reconciliation Forms?

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Question: Where on the tax form is the Covered California premium reduction reconciliation done? As I was going through my taxes on TurboTax, it told me that based on my income, I was not eligible for the full premium reduction that I received, which means I owe some of that back. I can't see this reconciliation anywhere on the summary of my tax return. Where does this appear and where can I see how much I owe?

Answer: There are 2 IRS tax forms that you are going to need. First, IRS Form 1095A (draft version of form here) is issued by Covered California to every household eligible for a subsidy in 2014. It will be sent to you by 1/31/2015. It documents your coverage by month including premiums paid and advance premium tax credits received in 2014. Then, you will use IRS Form 8962 (draft version of form here) to reconcile 2014 federal income tax due with advance tax credits received.


Adult Child in Household?

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Question; My daughter is 26 and will be needing her own insurance. She lives at home but files her own income tax and is not claimed on ours. Does she apply as a household of 1 or do all household members have to be put on her application.

Answer: Yes. If your adult child files a tax return, she would apply for coverage through Covered California as a one-person household. Her income alone will determine her eligibility for premium assistance or Medi-Cal.


No Way We Qualify for Medi-Cal?

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Question: Our stated family income for a family of 5 was $80k for 2015 yet they sent us a letter that we all qualify for medi-cal. Letter says we can appeal but I see no way to do it on their website and cannot get through on the phones. Can't read secure mailbox due to some java issue. Advice?

Answer: If you already have Covered California coverage and your status was recently changed to Medi-Cal eligible, it's because the IRS has reported that your 2013 AGI was $38,000 or less. So if you can show that your current income is closer to $80,000, then you will be able to to get your status changed back to subsidy eligible private coverage. If you are applying for for Covered California coverage the first time and you reported your income at $80K and are found eligible for Medi-Cal, you've probably made an error on the application. The most common cause for this error is by entering an incorrect "end date" when entering your income. LEAVE THE END DATE BLANK. (How a casual user would know to do this is beyond me as we only learned through trial and error.) As for how to get through to Covered California, I have no sure-fire advice other than to avoid the busiest times - normal business hours. Try calling just after 8:00 AM or just before 8:00 PM. Good luck.


Question: Can a Self Employed person continue to deduct INDIVIDUAL Medical Insurance Premiums in 2014? Does it matter if they got their coverage ON or OFF the exchange?

Answer: Yes. If you are self-employed, a tax deduction generally available for medical (on-exchange or off-exchange), dental or long-term care insurance premiums for yourself, your spouse and your dependents. (The insurance can also cover your child who was under age 27 at the end of 2014, even if the child was not your dependent.) You must have a net profit from self-employment. You would report this on a Schedule C, Profit or Loss From Business, Schedule C-EZ, Net Profit From Business, or Schedule F, Profit or Loss From Farming. You had self-employment earnings as a partner reported to you on Schedule K-1 (Form 1065), Partner's Share of Income, Deductions, Credits, etc. You were paid wages reported on Form W-2, Wage and Tax Statement, as a shareholder who owns more than two percent of the outstanding stock of an S corporation.


Preventative Care?

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Question: What is a preventative care appointment include? Labs, Pelvic Exams, Office visit?

Answer: All ACA-compliant health plans and must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. (This applies only when these services are delivered by a network provider.) 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 8. Diabetes (Type 2) screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. HIV screening for everyone ages 15 to 65, and other ages at increased risk 11. Immunization vaccines for adults—doses, recommended ages, and recommended populations vary 12. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 13. Syphilis screening for all adults at higher risk 14. Tobacco Use screening for all adults and cessation interventions for tobacco users


Newborn Coverage Gap?

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Question: I am currently pregnant and have Blue Shield Silver 87. Based on my family income, newborn will be placed to Medi-Cal. I am worried that newborn's cost of staying/treatment in the hospital will not be covered by Blue Shield since the doctors and hospitals are not Medi-Cal network. Do you know if they have exception for this case and cover newborn? Truly appreciate your answer.

Answer: Your Blue Shield policy will cover your newborn's medical costs automatically up to 31 days after birth. You should apply through Covered California as soon as possible after giving birth and if your infant is Medi-Cal eligible, his or her coverage will be effective immediately. In any case, you should not experience any gap in coverage for your child.


Adult Dependent Coverage Options?

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Question: I need to know if I am required to put my 21 year old son on my employer insurance now? He does not work and would qualify for Medi-Cal. Also, if I claim him as a dependant does that factor into if I must add him?

Answer: Your son can opt out of your group health insurance plan and enroll in Medi-Cal even though he has been offered affordable, minimum-standard value health insurance through your employer if you do not claim him as a dependent in 2015. If you do claim him, his eligibility for Medi-Cal (or subsidized private insurance) will depend on your household income, not his.


Question: My adult daughter is 24 and single. She is no longer our dependent for tax purposes. Due to the ACA, she continues to have insurance through her father's plan through USC until age 26. She is expecting a child in April 2014. Will the child be covered? And will the child continue be covered until our daughter turns 26?

Answer: No. Your newborn grandchild will not be eligible for coverage under your husband's employer-sponsored plan. Your daughter must complete a Covered California application for herself right after the child is born, indicating that she has "been offered affordable, minimum standard value health insurance" and that only the baby will be enrolling. Depending on your daughter's income, her newborn child may be eligible for Medi-Cal or subsidized Covered California coverage.


Help Select a Plan?

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Question: I need to find live person to help me select a plan.

Answer: Go to www.Coveredca.com, click on the Get Help menu, then Find Local Help, then Find a Certified Insurance Agent, then enter your ZIP code. Call one of those agents and you'll get the help you need. By law, only a Certified Insurance Agent is allowed to give you advice on selecting a plan, all other "helpers" can only get you to that point, but cannot advise.


Question: My husband is insured through his employer here in California. There is a very small staff (under 10). I have not been offered health coverage, for my husband says that the employer is not obligated to offer it to me, or our son. Is this true? I have read conflicting items online. Thank you.

Answer: It is virtually certain that your husband's employer-sponsored small group coverage includes coverage for dependents even though you may find it unaffordable because the employer is not required to make any contribution toward dependent coverage. That means you have "access" to small group coverage and are probably ineligible for premium assistance and cost-sharing reductions through Covered California. However, if you cannot enroll in your husband's plan now due to being outside the plan's open enrollment period, I see no reason that you can't enroll in CC with premium assistance until you can be added to his employer's plan at the next plan renewal.

Currently in California, SHOP and Cal Choice are the only sources that allow groups to offer coverage to employees without including dependents. Your husband's employer should consider changing coverage to SHOP or Cal Choice and elect "employee-only" coverage. That will free all the dependents to eligibility for premium assistance and cost-sharing reductions through Covered California. If the employer goes with SHOP, the company may be eligible for small group tax credits as well. Employers should contact their broker for more information.


How to Pay Now?

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Question: I just signed up through covered CA for Anthem Blue Cross policy. I tried to make a payment on site but got nowhere. Now what?

Answer: Log in to your Covered California account, go to the summary page and select the "Pay Now" button at the bottom of the page. If you can't do it, let your agent know. He or she can take your payment over the phone.


Question: After having so many problems with Blue Shield through CovCA, I have decided to just go direct with BS during open enrollment for 1/1/2015. Can I just apply directly to BS now and when confirmed I have coverage starting 1/1/15- terminate participation in CovCA/BS eff 12/31/14?

Answer: Yes, you can do that, but the carriers are not immune from screw-ups themselves. The safest way not to create problems for yourself is to do nothing. That way your coverage will renew without changes.


When One Applicant is Over 65?

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Question: I looked at rates for a 2 person household- age 67 and 63. Plan quotes seem to reflect both being covered although the 67 year old , while part of the household for premium subsidy amount, has Medicare and not eligible! Perhaps it would be settled out in application process but meanwhile quite shocking to see the huge rate for 1 person.

Answer: I will assume that you are referring to the "Shop and Compare" tool at the Coveredca.com site. I'll also assume that your 67 year-old spouse is on Medicare. In that case, he or she is not enrolling in Covered California. The online tool has a checkbox that should be left unchecked for the 67 year-old. The silver plan rate for a 63 year old should be about $700/mo unsubsidized. If the older spouse is ineligible for Medical and must enroll in Covered California coverage also, then the premium for the 2 of you will be about $1500/mo unsubsidized.


Question: I'm getting significantly different results when using the Shop & Compare tool versus logging in and using the Preview Health Plans tool. I put in identical data (zip, age, income), and get different premium assistance values from each tool. For example, the Shop & Compare tool gives me a final monthly amount of $80 for a plan I'm interested in (after premium assistance), whereas the Preview Health Plans tool gives me a total of only $17.54. Which number is likely to be correct?

Answer: I don't have a definite answer, but the net premium result you get in the plan selection step of your online application would appear to be the correct number as CC provides a confirmation of coverage and premium at the end of the process. Ideally, they should be identical, but that may not be practical at this point.


Add Dependent for 2014?

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Question: My daughter has her own CC policy in 2014 but I want to include her with mine for 2015 as we will be filing taxes together. A cannot find any way to add a dependent using the CC website. Any suggestions on how I would add her as a dependent?

Answer: Now that open enrollment has started, you can make the change yourself. If you know your username and password, you can use the "Account Sign-In" link (click image to enlarge) Sign-In.png. Once in your CC account, click on the "Renew" button. You will have to verify your identity by uploading a copy of your ID (license etc.) and then you can add a family member.


Non Tax-Filer Refund?

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Question: I overestimated my income for 2014. I do not pay any taxes, so I cannot get a tax credit. A Covered CA rep said I would get a refund check in the mail for the amount I over-paid on my insurance premiums. Is this correct?

Answer: No. If you do not file a tax return for the 2014 tax year, you are not eligible for a tax credit. If you should decide to file taxes, the tax credits based on your income will be reconciled on your tax return. You will pay less tax, but there will not be a refund check.


College Tuition Deduction?

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Question: I find the area of tuition with regard to CC to be confusing. The paper application identifies tuition and fees as a deduction from income. In looking at drafts of tax forms like 1040, 8962 and 1095A, I don't see how this will work. The tuition deduction has been removed from 1040 and I have not seen anyplace where tuition will affect income as it relates to CC. Thinking it should be deducted as the forms continue to have that as a deduction from estimated income. Would you have any insight into how tuition will be deducted from income for purposes and can you confirm that it would be deductible?

Answer: According to IRS Tax Publication 970, you can reduce your income subject to tax by up to $4,000 per year. This would apply to Covered California subsidy eligibility as well.


Spouse Eligible for COBRA?

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Question: I will be retiring at age 66 in February but will need to work part time as a self employed freelance electrical estimator. I will have Medicare, but my wife is only 63 years of age. The question is can she pick up the cobra plan for the spouse thru my company even though I will be retired and self employed.

Answer: (Corrects previous response) Yes. Your wife is eligible for COBRA continuation. She can also purchase individual health insurance any time after December 15th for coverage effective February 1st 2015.


Still Too Many Bugs?

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Question: I've been trying to submit an income verification via the website for the last week. Every time I try to do so, I get an error message. I just trying calling CoveredCA, and got a message that said their call volume is greater than normal, goodbye. So all this time, and they still haven't gotten the basics working yet? Anyway, my question is, should I wait until the fix uploading verification on the website, or mail or fax it in? Last year I was never sure which method to trust.

Answer: I would trust the online upload above fax or mail. If it doesn't work, wait until after 11/15/14 to try again. Let's review the online upload process, just in case it's not a bug. (1) Access your CC account and click on the "Eligibility" check-mark. (2) you will see the name(s) of each person in the household and the document requirements for each.(If you don't see a document verification required, then wait for after 11/15/14 to contact CC.) (3) Click on the "Upload Documents" link and select the type of item to be uploaded, (4) Browse your computer for the PDF file to be uploaded. (5) Click on the "upload" button in the lower right corner, The document should be received in a matter of seconds (look for a barely visible green verification of upload statement at the top of the upload window.


Underestimated Income Penalty?

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Question: I underestimated my daughters income thinking her college tuition would be deducted. Now, thinking it will not be which makes her income closer to 200% (around $22,000) which would put her in a bronze plan as opposed to the 94% shared plan she has had. Looks like her monthly payment would be similar for both. Should I contact Covered CA now to ask and potentially correct or just wait until next year when taxes are done? Will there be any charges if she no longer qualifies for the 94% plan she has had?

Answer: Your daughter can choose a Silver plan or any other "metal" level of coverage regardless of her income. Her income still qualifies her for cost-sharing reductions (lower deductible and lower copayments) which are only available with Silver plan. If she is no longer eligible for the Silver 94, then she will qualify for the Silver 87 plan. In any case her share of the premium will be around $110 per month. If she was advanced too much tax credit as a result of underestimating her income, she'll give some back when she pays her taxes for 2014, but it should not exceed $600 if her income is 200% FPL or less.


2015 Paper Application?

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Question: Has anyone found a link to a Paper Application for 2015 Open Enrollments?

Answer: The Covered California paper application used last year is still good. Here's the link to download:
https://www.coveredca.com/PDFs/paper_application/CA-SingleStreamApp_92MAX.pdf


Error Code "000"?

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Question: Got my renewal letter a few days ago. Have been trying to renew on my online account for several days, but when I get to the end to submit, I keep getting error code 000. It's allowing me to verify everything, its just at the end when I hit "submit" I get the error code - Does anyone know what this means?

Answer: Covered California recognized a software glitch causing a "000 error code". They advised to try again later. If you continue to have the same problem, wait until November 15th, when all should be running well.


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.


Estimating Income for Part of a Year?

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Question: Currently enrolled in CoveredCA with a subsidy. When I turn 65 in August of 2015 I will change my plan to medicare, will my subsidy for the first 7 months of 2015 be calculated on my income from Jan 1 - Aug 31 of 2015 of will my subsidy for the first 7 months of 2015 be calculated on my income for the entire year of 2015?

Answer: This seems tricky, but it's not. Your subsidy for the first 7 months of 2015, should be based on your estimated monthly income from Jan 1 to Aug 31 of 2015. The Covered California application software will convert this monthly average to an annual income number from which your subsidy is computed. This may seem to overestimate your subsidy eligibility, but since you will only drawing 8 months of the subsidy before moving to Medicare, you will not be drawing too much, or more importantly, leading to any unpleasant surprises on your tax return.


Question: What can agents who are dissatisfied with Covered California service do to be heard by the people who run the agency?

Answer: Max Her replies, "If you, like I, are dissatisfied with the performance of CoveredCA, the Call Center (FOUR hours on hold today pursuant to the notification that four of my clients' documents were not in order and that they are in jeopardy of losing their coverage -- none of which is accurate), $58 payments for Medi-Cal enrollments that have never materialized, and so on, please email me (max.herr@verizon.net) with your complaints and concerns."

"I have decided to fly to Sacramento for the September 18 CoveredCA Board Meeting and will try to find a way to air our grievances with the Board in public session. We are, I believe, not being given the credit we deserve for effecting a significant percentage of both Medi-Cal and QHP enrollments for 2014, nor are we being asked for our input on how to make the system more efficient and accountable, and I believe it's high time to hold Peter V. Lee and the Board accountable to us for a change."

I look forward to hearing from you. I will print your emails and deliver them personally to the Board at the meeting. Ideally, it will be a large stack of paper.


Question: I currently have my children covered under my employers group plan. Our group plan open enrollment is now. I have been told that if I add my children now, I can't remove them on 1/1/15 to go to individual plans. Is individual open enrollment a qualifying event?

Answer: Once enrolled in a group plan your cannot voluntarily drop your coverage without a qualifying event but you can drop coverage for your dependents anytime, no qualifying event required. There is no need to wait for open enrollment. Your children are not eligible for premium assistance (subsidy) because they are offered group coverage through your employer. You can purchase off-exchange individual coverage for them, or they may be eligible for Medi-Cal.


Rate Change for All on Jan 1st?

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Question: If a person signed up for a September 1st start date because of a special enrollment period due to loss of group coverage. Will their rate change on Jan 1st,2015?

Answer: Yes. All ACA-compliant individual health insurance plans change rates annually on January 1st.


Chargeback for Medi-Cal?

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Question: I have a friend who applied thru Covered CA using her current income which put her into Medi-Cal...but she also received some alimony payments earlier in 2014 which she did not account for. She expects her 2014 MAGI to be about $30,000 which is too high for Medi-Cal. Medi-Cal won't release her back to Covered CA to choose a subsidize plan unless her current income changes. Is it a problem that when she does her taxes, her AGI will be too high for her to qualify for Medi-CAL?

Answer: No. There is no chargeback, nor any other tax consequences, for one who is insured by Medi-Cal and subsequently reports income in excess of the Medi-Cal MAGI (modified adjusted gross income) benchmark. During the next open enrollment period, your friend should re-apply through Covered California and adjust her income to include the alimony income.


Question: My sons ages 12 and 16 are enrolled in Medi-Cal because of my income. Their primary care doctor will no longer treat them while they are on Medi-Cal, and I can’t find one who will take him. What can I do?

Answer: It was bad before the ACA (2011-2013), with only about 60% of the California primary care doctors accepting new Medi-Cal patients. It has gotten much worse this year as the ACA added over 1 million new cases to the Medi-Cal roles. However, the distribution of Medi-Cal visits among California physicians is highly skewed. About one-third (35%) of physicians accounted for 80% of Medi-Cal visits. Emergency doctors and others who work primarily in hospitals had the highest rate of Medi-Cal participation (82%). Physicians at community health centers and public clinics had the highest rate of Medi-Cal participation (92%), and those in solo practice had the lowest (54%). You may have better luck finding a doctor for your sons in a large multi-doctor practice or community health center.


Reporting a Change?

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Question: If after I completed my application and my QHP has been effectuated, I now need to change an incorrect birth date. Do I make that change through Covered California or through the QHP. If Covered California what is the process?

Answer: To change a date-of-birth go to Covered California not the carrier. Login into your CC account and make the change yourself, have your broker do it, or call CC at 800-300-1506.


Employer Offers No-cost Plan?

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Question: Employer is offering what is exactly like the lowest cost bronze plan on covered CA and it would not cost me anything out of my monthly salary. In fact, they said that I would even get an extra 1300.00 at the end of the year from them. However, I have type 2 diabetes and would be paying 100% of lab and drs visits before the $5,000 deductible is met. I am in the 138% of poverty range and am not able to do this. unfortunately if I turn it down I cannot get any help from subsides because of their offer being considered affordable. Any ideas?

Answer: Sorry, I have nothing. You cannot get any help from subsides because your employers group coverage offer is considered "affordable". You have to accept the company plan. However, the $1,300 you receive at the end of the year will go a long way in covering your out-of-pocket expenses for doctor visits and labs.


Health Insurance Tax Deduction?

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Question: Can I claim self-employed health insurance deduction (1040, line 29), if now part of my premiums are subsidized by Obamacare? If yes, what will happen after IRS reconciles the advance premium tax credits (subsidy) for 2014 and withholds certain amount, because my income is more than I projected? Will I be able to claim that I paid this extra amount as health insurance premiums and add it to 2014 deduction?

Answer: You can only claim the net premium - the portion you actually pay after the subsidy - as an expense. Enter that portion as your self-employed health-insurance deduction. If there is a subsidy reduction for added income at the end of the year, that incremental net premium would also be added to your self-employed health-insurance deduction.


Former Employer Won't Drop Me?

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Question: Hi, my ex employer refuses to drop me from his group health insurance policy. i dont understand why he is doing this but it's barring me from getting my own independent coverage from the same provider. Should i just try to find a different provider or is there something I can do?

Answer: Your former employer is breaking his contract with the insurance company that underwrites his company health plan. Group coverage is only for employees currently on the payroll. You can put a stop to it by calling the insurance carrier's customer service department and explaining what he is doing. In the meantime, buy coverage from another carrier if the value proposition is similar.


Mid-Year Income Change?

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Question: I estimated my income to be $24,000 for 2014 at the beginning of the year. As months are going by I am now estimmating it at $60,000. Should I make that change on my profile or wait?

Answer: That's a pretty significant change of income. It makes a big difference to your bottom line. If you are a single person, you're net premium now is about $150/mo at $24K annual income. At $60k, you are no longer eligible for a subsidy, so you pay the full premium based on your age and zip code - anywhere from $200 to $800 a month. If you don't bite the bullet now and pay the higher premium, you'll pay the difference in a lump on April 15, 2015 tax time.


Question: After enrolling in Brnoze plan on 3/14/2014, my income dropped down much in 8/14/2014. 1)What proof of income like Bank statement for that month to be submitted? 2)Only silver plan is to be selected for cost sharing? 3)Suppose after 90 days if proof of income could not be shown what happens.? Will the new revised plan be cancelled or will it continue but without subsidy?

Answer: Your change of income can be verified in a number of different ways depending on whether you are an W2 employee or self employed. Covered California can help you with that if you call 800-300-1506. Yes, only the silver plans qualify for cost-sharing reductions. If proof of income to support the change is not supplied within 90 days, the new plan will continue without subsidy and cost-sharing reductions.


Question: Does "ca covered" offer dental for adults? I have kaiser if it makes a difference.

Answer: Adult dental coverage cannot be purchased during the Covered California enrollment process nor as an add-on later. You can purchase your adult dental coverage directly from your current carrier (Kaiser) or from a wide selection of other stand-alone dental insurers. Click here for a quote and online application.


Two Residences?

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Question: Adult lives approx. half the year in California and the other half in North Carolina. Currently has coverage in California but needs to see doctors in North Caroline as well while there. Do you have coverage for this?


Answer: You could qualify for a special enrollment period in North Carolina if you claim NC as your home address. If so, select Blue Cross Blue Shield of NC PPO coverage (once you confirm that they offer Blue Card coverage outside of NC). You will be covered by in-network benefits while in California as long as you see a Blue Shield of California PPO network provider. If you want California based coverage, select Blue Shield of California PPO (only Blue Card in CA) coverage effective 1/1/15 during the next open enrollment period starting November 15th.


Question: My family is losing COBRA coverage on 9/16 (expired). Anthem, Blue Shield, and HealthNet and Cigna all will only give a 10/1 effective date. Will anyone give a 9/17 effective date to avoid a gap in coverage?

Answer: No help from the carriers on this loophole. Right now the consumer with expiring COBRA coverage may have to wait up to 30 days for the ACA compliant coverage to kick in. Eventually the feds will get it ironed out. In the meantime there's short-term coverage perhaps?


Report Income Change?

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Question: I estimated my 2014 income to be about $35,000. My 2013 income was $33,070. Due to a lay off of one of my jobs, it looks like I will make about $30,00 for 2014 if I don't find another part time job. I am being subsidized from the state for my Anthem Blue cross. If I don't make the money I estimated on, will I get a refund from the California Exchange if I don't have an adjustment made now? Or do they apply it to the next years premiums? (still looking for another part time job)

Answer: The IRS will reconcile the advance premium tax credits (subsidy) you have received for the year on your 2014 tax return. In your case, there is no need to report a change in income at this point as the difference between estimated income and actual income is not very great. In cases where the taxpayer's income increases greatly during the year, reporting the change to Covered California will prevent a big tax bill come tax time. If income decreases significantly, reporting the change immediately may greatly reduce your net premium for the rest of the year.


Question: Retired couple on Covered CA has husband turning 65. Husband is the only income in the household and they are APTC eligible. Now that husband is going to be eligible for Medicare and ineligible for Covered CA how is the income counted for the wife in Covered CA. Will his income be used to determine what her premiums will be in Covered CA? Will she now be eligible for Magi Medical since she has no income? Thanks

Answer: The husband's income is still counted even though he will not be enrolled in Covered California. Since the premium assistance (subsidy) is based on a 2-person household, the wife in this scenario will continue to pay less net premium they were paying as a couple.


Question: I know the 2013 Federal Poverty Level rates were used to determine the premium tax credit subsidy. However, when it comes to reconciliation at tax time will the 2013 or 2014 Federal Poverty Level rates apply? This could make a big difference if a single persons MAGI is $46,500 for the 2014 tax year. Which one? 400% of the FPL for 2013 is $45,960 (No subsidy) or 400% of the FPL for 2014 is $46,680 (Subsidy).

Answer: The IRS will use the 2013 FPL standard to reconcile 2014 MAGI and advance premium tax credits (subsidies). See Fred's comment below for more detail.


2015 Auto Renewal?

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On Thursday, HHS announced that most U.S. residents who have health coverage through HealthCare.gov could automatically be enrolled in their existing plan next year, cutting the need to fill out a new coverage application form through the website, the New York Times reports (Pear, New York Times, 6/26).

About 95% of current exchange enrollees could qualify for automatic re-enrollment if they do not change their coverage plans proactively (Radnofsky, Wall Street Journal, 6/26).

While the automatic re-enrollment feature is designed for the federal health insurance exchange, it also could apply to state-run insurance exchanges, officials said. State officials will also have the option to submit an alternative renewal proposal (O’Donnell, USA Today, 6/26).

While the proposed re-enrollment process would be automatic, consumers would be urged to re-evaluate their coverage benefits and needs during the next open enrollment period (HHS release, 6/26). In addition, enrollees would receive information about how to move forward if their incomes or other life circumstances have changed, which could affect their eligibility for future tax credits.

According to Modern Healthcare, HHS drafted the proposed rule with input from the National Association of Insurance Commissioners and other stakeholders. The rule is open for public comment for 30 days, after which HHS will issue a final rule (Demko, Modern Healthcare, 6/26).


2015 Covered Ca Rates?

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Question: There’s confusing talk about how much Covered California will increase for the 2015 year. When will the new rates be published.

Answer: Rates will be public in early August. As of June 1st, Covered California has been receiving submissions from the insurers in the exchange. An evaluation process will follow, and then a negotiation process through the month of July. Peter Lee announced at the June board meeting that Ca rates will be public “first week in August”.


Question: My Medi-cal was terminated 5.28.14 with no explanation or warning. My pharmacist informed me. After several phone calls, everyone agrees I should have no been terminated but they have no advice (CA Calif. and Medi-cal reps). No one would escalate my call. I reapplied to CA Covered and they will recommend Medi-cal. Meanwhile I am without coverage of any kind. Is the re-instated insurance retroactive is there some protection from termination that was not my fault. The law 14005.37 states that I should have been notified and received a chance to advocate for myself. I have heard nothing. What recourse do I have. Aren't they effectively ignoring the law?


Answer: You'll have to file for a hearing. You have 90 days from the date of the termination letter to request a state hearing. The form for that is on the back side of the termination notice or you can do it by phone. When you file you will receive "aid paid pending" meaning that your benefits will be reinstated pending the outcome of a hearing. When your Medi-Cal coverage is reinstated, coverage will be retroactive to the cancellation date. In the end, you shouldn't be out anything but the massive headache of getting your case back on the tracks.


Non-Resident Child Covered?

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Question: I am the non-custodial father of a child who lives outside the country in Australia. Court orders require me to add her to my health insurance as a dependent for occasions when she visits me in the U.S. (California). Can she be covered under my policy? I was told no because she is not a full-time resident of California. What can I do?

Answer If your daughter is visiting you for a few weeks, international travel insurance will do the trick. If your daughter will be living with you for an extended period of time, you can add her to your health insurance coverage. Your daughter is eligible for a special enrollment once she resides in California. The is no minimum stay required. What might have confused you otherwise is the rule that people who reside outside the US more that 6 months per year are exempt from mandated coverage and penalties.


Question: I am currently pregnant and I don't know how the process works for getting my newborn health coverage. I also have a one and a half year old who is covered under Medi-Cal. Please help!

Answer: As soon as possible after your child is born, notify Covered California to add your newborn to your account. The newborn is covered under the mother's CC coverage during the first month after birth. You say you already have a child on Medi-Cal. If this is because your household income (less than 250% of FPL) makes all of your children under 19 eligible for Medi-Cal, your newborn will be covered by Medi-Cal retroactive to his or her date of birth.


Subsidy Change?

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Question: I qualified for a Covered Cal subsidy based on my estimated 2013 income. Due to higher than estimated investment income my tax filed 2013 income exceeded the subsidy qualification limit. However, my 2014 income will be considerably lower and under the subsidy qualification limit. Do I need to stop the subsidy due to the filed 2013 income?

Answer: No. Your 2013 income is not a factor at this point. If you still expect your 2014 income to be reasonably close to the estimate you used on your application, there is no need to make any changes now. Remember, your advanced tax credits (subsidy) will be reconciled with your actual tax due when you file your tax return for 2014.


Medi-Cal Ineligible?

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Question: I'm a 31 yr old single mother. My 3 month old is eligible for Medi-Cal until he is 1. My 12 yr old is ineligible because of my income, yet I can't enroll him on Covered CA. I'm making $39,000 a year. What can I do?

Answer: If your household is made up of 3 or more individuals and your income is less than $52k, then all of your children age 18 or less are eligible for Medi-Cal. Medi-Cal enrollment is open throughout the year. You may enroll through Covered California at 800-300-1506.


Question: We were approved for Covered California but I chose the wrong health insurance plan. It has not yet take effect (it takes effect in 5 days). Can I change the health plan, or should I terminate Covered California and start over again? Thank you!

Answer Don't terminate your current coverage. Open enrollment for 2014 has ended. You cannot change your plan unless you have a qualifying event which makes you eligible for a special enrollment period. Making the wrong plan selection is not a qualifying event. However, if you can make the case that you made the wrong choice "as a result of an error, misrepresentation, or inaction by an insurer or agent", then Covered California may grant you an exception.


Question: When open enrollment starts Nov. 15, 2014, can I get off covered CA and look for my own private plans or do I have to stay on the plan I am on now for a full year?

Answer: When you apply for another plan during the next open enrollment period starting next November 15, your new coverage will start January 1, 2015 at the earliest. You do not have to keep your present plan for a full year.


Catastrophic Plans

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Question: I have a client who is eligible under the federal guidelines for a catastrophic plan. He was recently approved by the federal marketplace and has the paperwork to prove it. To date, I have not discovered the mechanism to offer him anything other than the Bronze plan, either off or on- exchange. Is there now a streamlined process now by which I can help them enroll in a catastrophic plan?

Answer: If the applicant is eligible for a catastrophic clan because of age (19-30), then the catastrophic plan will show an an option in the enrollment section of the online Covered California application. However, since catastrophic plan are unsubsidized, you can go directly to the carrier's online application. If the client is eligible for a catastrophic plan but 30 or over, I don't know of any online mechanism on or off the exchange to get the app started. You can submit a paper application to the carrier with your eligibility documentation.


How to Verify Income?

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Question: I was told to verify my income for the covered california insurance plan. How do I do that?

Answer: You can upload documents from within your Covered California account, but few people seem to be able to do that so I have stopped providing directions. Instead, call Covered california at 800-300-1506 and talk to a customer service rep. He or she will tell you how to submit the relevant documents for your situation.


Question: My family of four has a Covered CA plan, which we purchased when both my husband and I were unemployed. I am listed as the subscriber. I recently began work and have employer coverage beginning June 1. If I terminate the entire CC plan will that act as a qualifying event to get off-exchange coverage for my family? I don't want them covered on my employer plan due to cost.

Answer: Once you and your family have been offered employer-based coverage, you are no longer eligible for premium assistance in Covered California. You are obligated to contact Covered California and change your status. You may opt out your family from your employer coverage, but they will only be eligible for unsubsidized individual coverage.


Question: About a week prior to the deadline they gave me for my conditional 90-day acceptance, I mailed Covered California a monthly bank statement with the preface form they asked me to return, but I am not sure how/if this will truly prove my eventual 2014 income. What will happen if they still think this is not proof? Will they end my coverage completely, or give me another chance to help them determine what they need and re-establish my policy after a lapse?

Answer: No. Your coverage will not be ended. If your income verification is not acceptable, your premium assistance will be recalculated based on the best information available.


Question: I am currently enrolled in covered california, MediCal, for 2014. I have been job hunting for a while, and I believe that I may be getting a job soon that pays above 138% of the poverty line (the limit for covered california). If I get this job, will I be required to drop MediCal immediately? By the end of the year? Within a certain number of months? Thank you.

Answer: Yes. it is your responsibility to notify Medi-Cal of your change in income. You will no longer be eligible for Medi-Cal once your household income exceeds 138% FPL. However, if your new household income is between 139% and 400% of FPL, you will be eligible for premium assistance and perhaps cost sharing reductions through Covered California.


Question: Has Covered California officially decided to implement the Special Enrollment Period through July 1, 2014, whereby the Feds allow folks who currently are under COBRA to switch to ACA Marketplace health insurance plans?

Answer Yes. Covered california adopted the COBRA SEP guidelines regarding SEP exceptions for COBRA beneficiaries on May 15. The SEP enrollment period in California will extend to July 15, 2014.


COBRA SEP in CA?

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Question: Is the COBRA SEP adopted by CA the same as the feds?

Answer: No. The COBRA SEP in CA extends from May 15 to July 15 (SEP in fed exchanges ends July 1st)So people currently enrolled in COBRA coverage have until July 15 to apply for coverage through Covered California or off-exchange in a ACA compliant plan.


Question: I currently qualify for premium assistance, falling just under the income limit for our 4-person household. My son expects to attain a full-time job with employer benefits in August. Will this reduce the income level to 3-person, meaning no premium assistance? If so, would it be effective in August or retroactive to Jan 1?

Answer: You are committed to notifying Covered California when your son's coverage starts, so you will stop getting advance premium tax credits at that point - not retroactively. It remains to be seen whether the IRS system has the sophistication necessary to reconcile the annual tax credit to reflect the midyear change like this.


Question: What will happen if I have not sent proof of income and request for social security validation by stated deadline, for my 90-day conditional acceptance?

Answer: Your eligibility for premium assistance and enhanced benefits could be withdrawn.


Premium Locked For How Long?

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Question: If I purchased a Covered California health insurance plan for my family that was effective on May 1, 2014, will my premium stay "locked" at this level until May 1, 2015? That is traditionally how my health plans have operated in the past...with 1 Year Guarantees.

Answer: No. The rates for individual health insurance purchased in 2014 will change on January 1, 2015.


Question: I just got a rate increase on my grandfathered individual plan. It going up 24% effective July 1st. Can I still buy an Obamacare plan?

Answer: Yes. This is a qualifying event for a Special Enrollment Period (SEP). According to Covered California, “You have a health insurance plan outside of Covered California, and your renewal date is not between Nov. 15, 2014, and Feb. 15, 2015, or future open enrollment dates and you would like to switch to a Covered California health insurance plan instead of renewing your current plan.” Here’s how it will work: You can apply for coverage either through Covered California or directly with the insurer of your choice when your non-calendar-year individual plan renews. You can report to your insurer that you will not renew their plan up to 60 days before the renewal date. Your current carrier must provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014 to select and ACA-compliant individual plan. If you choose to enroll through Covered California, you will have up to 60-days from the renewal date to select a plan in the exchange. Reference: https://www.coveredca.com/coverage-basics/special-enrollment/qualifying-life-events/


SEP for COBRA Enrollees?

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Question: I got on COBRA when I lost my job last month because my former employer pushed me to do it. I didn’t look into Obamacare because I thought it was over. Can I still switch to a Covered California plan?

Answer: Probably, but not for sure yet. The Department of Health and Human Services is concerned that people newly-eligible for COBRA, as well as COBRA beneficiaries, may have had insufficient information to understand they only can enroll in the exchange during an open enrollment period, when initially eligible for COBRA or when COBRA coverage expires. So HHS is providing an additional special enrollment period based on exceptional circumstances so that persons eligible for COBRA and COBRA beneficiaries are able to select QHPs in the exchange. Affected individuals have through July 1, 2014, to select QHPs in the exchange. This is for federal exchanges. At this point, Covered California has not decided whether they will follow the recent CMS regs. Reference: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/SEP-and-hardship-FAQ-5-1-2014.pdf


Changing Doctors?

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Question: I live in Amador County and my only 2 options thru Covered CA were Anthem PPO or Blue Shield EPO. The doctors/imaging specialists I saw all last year were in network with my Blue Shield PPO. Despite telling me they would take the EPO, turns out they don't and they don't accept Anthem. Can I get a PO Box in Sacramento and use that as my (mailing) address so I can have the option of getting the Blue Shield PPO next time around? Or do you know of any other way around such a dilema?

Answer: Putting aside the fact that you would be breaking the rules, using a Sacramento mailing address to enroll on a Blue Shield PPO will not accomplish what you want. The "old" Blue Shield PPO network that was available in Amador County is not the same as the "new" PPO network available in Sacramento county.

I have no doubt that this will touch a nerve with some of my readers and I invite you to comment to this post with your opinions, but I wonder if keeping the same doctor and imaging facility you used last year is of such great value. Obviously, using a different imaging facility is no problem at all but what about the doctor? How much does he know about you that could not be passed on to another equally competent doctor? Seriously, what's the big deal?


Find Family Doc?

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Question: I need family doc for my plan - Anthem Blue Cross Silver PPO

Answer: To view a list of doctors that are in-network for your Anthem individual plan, go to:
https://www.anthem.com/health-insurance/provider-directory/searchcriteria?qs=*U+6hK7rK6dMu/ioZcqYOcg==&brand=abc
(Note: Copy and paste this link exactly as it listed here and paste it into the address bar of your internet browser. Other links will take you to a page that looks the same but is not.)
2a. Leave "Name" field blank
2b. Leave "Specialty" field set to "Family/General Practice, Internal Med"
3. Enter your city or zip code
4a. Enter state "California"
4b. Select the network called "Pathway X - PPO / Individual via Exchange"
4c. Select Plan "Anthem Blue Cross Silver DirectAccess"


Qualifying Events?

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Question: Back in December, I applied for an off-exchange Blue Shield plan because our household income was well over the income range for subsidies. But now we definitely are eligible for a subsidy, because my husband just lost his job a few days ago. Can I still apply through Covered California.

Answer: Yes. A change of income that affects your eligibility for a subsidy is considered a qualifying event that make you eligible for a special enrollment period of 60 days from the date of the change - in this case his employment termination date. Here is a list of other qualifying events:

  • Getting married
  • Gaining a dependent or becoming a dependent through marriage, birth, adoption, or placement for adoption
  • Permanently moving to a new area that has different health plan options
  • Losing other healthcare coverage that is considered minimum essential coverage.
  • A change in income that would affect an enrollee’s eligibility for financial assistance
  • Becoming a U.S. citizen
  • As a result of an error, misrepresentation, or inaction by a QHP or agent

How to Pay Kaiser?

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Question: We were told to pay kaiser but whe we went to pay they needed a number for the account we didn't know it how do we pay the payment.

Anawer: If you have not received an invoice by mail within 15 working days of your application, you can call Kaiser Member Services at either of these phone numbers: 800-464-4000 or 800-290-5000.



CoveredCA HSA Qualified Plan?

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Question: I signed up for an Anthem Bronze PPO plan in December. Although it is not designated as a HSA plan, it fits the IRS definition of an HDHP, i.e. it is $5,000/$10,000 deductible, out of pocket limits $6,350/12,700. I already have an HSA account set up from my prior insurance and I would like to continue to fund this for my expenses this year. Why would Anthem/CoveredCA not list this as an HSA compatible policy and would I be breaking any rules to claim my HSA contributions on my taxes next year?

Answer: Only one plan in the individual market is designated as an HSA qualified plan, the Bronze HSA Plan. Apparently, you bought the other Bronze plan. You can try calling Covered California at 800-300-1506 to see if they will accomodate you with a plan change.


Question: My Mom has been receiving health care under Covered California since January 1st. She can no longer afford the home she is in and must sell to continue to live. From the sale she will make some money which she will need to live. Will this be considered income even though this will be a one time occurance? If this is so, then she will become disqualified for assistance. Am I correct?

Answer: Any profit above $250,000 will go into her adjusted gross income for the 2014 tax year. (Your mom can exclude from tax up to $250,000 in profit from the sale of her primary residence or $500,000 if she's married as long as she has owned and lived in the home for a minimum of two years.) So selling the home will have no effect at all. If the sale of the home raises her AGI, the advance tax credits she has received to help pay her 2014 health insurance premiums will be reconciled by the IRS when she files her 2014 tax return. Any undue advance tax credits will be added to her 2014 taxes due. This should not be a problem for your mom since she will have the cash from the sale of the home to take care of the additional taxes if there are any. She is not "disqualified" for health insurance premium assistance and she will continue to be eligible for subsidized coverage or Medi-Cal the following year based on her 2015 income.


Employer Coverage Over 9.5%?

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Question: How do I go to Covered Ca if my share of employer sponsored insurance is greater than 9.5% and receive the advance tax credits?

Answer: Complete a Covered California application online before April 15th. When you get to the Health Care Information section and this question, "Does this person have or has this person been offered affordable minimum standard value health insurance for 2014?", answer "None of the Above".


Medi-Cal Application Lost?

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Question: My wife and I have been covered on a Blue Shield Obamacare plan since January 1st. Our two kids are supposed to be on Medi-Cal but we haven’t gotten anything from them yet. We called the county office, but they are no help at all. Should we apply again before the deadline on April 15th?

Answer: No. I recommend against applying again. It could really mess things up for you at this point. Your children’s MediCal application is probably not lost. About 800,000 people who applied for Medi-Cal coverage through Covered California still are awaiting approval because of software glitches. State officials say the backlog of Medi-Cal applications was caused by problems with a system that was supposed to link county and state computers to confirm applicants’ eligibility for the program. Even though the glitches have been fixed, workers at the county social services offices face a large backlog of applications. Unfortunately, if your Medi-Cal applications are awaiting approval you could be foregoing needed medical care for your children or paying out-of-pocket for health care services. You do have the option of requesting a temporary Medi-Cal card from county services but some MediCal providers might not accept them because of concerns about whether they will be reimbursed for the care.


Change EPO to PPO?

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Question: I currently have Anthem Blue Cross (Silver Plan) EPO and it's come to my attention that my regular doctors only accept PPO. I can use the EPO except the service would be considered out-of-network. Do I need to wait until the next open enrollment cycle before I can change to a PPO? And, when would this be?

Answer: You must make your plan change by April 15th, or wait until the next open enrollment period starting in November. Be sure to research the carrier provider networks for your doctor(s) before you change. Anthem Blue Cross does not offer both EPO and PPO plans in the same geographic area. You would have to select another carrier with a PPO available where you live.


Still Covered After 90 Days?

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Question: I received the conditional 90 day coverage from Blue Shield, through CC. I needed to verify my income, but was not able to pull together any of the required documents in time. I have been working as an independent contractor in this past year (for the first time ever) and am definitely on a learning curve for documentation. I have been billed (by Blue Shield) for the month of April, so I went ahead and paid it, but I am not sure if I am still covered from CC's point of view. I tried calling CC a number of times before the March 31st deadline to try to resolve the matter but was never able to reach anyone. As luck would have it, I have need to see a doctor now, due to injuries from a fall, but I am reluctant to proceed, for fear I will find myself without coverage and facing exorbitant bills which I cannot afford. Is there a grace period or a next step when the provisional coverage period ends?

Answer: Yes. You are still covered. Neither Covered California nor Blue Shield will cancel your coverage for failing to comply with a request for income verification. At worst, CC could take away your premium assistance, but that would not happen until you have been given additional opportunities to comply. For starters, they have to start providing adequate customer service before they can hold you to your reporting obligations. Wait until you can get through to 800-300-1506 and ask the Customer Service Rep for assistance in providing the necessary documentation.


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By on | 29 Comments

Question: I have enrolled and been conditionally accepted for 90 days and I have signed up and paid for a health plan. Now I am thinking of cancelling the plan and get out of the Covered Cal exchange altogether. How do I do that, and if I do, when will my current account with the insurance company end?

Answer: If you applied on your own, log into your CC account and select "Terminate Coverage". You can cancel your coverage as soon as 14 days from that date. If an agent signed you up, ask him or her to do it for you.


Is Employer Coverage Verified?

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Question: How does Covered CA obtain information from individuals who have affordable employer coverage and submit application for coverage through exchange.

Answer: There is no requirement for employers to supply information about their employees' health care coverage, at least for the 2014 tax year. Nor have I seen any verification requests from Covered California to applicants.


Wait Two Weeks to Reapply?

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Question: I had already applied and got a plan and payed, but my payment was not accepted. I had to terminate and wait 14 days to apply again, but this will take me past the march 31st deadline. Any advice? Can't get a hold of customer service.

Answer: After terminating your current coverage at least 14 days from that day, you can choose a new plan immediately using the same application. You do not have to wait 2 weeks to reapply. I think that misinformation may have originated in our Q&A comments section, but that person was wrong.


Question: I signed up for anthem ppo & paid for it on March 25 (which at that time appeared to be the deadline), then found out that my doctor has just been added as a provider on the blue shield epo. I am in the midst of some complex treatment issues and will be forced to pay out of pocket to see my current doctor about these matters (forced to put these payments on credit card because I am currently out on disability leave from my job). Is there a way to switch from Anthem to Blue Shield?

Answer: Yes. You can terminate your Anthem Plan effective April 30th and choose the Blue Shield plan you want effective May 1st. This is a quirky process in the Covered California online application system. I suggest you delegate a Certified Insurance Agent to help you with it.


Temporary Job and Subsidy?

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Question: I was unemployed and getting a generous subsidy through CoveredCA for my health insurance. I recently landed a 6 month assignment that pays just enough to have my subsidy taken away. I really can't afford the insurance on its own. Is there anyway to average out what ill make these 6 months for the year so I can still have a subsidy? My plan went form 59 a month to 263 a month because I took a 6 month temp job.

Answer: You could do nothing at all and save up for a larger than normal tax bill in April 2015. You could also change your Covered California account to reflect your new income from your temporary job by taking the total income for the 6-month job and dividing it by 12 if that would still make you eligible for premium assistance.


Special Open Enrollment

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Question: If a person is enrolled in an individual health insurance plan (not employer sponsored) outside the exchange and currently does not qualify for any subsidies because his or her income is above the threshold; what happens if he or she loses their job, becomes unemployed and now qualifies for subsidies, would this person be able to join Covered CA under the special enrollment rule and be eligible for advance tax credits?

Answer: Since your individual coverage is independent of your employment, losing your job will not trigger a Special Enrollment Period. If you were to apply for coverage through Covered California during open enrollment - by March 31st - even though your income makes you ineligible for premium assistance now, you could be eligible if you do lose your job later in the year.


Untaxed Disability Income?

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Question: I retired as a Police Officer due to an industrial disability. The money I receive monthly is tax exempt(Fed and State)except for a small portion (190.00 a year currently) and that amount is my AGI for taxes. What amount do I enter as income? AGI per taxes or the monthly amount that is protected?

Answer: Use your AGI of $190. You are eligible for Medi-Cal.


Mixed Immigration Status?

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Question: Husband stays in CA with a valid working visa. Wife and a child currently live in outside of the US and do not hold any valid US visa. They are going to come to the US with valid visa later this year. Can the husband apply for CoveredCA at this time? If so, should he apply as "single" or "married"? Should the income be calculated as 1 household or family of 3

Answer: The husband should apply as a 1-person household. His wife and children are not part of the household at this time. When they arrive in the US with legal residence status, he should change his application to reflect the new household status.


Question: I am trying to apply for Covered California health care. I am an adult (over 26) who is living at home with my parents. I am also listed as a dependent on my parents income taxes because they are helping to pay for my college tuition fees. Should I be applying as a household as 1?

Answer: No. Since your parents are claiming you as a dependent, you must apply as a 3-person household of with them on the application and opting out of coverage and using the entire household's income. If you agree to file your own tax return in 2014, you can apply as an individual using your own income. Here are some things to consider if you do strike out on your own: (1) Unless your 3-person household income is less that $50K, you'd be better off buying coverage for yourself off-exchange, (2) if you estimate your own income to be less than $15,500 in 2014 you will be eligible for Medi-Cal, (3) your parents will give up a $2,000 tax deduction.


Question: I have an individual grandfathered health insurance for my family. 1) Am I excluded from ACA tax penalty for 2014? 2) Can I change my plan in 3-6 months & get an ACA compliant insurance?

Answer: Yes, your grandfathered plan exempts you from the tax penalty for mandated coverage non-compliance. No you cannot change your grandfathered plan to Covered California anytime it suits you. After this open enrollment (OEP) period ends on 3-31-14, you must wait until the next OEP, starting 10-15-14 for 1-1-15 effective date of coverage.


Question: Family of 4 with an agi of $45,000. The Covered California online application says the children qualify for medi-cal. Family wants to pay the premium for their daughters. Can they still apply in Cover California for the four of them? If they receive medi-cal can they use it as a supplement for their Cover California policy?

Answer Yes. This family should apply through Covered California because the husband and wife will get a substantial subsidy. Be careful to indicate that the children do not want coverage, otherwise they will automatically be enrolled in Medi-Cal. Then they can apply for the children off-exchange in the plan of your choice. Yes you can have both Medi-Cal and private coverage.


Question: Phil please comment on the new CMS guidance on this subject. Here are the main points from the CMS bulletin:

  1. The health insurance exchange still is responsible for determining eligibility to obtain a marketplace plan and for financial assistance, and individuals must submit an application to begin the process.
  2. If an individual was unable to purchase a marketplace plan in time for the coverage to begin Jan. 1, the marketplace can set a date for retroactive coverage based on when the application was submitted.
  3. If an individual diverted the exchange and enrolled in a health plan directly through a carrier, and the health plan also is offered on the marketplace, the marketplace can treat the enrollees as if they made their arrangements through the exchange.
  4. In both of the above circumstances, if the enrollee also is determined to be eligible for premium subsidies by the marketplace, CMS will provide the tax credits retroactive to the policy start date directly to the insurance carrier. The insurance carrier would either credit or refund to the enrollee any claims or excess payments retroactive to the policy start date.

Answer: The CMS Guidelines are just that - guidelines. The devil is in the details and once the i’s are dotted t’s are crossed, I think you’ll see these guidelines are a nonstarter in California. But some state exchanges are really in deep doodoo. The “Cover Oregon” exchange still (March 1) does not have a working online application. Paper applications are reviewed manually by state workers wearing green eyeshades. So Oregon Governor John Kitzhaber worked with the feds to figure out a solution for Oregonians screwed over by his state’s disastrous Obamacare rollout. Realizing the need, the Obama administration opened up alternative avenues for states like Oregon (the CMS Bulletin to which your refer above) to make up for lost coverage time and federal tax credits caused by the technical problems at their state health insurance exchanges.

However, to answer your question directly: yes, applying through Covered California is still the only way to get a subsidy in California. To quote item 1 in the CMS Bulletin, “the health insurance exchange still is responsible for determining eligibility to obtain a marketplace plan and for financial assistance, and individuals must submit an application to begin the process.”

While the California exchange rollout was anything but smooth, the technology was adequate to get most of those who met the December 23rd application deadline covered on January 1. So item 2, does not apply in CA and it follows that item 3 does not apply here either. For item 4 to work, items 2 and 3 would have to be met, so that doesn’t apply either.

Admittedly, most of those January 1 enrollees were not able to actually use their health care coverage for most of the month of January for lack of insurance cards, but that was due to (a) extending the application deadline twice, (b) delays in handing off application data from the exchange to the carriers and (c) the carriers’ inability to get invoices out in a reasonable amount of time. Worst case, some people will have to go through the hassle of submitting claims to recover out-of-pocket costs after their effective dates of coverage. I guess we can be thankful, once more, that we don’t live in Oregon.


Coverage for Dependent Parent?

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Question: My mother (64) is an immigrant and lives with me and my family, and makes 0 income. I have claimed her as a tax dependent on my 2011 and 2012 returns, though she files her own returns with 0 income. When I created a CoveredCA account for her, I used MY income as the household income, which precluded her from receiving subsidized insurance either through the exchange plans or through Medi-Cal. The definition of household income here is unclear. Any insight on what's the right definition here for household income?

Answer: Assuming your mother has legal resident status, she is eligible for Medi-Cal. Her application has to be changed to a 1-person household with $0 income and she has to agree to file a tax return in 2014 as "single" status. You need to stop claiming her as a dependent. You can't have it both ways.


Undocumented DACA Immigrants?

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Question: I have a two-year work visa under President Obama’s DACA law but I am not a citizen and do not have a green card. Can I get California Covered?

Answer: You are definitely eligible for Medi-Cal, not sure about premium tax credits and or cost sharing reductions in Covered California. You have legal status under the Deferred Action for Childhood Arrivals (DACA) program and as such are eligible for Medi-Cal in California. Background: In 2012, President Obama developed DACA, which grants undocumented children legal status and authorization to work in the United States for two-year periods. To be eligible for the program, children must:

  • Have arrived in the U.S. before age 16;
  • Be under age 31 as of June 2012; and
  • Have continually lived in the U.S since 2007.

While the expansion of Medicaid under the ACA specifically excludes undocumented residents, California ruled that DACA residents are eligible for Medi-Cal.


Change Plans Now?

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Question: I began coverage on 1/1/14 on the Blue Shield Bronze PPO. Can I change to the BS Silver PPO now or do I have to wait til next year?

Answer: You can change plans until March 31st. After that you will have to wait for the next open enrollment period.


Question: My doctor wants to know how to get into the Covered California network.

Answer: Once again, there is no Covered California provider network. Your doctor must contact the provider services department for each qualified plan within Covered California - Blue Shield, Anthem Blue Cross, Health Net, Kaiser, etc. The Blue Shield Provider Services phone number is 800-258-3091. I try to get the other carriers’ numbers and post them here.


Deductibles Individual or Aggregate?

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Question: There are 2 members in my family, a 59 y/o and an 18 y/o out-of-state college student. We are looking at the BS Silver 70 PPO plan. If one of us is hospitalized, is the deductible $2,000 (individual) before the 20% starts or would it be $4,000 since we are a family? Likewise, is the same true for maximum out-of-pocket expense? If it is the $4,000, it seems wiser to go with the Gold 80 plan at $100 more per month rather than risk the deductible. Your thoughts?

Answer: Nearly all of the ACA-compliant individual plans (the only plans you can buy now), have individual deductibles. So in your example (if one of us is hospitalized...) once the $2,000 deductible is met the 20% coinsurance goes into effect. The Bronze HSA plan is the only plan in the new portfolio where the deductible is collective or aggregate, meaning the family deductible of $10,000 would have to be met before the 20% coinsurance goes into effect. The out-of-pocket maximum is individual as well. Also, the Blue Shield PPO is the only Covered California qualified plan that will cover your college student "in-network" while out-of-state.


Question: Hi Phil, if a husband is offered insurance through his job (employee portion paid at 100%) and the wife/kids waive because they are on Medi-Cal, would they be required to leave Medi-Cal immediately (or would they have to notify them) because they are offered affordable insurance through the husband's job? Or would they just wait until Medi-Cal says something?

Answer: Medi-Cal beneficiaries are obligated to inform that agency of any changes of status that will affect Medi-Cal eligibility. So yes, you would have to notify them though I don't think that being offered employer-based spouse and dependent coverage would exclude you from Medi-Cal eligibility by itself. But then I'm not a mediCal expert. Keep an eye open for comments to this post as I'm sure some of our Medi-Cal gurus will provide added perspective.


Covering Child with 50% Custody?

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Question: If a person has 50% legal custody of a their child, can the child be covered by both parents that live in different states?

Answer: No. The child cannot be covered by both parents. The child should be covered by the parent who claims the child as dependent for tax purposes.


Question: I (age 27) make 23K a year and I claim my Mom (age 58, 0 income) as dependent in my tax. Do you know why I am eligible for the plan(silver 94) but my Mom is not ? She was transferred to MediCal.

Answer: That's interesting. It seems that even though you claim your Mom as a dependent, her eligibility was determined on her $0 income rather that yours. Yet your benefit level (Silver 94) is based a 2-person household. In that case, it seems as if they are regarding her as if she were a dependent under the age of 18. Might be worth filing an appeal if your Mom wants off of Medi-Cal.


Income changes and CSR?

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Question: I'm currently on a Silver 94 PPO with Blue Shield. I'm sort of expecting to make more money than I anticipated around midyear. The way I understand it is that I have to report changes on income to Covered CA. Will this bump me out of the Silver 94 plan and force me to a plan with full deductible at mid year whenever I make the change?

Answer: Yes. Higher income will change your eligibility for cost sharing reductions (silver plan benefit enhancements) as well as advance premium tax credits (subsidy).


No Prior Tax Returns?

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Question: My daughter has not made sufficient income to be required to file tax returns. She is enrolled with a plan but has received a Covered California request for a copy of her W-2 or prior tax return, her birth certificate and social security card. We have the card and birth certificate. How do we respond to the request for proof of income?

Answer: I'm surprised they didn't ask for her high school transcripts? I mean, these CC requests for verification are wildly off the mark. Here's the scoop. You have 90 days to comply. Wait until you can get through to CC on the phone without waiting 30 minutes or more to talk to someone - probably another month. Once you can conveniently talk a CSR, he or she will sort out what you really need to provide and tell you how to submit it. They will also remove the unnecessary requirements from your account. As for your daughter not filing taxes in the past, that's not a requirement. She only has to agree to file taxes for the 2014 tax year and beyond.


Getting Off Medi-Cal?

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Question: I got onto Medi-Cal last year becuse I lost my job. My income will soon go up and I really want to sign up for Anthem or Kaiser, etc. My agent says CC will NOT let me sign up for a plan unless I "disenroll" first, from Medi-Cal. Is that true?

Answer: Yes. The CC system can now instantly access Medi-Cal data during the application process. Applicants currently on Medi-Cal will automatically be found ineligible for Covered California coverage, with or without advance premium tax credits. The individual(s) must get off the Medi-Cal system before becoming eligible for CC coverage.


Negative AGI?

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Question: How about a loss carry forward that comes from a theft loss? This creates a net loss on line 37 of our 1040. How do we enter it on the Covered California website or the Medical website. It doesn't allow us to enter a negative number for AGI.

Answer: The CC application asks for your current income whether W-2 employed or self employed. Jeeze Louise! What did you make last month? If you start making a lot more, or a lot less, you can correct later. After personally assisting on over 300 CC applications, I can tell you that for most people, the whole AGI thing makes things more complicated than they need to be. Fuhgeddaboudit!


Employer Mandate Delayed?

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Question: I read in the news that the requirement for employers to provide health insurance has been delayed another year, but when I got into the details I just got more and more confused. Help?

Answer: Under the latest regulations, only employers with more than 100 full-time workers will have to pay fines next year and only if they do not cover at least 70% of their workers. In 2016, when the full mandate takes effect, employers with more than 50 full-time employees will have to provide insurance to at least 95% of their employees.


Question: When I enrolled in Covered California Anthem Gold PPO in December, I first called all my doctors offices, twice, and asked what CC plans they would be participating in. Each time they all told me if I picked a “Blue PPO” I’d be fine. As Anthem is the only PPO available in Alameda County (Blue Shield is an EPO), I signed up for Anthem. Yesterday I looked on the website and my large internal medicine group had dropped. I emailed them and my doctor confirmed, saying it would “Be Prudent” for me to find a new doctor ASAP. What are my options? I could try to get back on my HealthNet high-risk pool plan ($1080/mo, $4000 deductible, cancelled Nov. 1 then reinstated, but it’s so infuriating when I’m eligible for a significant subsidy on the exchange. I work 3 jobs to be able to pay for health insurance. What do you recommend as a pathway to finding the cheapest insurance that does cover Alta Bates Medical Group, Hills Physicians Med Gp, Sutter East Bay Med Fndn, or multiple of those groups)? Advice welcome.

Answer**; You seem to be someone who is receiving ongoing treatment for multiple conditions. So I understand that changing providers is a bitter pill to swallow. However, think of it as a trade-off. You couldn’t even get regular health insurance a couple of months ago because of pre-existing conditions - paying over $1,000 monthly for a high deductible risk pool plan. Now you can get covered for the same rate as a triathlete. Now you are “eligible for a significant subsidy” making a no-deductible Gold plan available at a fraction of what you were previously paying for substandard coverage. Narrow networks are necessary to keep costs down - one of the trade-offs for all the good stuff you now enjoy. You welcomed advice - pick new providers in-network for the plan you selected and move on.


Question: My husband and I are both self-employed so our income varies. Likely we will fall around the $60,000 mark for 2014 and qualify for a subsidy. The problem arises because we would like to choose two different plans based on different medical needs. Both plans are offered on “Covered California.” We want to choose a bronze plan for him, and a platinum plan for me. According to some info on the web, this should be a possibility, if so how would we do it?

Answer: The CC online application allows for multiple plan selections for households with 2 or more applicants when applicants are eligible for CC coverage without subsidies. Ths plan selection screen Plan Selection.png (click image to enlarge) is in the Enrollment Section. This would require overestimating your income on the application so as not to be eligible for advance premium tax credits and getting full tax credit due when your tax return for 2014 is filed.


Question: There are 2 members in our household. I am self-employed, with an 18 y/o dependent, with an AGI of $55,000. My 18 y/o attends college out-of-state and has no income. She will turn 19 October 2014. My understanding is she will be covered out-of-state under a family plan if I purchase BS PPO Silver 70. What happens mid-year when she turns 19? Does she have to go on Medi-Cal? If so, will it cover her out-of-state? Would it be better to purchase a catastrophic PPO policy for her now and for me to get my coverage through CC?

Answer: No worries. Your income $55K is high enough that your dependent under 19 will not be eligible for Medi-Cal and your Blue Shield Silver 70 PPO Plan will provide her with excellent coverage out-of-state. When she turns 19 she would be ineligible for Medi-Cal in any case as long as she is included in your household as your dependent. If your income was below $38,775 (250% FPL), she would be eligible for Medi-Cal until age 19 with only emergency health care coverage out-of-state.


I need to change my plan. How?

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Question: I signed up for Blue Shield enhanced PPO through CC. But, my OBG does not seem to be getting paid from them so they do not take this insurance. How do I change my plan so I am covered with her? She is in the Cedars Network I believe.

Answer: From what you've said, It's possible that your doctor is in the Anthem Pathway network. In any case, you have to find your doctor in the right network before you change carriers. At this point-in-time, it is difficult to search the right carrier networks for a doctor. No offense, but you are not likely to do it right. You could use the assistance of a Certified agent. Go to coveredca.com, select "Find Local Help", then select, "Agents".


Catastrophic Insurance Over 30?

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Question: I am eligible for catastrophic insurance due to my old plan being cancelled and my inability to find a plan that I can afford. I have been trying since December to find someone to quote me a price for catastrophic coverage and have yet to find anyone who can do that. Any suggestions on how to break through the Obamacare firewall and access these plans?

Answer: No over-30 rates or online applications available yet. Carriers are just beginning to set up application processes to open off-exchange catastrophic plans to new or current individual members, 30 years of age or older to apply if the attest to their plan being cancelled due to the ACA, and finding other plans unaffordable. So far, no news from Covered California about opening on-exchange catastrophic plans. Background: In late December, HHS released guidance that allow individual plan members with discontinued policies to be eligible for a hardship exemption from the individual mandate and enroll in catastrophic plans that were previously only available to individuals under 30.


What's a Physician to Do?

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Question: I work for a private physician's office, and we have multiple patients switching to CC. How do we know if we can still see these patients? Do we need to contract? If so, how do we do that? Also, how do we set a reimbursment rate? None of this is clear on the website. Is there even a providers line to call?

Answer: Providers do not contract with Covered California directly, but with each individual carrier selling plans through CC. So you need to contact Anthem, Blue Shield, Health Net, etc. and inquire about getting included in their 2014 Individual and Family Plan networks.


Medi-Cal Asset Recovery?

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Question: I am hearing contradicting statements as to whether or not the new recipients of Medi-Cal are subject to recovery of assets upon death. Is there a definitive answer and how would it apply to a child only Medi-Cal recipient if the parents qualified for a subsidy while the child was placed on Medi-Cal.

Answer: Read the comments to this previous post on this question to get as definitive an answer as is possible at this point.


SSN Doesn't Match? Impossible

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Question: Why do I get a letter telling me that my husband's social security number doesn't match what they have on file? How can that possibly be?

Answer: At this point, Covered California's requests for verification are often nonsensical. I advise you to ignore this request for 2 or 3 weeks when hopefully you will be able to get through to Covered California on the phone and to remove this requirement from your record.


Question: I have an Anthem Platinum Guided Access cead plan. It says Pathway X HMO on the card. I can’t find a list of in-network providers anywhere.

Answer: Use this link: https://www.anthem.com/health-insurance/provider-directory/searchcriteria?qs=*U+6hK7rK6dMu/ioZcqYOcg==&brand=abc. The page looks like this Anthem Find a Doc.png (click image to enlarge). Section 4 is the important part. After selecting California, you will click on the Plan Type/Network selection and a drop-down menu will appear that looks like this Network.png. Scroll within the menu to find the Pathway Networks. The correct selections for your scenario would look like this Search.png. Now you are ready to click the “search” button and go.


Finding a New Doctor or Hospital?

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Question: Well, I need to find new doctors and hospitals and facilities as none of my current ones are in my plan. Does an independent and reliable ratings system for hospitals, facilities, and doctors exist? Blue Shield rates hospitals but it seems limited and maybe it is biased.

Answer: Believe it or not, YELP.com to be a great way to find a new doctor. The reviews are written by patients like you. Look for negative reviews retold by more than one patient. For example, I checked on a doctor I used to see. Several reviews complained about her staff being deliberately rude and incompetent, which was exactly my experience. As for hospitals, try a Google search for "best hospitals in (city or county name)" and read more than one search result. You'll get the picture.


Question: I am suppose to submit proof that I do not qualify for employer insurance. I have been paying for an individual Kaiser plan that is up to 270/mo , 80 dr visit, 1500 deductible. Income wise I qualify for a Kaiser enhanced silver plan but because my employer offers non kaiser insurance I haven't taken it because I've have cancer and psoriasis. I was provisionally approved by CalCov and paid $105. My individual plan expires in Feb since I haven't paid January and now I owe them $540 if Cal Covered doesn't go through. What am I suppose to do?

Answer: You say "my employer offers non kaiser insurance I haven't taken it". The ACA and the IRS are very clear on the fact that if you have access to employer-based health insurance, you will not be eligible for a subsidy. You have Covered California coverage for 90 days. Then you will have to decide between employer coverage or unsubsidized individual coverage.


COBRA with CC as Secondary?

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Question: I have COBRA coverage through March 31. I also applied for a Covered California plan, then found that none of my doctors are in-network with the new plan. Can I keep COBRA AND use the CC plan as secondary insurance?

Answer: No. You cannot use any ACA compliant health plan as a secondary plan. You can reapply for Covered California coverage before March 15 to replace COBRA coverage on April 1st.


Question: Please help me. I enrolled and was accepted. However, I selected the wrong health plan... I un-enrolled. I waited 3 weeks. I am now trying to re-enroll. The system recognizes me by my SS# and says I already have an account, and won't let me initiate a new one...HOW DO I CHANGE MY PLAN ONCE I'VE ENROLLED? Any help you can provide that will spare me the miserable phone wait would be much appreciated.

Answer: It is not necessary to create a new account and you misunderstood the part about waiting 2 weeks. Login in to your existing Covered California account and select "Terminate Participation" terminate.png (Click on image to enlarge.) You will directed to select a termination date that is a least 2 weeks from today. If you want the new coverage on March 1st, select a termination date of February 28. Now you should be able to select another plan effective March 1st.


More Income Verification Requests

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Question: I have already received my medical card from Kaiser, selected my primary doctor. I thought I am all set. Out of the blue, I received another letter from Covered California asking for more income verification. At what point do I know that I am approved? Will they send me a letter of approval? My current premium was based on my income in 2012. I told them that I may make less in 2014. They said that I can qualify for more subsidies if I can prove my lower income. How can I prove my 2014 income now? Should I ignore the request and just pay the higher premium. I understand that I will get tax credit if I turn out to make less in 2014,correct?

Answer: You are approved. At this point, Covered California's requests for verification are out of control. I advise you to ignore these requests until you get closer to the 90-day deadline when you will be able to get through to CC on the phone and get them to sort out which of these requests are really needed.


Decline Medi-Cal for Kids?

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Question: If a family is eligible for mixed health care coverage - the parents qualify for APTC and the children are eligible for Medi-Cal - are the parents still eligible for the APTC if they decline the Medi-Cal benefits for the children and enroll them in a private plan?

Answer: Yes.


Question: It is my understanding that individual carrier networks should mirror on and off the exchange as per previous posts. How do you then explain Cedar-Sanai hospital who is doing just that with their contract through Health Net and are specifying down to plan level what they are accepting.

Answer: My read on the Cedars’ statement below is that the Health Net network is broader and more inclusive at the Bronze and Catastrophic plan level than are other levels. This is not an on exchange / off-exchange issue.

From Cedars Sinai website; “If you choose to purchase your health insurance through the exchange and want the option of receiving full coverage for care provided by Cedars-Sinai Medical Center and its physicians, there are three Covered California plans that will work for you:

  1. Health Net Bronze PPO Plan (available to all)
  2. Health Net Catastrophic PPO Plan (available to people under the age of 30)
  3. Health Net Tribal PPO Plan (available to Native Americans and Alaska natives with certain income limitations)

Question: My wife and I are both self employed. We really have no idea of what our income will be in 2014. We based our application on our 2012 return; that all we can really do. Do they look at your returns each year and then adjust? Or send a bill? I am very worried about getting a large bill for a year past, that could break us. P.S. Our insurance costs have doubled from last year, for basically the same coverage. I am not a fan of Obamacare.

Answer: Covered California has access to your 2012 AGI from the IRS data hub. However, it is only a benchmark. If you feel that your 2014 income will be substantially more or less, use your 2014 estimate instead. To avoid the possibility of a big tax bill at the end of the year, you can choose to take only a percentage of your tax credit as a monthly advance. This step is in the online application just before selecting a health plan, if ignored it defaults to 100% advance tax credit monthly.


Question: I ... put my wife on Covered CA Blue Shield plan. My job opportunities fell through ...and believe I would qualify for assistance for my wife and myself. I need to add myself to the plan. The Covered CA website does not address this and the phone chat lines seem impossible to get through. Any suggestions?

Answer: "Terminate participation" on you wife's plan effective February 28th, then "withdraw" your wife's application (you'll find lot's of info in previous posts and comments on how to do this. Just search this blog for the keywords in quotes above.) After the application is withdrawn, log back into her account and click on apply now. All of the data previously entered will still be there as you go through page by page and you can make changes as needed including adding yourself and changing the income figures. Your new coverage will be effective March 1st. This same process can be used to change the plan selected, just don't take the withdraw step.


Question: I have a BS PPO family plan through Covered California. I have been told by UCLA Hospital & affiliated doctors that if you purchased BS PPO through CC then you are not in network. But if you purchased the same plan through an agency you are in network. When I asked the BS agent, prior to signing up at CC, about providers accepting BS PPO/CC I was told that if providers are in network with BS PPO then they're in network through CC. They said it was the same. Can you please explain this? The doctors offices are unaware and uninformed.

Answer: The provider networks of the health plans participating in Covered California, like Blue Shield, must match their off-exchange plans networks to their Covered California networks exactly. The are the same. However, the reverse is not true, these same carriers have other networks that do not match their Covered California networks. Examples of these are grandfathered individual plan legacy networks and group plan networks. So this statement "if providers are in network with BS PPO then they're in network through CC" is not accurate. Some doctors' offices are of the opinion that Covered California has it's own network and this is way not accurate.


No Tax Filing, No Subsidy?

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Question: Per IRS and Ca State law (I have letter from CA confirming I don't have to file ) I don't file yearly taxes... I was denied and the lowest cost is 16% of my monthly income...Why does it matter ? Why is everything centered on tax filing?

Answer: You remind me of the car crash driver who refused to stop because he had the right of way. How much are you will to spend to make a point? The Covered California application requires you to promise to file by 4/15/15 for the 2014 tax year, so why not file for 2013 as well, then you would be able to answer "yes" on both counts and be eligible for all that IRS money. Yes, IRS money: that's why they have a say in your eligibility for tax credits.


Tax Filing Requirement?

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Question: I am a tax professional and need to ask what happens, as with many self employed clients, if they don't file by 4/15/14, even though they signed up promising to do so. Will the extension rules be the same or are there addtional penalties?

Question: Filing for an extension by 4/15/14 should satisfy the letter of the law, but I would ask one of my legal-eagle commenters to find a citation for this.


Question: We recently received an e-mail from Covered California saying we have 90 day conditional approval. This is due to not verifying our SSN to our application. My wife and I are both lifelong California residents and had the same SSN for over 50 years. How could Covered California not be able to verify this? Also, I have Blue Shield now thru Covered California and have paid the premium. Could I lose this insurance after 90 days?

Answer: Covered California's enrollment processing system has some bugs, like making illogical requests for verification documents. You can clear this up once you can get through to a Covered California service rep on the phone. They can remove the requirement from your account. The CC phone situation should begin the loosen up this week but there's no rush to resolve this.


Pediatric Dental Required?

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Question: Do I have to select a pediatric dental plan for my kids through Covered California? Do I have to select one at all?

Answer: No on both counts (correction). (See very informative and detailed comments on this article)


Question: I managed to reach Anthem by phone and paid my premium for January. They processed the payment last week. I still have not received any membership information, card or number. My pharmacy will not honor this plan without a card. Will Anthem will reimburse me for these prescriptions when I file a claim?

Answer: As long as you pay Anthem by January 31st, you can use services covered by your health plan starting January 1. First, be sure the provider (a doctor or pharmacy) is participating in the Anthem "Pathway" network.Once you have proof of health insurance coverage effective January 1, 2014, you can submit the provider's bill to Anthem to process.


Question: I have a self-employed client who sent an affidavit for estimated 2014 and CC is still requesting for more "proof". I see a huge problem on the way if this is going to be their regular mode of operation. How in the world will any self-employed person "prove" their estimated income for the year?

Answer: If CC is still requesting more proof, it may simply be due to a recognized glitch in their system and not the fact they find the income affidavit unacceptable. They are making all sorts of unreasonable requests for documentation right now. I would wait a while before submitting anything else.


Question: Does the Maximum Out-of-Pocket of $6,350 include total cost to the consumer for any given care or is it limited to the insurance company's "negotiated rate" for a given treatment? In other words is the patient stuck with the costs above and beyond the negotiated rate and if so, will that cost go towards the "maximum out-of-pocket" or will it not?

Answer: The out-of-pocket maximum of $6,350 for covered expenses in a calendar year is based on the negotiated or contract rate. There is no patient responsibility beyond the contract rate for in-network expenses. Out-of-Network coverage has a higher out-of-pocket maximum and the patient is responsible for charges beyond the contract rate.


Question: I had enrolled in KP HMO Silver 87 Plan through Covered CA website. I received my first billing from Kaiser Permanente indicating that I was on their KP CA Silver 2000/45 Health Plan. I was charged the same premium as quoted by Covered CA for the KP HMO Silver 87 plan. Copays/Deductible for KP 2000/45 plan a lot higher. What should I do?

Answer: Don't be concerned. Kaiser knows that you are on an enhanced version of the Silver 2000/45 Plan as evidenced by the correct premium. They apparently lack the ability to reference the enhanced version of a Silver in their billing system.



Changing Insurance Company?

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Question: I have submitted payment to Blue Cross but have not received a card. In the meantime, I found out that my therapist only takes Blue Shield. (I thought Blue Cross/Blue Shield were the same company because this is my first experience purchasing in CA. Also some of their paperwork includes both names suggesting they are the same). I want to change carriers because I want to remain with my therapist, but I don't know if that is possible or what the smartest, most efficient process is to complete the switch. Do you have any helpful suggestions?

Answer: You can change plans or carriers within the open enrollment period, that is before March 31st. It can be done online by "terminating participation" (in your CC account on the home screen click on "terminate participation" at bottom left of page) in the previous coverage and selecting new coverage. It's important to get the dates right so that you do not have a gap in coverage or double coverage. The smartest, most efficient way to do this is to contact a Certified Covered California Insurance Agent.


Submitting Verification Documents?

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Question: There's a message on my eligibility page saying to check my manage verification page for new doc requests; of course, there's nothing new on the MV page. My eligibility states that unless they get whatever it is they need by Jan 31st, I will not be eligible for CSR and APTC. My question is whether they will cut off those payments if I can't reach them to find out what in the world they really want? Do I need to wait on hold all day or can I wait until after Jan. 31 - safely - to try to call?

Answer: The documents required for verification are available on your Covered California online account, you haven't looked in the right place yet. Look for a documents link on the left side of the home page. If you don't have an online account or can't get into it, you will have to call Covered California. I know. I know. But the phone situation should start getting better this week. Covered California puts out a variety of contradictory and seemingly random deadlines for this or that. You have 90 days from the date of your application to provide verification documents (probably more if you show that they contributed to your tardiness).


Group Coverage Without Dependents?

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Question: I have a group and want to exclude dependent coverage so my employees can apply and receive a subsidy on the individual plans for there dependents, spouse and children. Is that possible and is the system set up to handle those options. As I understand all the insurance companies need to include dependents.

Answer: Yes. It is possible through Covered California SHOP right now. The employer has the option of excluding spouses and dependents. Expect carriers to follow soon.


COBRA and Subsidy Eligibility?

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Question: I applied for coverage and have a COBRA plan that is way above the 9.5% of income, but when I answer on the application that I have COBRA it remove the subsidy? on the application how do I explain that the Cobra premium is above 9.5% and that a subsidy should be applied?

Answer: You are free to drop the COBRA plan and enroll in a Covered California qualified plan with eligibility for APTC anytime during the open enrollment period. Select, “None of the above” in answer to the question about other coverage, as if you had already cancelled you COBRA coverage. Dropping COBRA outside of open enrollment will not create a special enrollment period so you can’t be eligible until the next open enrollment period, COBRA was meant to protect individuals who lost their group coverage in a medical underwriting environment where they may not have qualified for individual coverage. The ACA did not intend for COBRA to be an obstacle for individuals desiring coverage and premium assistance through the exchange. Being held hostage by a costly COBRA plan because of preexisting conditions is one of the problems the ACA seeks to solve.


Pregnant Applicant Dual Eligible?

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Question: For a family of 2 earning $45,000 a year qualifies for PTC. Since the woman is pregnant, Covered California is forcing the woman into Medi-Cal? Why is this happening? Can she opt out and still get the PTC? This couple is far from poor why would this happen?

Answer: She’s not “forced into MediCal”. It is offered to her as another option. She is eligible for Medi-Cal due to pregnancy and income, but it does not prevent her from choosing a Covered California qualified plan with APTC and CSR for which she is also eligible.


Changing the CC Application?

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Question: I’m at the eligibility verification stage but realized I didn’t count some of my self-employment income. I need to go back and change my income amounts, but I can’t figure out how to do that.

Answer: If your eligibility was already determined using the original income figures, you cannot change the eligibility outcome by making changes to income. It will look like you successfully changed the income numbers, but the final outcome will not change. You will have to “withdraw” and restart the application.


Only Conditionally Eligible?

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Question: We signed up on 1/14/13. However, under the Eligibility tab, we’re told we’re only conditionally eligible for APTC (Advance Premium Tax Credit) and CSR (Cost Sharing Reduction), pending submission of documents verifying income eligibility. We’ve both been given until April 14 to submit the relevant documents. (1) Do we count as having applied in time for Jan 15 deadline for coverage beginning Feb 1st? (2) Will we have to pay the full premium without the APTC until we are no longer “conditional”?

Answer: While conditionally eligible you enjoy the full benefits of your coverage, including tax credits and cost-sharing reductions. If your application was completed by the application deadline (the 15th of the month), your coverage will be effective on the first of the following month.


Anthem "Find a Doctor" Confusing?

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Question: We enrolled for the Anthem Blue Cross Preferred Direct Access Pathway PPO plan. My PCP is part of Palo Alto Medical Foundation / Sutter Health. When I lookup his profile directly from Anthem’s website, the insurance plans he accepts show “Preferred Direct Access - CA”. He also shows the other tiers offered - Core, Essential, Premier Direct Access of the Pathway PPO and Guided Access HMO plans available through Anthem BC for 2014. But if I login to the Anthem website as a member, the search does NOT include my doctor s “In-Network” under the Pathway PPO /Preferred Direct Access Plan. This is true of most if not all doctors from PAMF listed on Anthem’s website.

Answer: The name “Preferred Direct Access” refers to gold-level plans in Anthem’s small-group plan portfolio and off-exchange individual and family plan portfolio. “Pathway” is the network name used by all individual plans effective 1/1/14 and later. “Pathway X” is for Anthem individual plans sold through Covered California. he Pathway X network is exactly the same as the Pathway network without the X. When using the Anthem “Find-a-Doctor” online app, select the Pathway network first, then the plan type and name.


Question: Under 65 and covered on Medicare Part A & B due to cancer, she would like to cover herself, husband and son through Covered California because they qualify for subsidy. Can all three enroll under Covered California and get Premium Tax Assistance, or will she be excluded?

Answer: Since she has minimum acceptable coverage through Medicare, she will not be eligible for APTC or CSR through Covered California. The rest of the family can be of course.


Question: With the much narrower networks in all EPO/PPO plans the chances of an out-of-network provider providing services to me on ER are high. Seems like in California, balance billing, where the out-of-network provider charges you the difference between what insurance pays and whatever rate they may please, has been banned for HMO plans since 2008. It is not so clear to me what is going on for PPO/EPO plans. Seems like consumers from PPO/EPO plans licensed by the California Department of Managed Health Care can't be subject to balance billing on ER visits according to this http://goo.gl/bqZBgf. Any idea if using the plans on Covered California one would not be subject to balance billing on ER visits?

Answer: No. Qualified health plans offered through Covered California are underwritten by private insurance companies licensed by the California Department of Managed Health Care or the California Department of insurance and as such all Covered California HMO, EPO, and PPO plans are subject to restrictions against out-of-network providers balance billing for emergency room services (not including ambulance services).


Question: My parents are US citizens, but they have lived in Europe for the past ten years. My mom is 63 and my dad is 76. They want to move back to California. Their combined income is roughly $40,000. Will they be able to sign up for private plans and use the Covered California subsidy, and get plans thru that. Or will they HAVE to use Medicare because of their age? They want to get the BEST platinum-level plan possible, and I am willing to help them financially. Will the Medicare best plan be comparable to the private level platinum best plan? I am concerned and want to know what their options will be, and what the BEST coverage will be through Medicare.

Answer: The ACA mandates that individuals age 65 and older to enroll in Medicare. If your father does not have fully insured status (40 credits) he will pay a premium of up to $426 in 2014. He may also have to pay a premium penalty for not registering at age 65 (not sure if there is an exemption for being out of the country). In your father’s case original Medicare coverage with a Plan F Supplement (an additional $200/mo) would be even better than Platinum private coverage (100% coverage with unlimited network). Your mother (age 63) is eligible for a premium tax credit of about $330/mo. Which she can apply to the purchase of a Platinum Plan through the exchange, leaving her a net premium of approximately $500 per month. The total monthly cost to accomplish what you outlined above is approximately $1,200 per month (assuming no Medicare premium penalty).


HSA Plan with Subsidy?

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Question: If I choose a plan with an HSA will the amount I deposit into it drop my AGI and therefore drop my subsidized insurance premium in the exchange?

Answer: Yes. Since HSA contributions lower your adjusted gross income, your eligibility for tax credits will be increased and your net premium reduced. Keep in mind when selecting any bronze level plan that you may be giving up substantial cost sharing reductions that may be available to you at the silver level.


Will Medi-Cal Take my Assets?

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Question: Will Medi-Cal take my assets to pay my medical expenses after I sign up.

Answer: Not while you’re alive. But the state of California may seek to recover medical and long-term care expenses paid for by MediCal from deceased clients who leave behind significant assets. This only applies to beneficiaries over the age of 55.


Can I Buy Off-Exchange Anytime?

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Question: I make too much to qualify for a subsidy. If I buy a plan directly from Anthem or another provider, can I purchase an individual plan directly outside the exchange after March 31?

Answer: No. You cannot purchase individual coverage outside of the open enrollment period without a qualifying event, on or off exchange.


No Blue Shield Member Card Yet?

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Question: I paid my premium on the blue shield website. Have confirmation # and case #. Have not received member ID card yet. Need to go to doc before card arrives. Doctor says they need Member ID # to confirm. What to do?

Answer: Blue Shield says that they send ID cards to clients 7 to 10 business days after the installation process is complete. You can also print an ID card at this web address: https://www.blueshieldca.com/bsca/registration/step-1-subscriber-id.sp?showError=true, but you must have a membership number to do that, so I’m not sure how helpful that is right now. BTW members ID numbers are 9 digits beginning with 900.


How to Change Plans?

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Question: I’m now enrolled on the Enhanced PPO plan of BlueShield but I’m coming to realize that their PPO network has been brutally cut back. In my region, San Francisco, it’s about 25% of the full PPO I had before. None of my regular doctors I have been with for years are in it and I’m looking at the correct provider directory on blueshieldca.com. Can I change still my plan to something else? (How does one do it in coveredca.com to change just the plan and nothing else?

Answer: Login in to your Covered California account and select “Terminate Participation” terminate.png Click on image to enlarge. You will directed to select a termination date that is a least 2 weeks from today. If you want the new coverage on February 1st, select a termination date of January 31st. Now you should be able to select another plan effective February 1st.


Question: I heard the premium payment deadline has been extended once again to 1/15/14. It that accurate>

Answer: Yes. True for all Covered California carriers. CC made announcement late yesterday.


Question: I’ve submitted my payment info twice on the Anthem payment landing page. Once on Dec. 13 and again on Jan 2. Both times I receive a confirmation email, but with no payment info or receipt. My credit card remains uncharged. Anthem call center says I’m in the system but says they are backlogged and I won’t receive a member number and card until the payment is processed. How can I access services for which I am supposedly insured as of Jan 1? I need to refill prescriptions. Is cash out of pocket and submitting a claim after I get my member info the only way?

Answer: The good news is they have you “in their system”. I don’t know how you made payment without receiving an application number. You will receive your application number by mail, then make an online payment at https://shop.anthem.com/sales/eox/payment/enroll/landing/CA or by phone at 855-634-3381. Assuming your coverage is effective on 1/1/14, you can recover the covered portion of any medical expenses you paid for by filing a claim (which is no fun, so don’t do that unless you have to).


Question: If a family’s estimated income for 2014 is just above the threshold of California Poverty Line that makes them eligible for premium assistance and cost sharing and in June 2014, it finds that its annual income is dropped below the poverty line making it ineligible for premium assistance and cost sharing. Please answer the following questions. a) Will this family’s health coverage be switched over to Medi-Cal in July 2014 or continued to the end of 2014? b) What will happen to its monthly premium assistance and cost sharing benefits availed of from January to June 2014? How those ones will be considered at the time of filing 2014 tax return? c) Also answer these question in vice-versa circumstances i.e a family’s estimated income comes under poverty line and in June 2014 its income increases making it eligible to premium assistance and cost sharing.

Answer: a) If this family were to report a change in income to the exchange that would make them eligible for Medi-Cal, for example becoming unemployed, they would be switched to Medi-Cal. The IRS would reconcile Advance Premium Tax Credits (APTC) received to that point on the family’s tax return. If the family’s income was below 100% of FPL for that year, there would be no recovery of APTC. (See previous entry on this subject). There is never any recovery of Cost Sharing Reductions (CSR). b) Conversely, increased income reported mid-year could move this family from Medi-Cal to subsidized exchange coverage. Again, the IRS would settle-up for the tax year.


No News on Mailed CC App?

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Question: Can I check online if I submitted my application by mail? I sent the paperwork by mail Nov 15, and I haven’t heard anything.

Answer: At this point, there’s a good chance your application has slipped into a black hole. I’d suggest that you complete a Covered California application by phone or online, before Jan 15 to be covered for Feb 1.


Question: I enrolled in a Blue Shield Silver PPO plan on Covered California’s website. That was 3 weeks ago. I can’t get through to Blue Shield on the phone. How can I make my payment to Blue Shield?

Answer: Your Blue Shield payment can be made online. To make your Blue Shield payment online, go to http://service.healthplan.com/blueshieldca/binder You will land on a login page that looks like this BSC Reg 1.png (click image to enlarge). You don’t have a login and password yet so you must register first BSC Reg 2.png. If you get this result BSC Registration.png, it means your application is not in their system. Blue Shield expects by January 3rd, 2014, to have everyone who applied by the Dec 23rd, 2013, enrollment deadline to be processed. Here is a direct number for Blue Shield (855) 836-9705. Hopefully you will get the account registration screen BSC Reg 3.png where you will create a username and password. Once the registration is complete, you’ll move to the payment screen BSC Reg 4.png where you should see the exact amount of net premium due . You can relax now, all that remains is is creating a payment account either electronic debit (EFT) or credit card (CC). Print the confirmation page and you’re done.


Can't Sign in to CoveredCA?

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Question: My husband and I have been working on our CoveredCa application & submitted ALL necessary IRS forms, etc. & qualify for the Fed. Tax exemption. We get to keep Kaiser as our insurance but at a much more affordable premium…however, I have tried both last night and just 10 min. ago to sign unto CoveredCa. website and I get sent immediately to a “page does not exist..blah, blah, blah”…I have my “username & password” but still get kicked off…what do I do?????

Answer: The coveredca.com website is down right now. Middle of the day on a Thursday. No warning, no explanation. Just wait I guess.


Question: Peter Lee is quoted in the Wall Street Journal saying if you made a good faith effort to start, you can finish up later. What is actually being offered in the way of an extension beyond December 23rd?

Answer: Covered California’s Certified Insurance Agents have been notified that they can continue to assist consumers to enroll for a January 1st effective date of coveragefor applications keyed into the CalHEERS system by 6:00 p.m. on December 28th.


Question: I just signed up for Health Net PPO - Enhanced Silver. I am confused by the conflicting info on provider networks. EG, on CC website California Pacific Medical Center (CPMC) is NOT in network. On HNet website, using CC-PPO as the filter, CPMC is IN network for 2014 for that plan. CPMC’s own website says it is “in process of negotiating” with Healthnet. Who do I rely on? When will I be able to know FOR SURE whether Hnet covers this hospital? Any guidance will be appreciated. Is it safe to think that Health Net will honor its OWN provider directory for its Covered California plans?

Answer: I can provide guidance, but not a definitive answer. In this scenario, the Health Net website listing of its Covered California PPO network is more likely to be up to date than the other choices. My guess, we won’t be “sure” about the accuracy of the carrier network listings until mid-January. As for Health Net “honoring” an inaccurate listing: they will not provide in-network coverage for a provider who was erroneously listed. You will however have the option of changing plans,including carriers, even beyond the open enrollment period if you erroneously picked a plan without your desired provider(s).


Question: What happens after my Covered California application is complete? I have received nothing from them?

Answer: You will not get any response from Covered California (CC) beyond what you can find in you online CC account. Login to your CC account. The “Progress Bar” is that horizontal line across the top of the page with checked boxes.

Confirm Enrollment: The “Enrollment” box should be checked. If not click on the “Eligibility” box and now you should see a check the enrollment box. If your application is complete, you will see an enrollment summary page with the health plan selected, effective date of coverage, and net premium due. You may want to print that page for your records. If you do not see your enrollment summary, your application is not complete. Complete it by going through the plan selection step again.

Confirm Eligibility: From the progress bar, select “Eligibility”. You will see a very busy page with your eligibility results. Each family member is listed separately and you may find that eligibility varies by individual. Most commonly, for example, parent(s eligible for APTC (Advance Premium Tax Credit - AKA Subsidy) and CSR (Cost Sharing Reduction) and child(ren) eligible for Medi-Cal. Do not be concerned if you see that you are “Conditionally Eligible”, that just means that you will have to provide verification documents within 90 days.

Once your enrollment is confirmed, your next contact will be from the insurance carrier you selected by automated phone message and mail, with instructions to pay your initial premium by January 6th.


How Long for Document Verification?

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Question: Only proof of citizenship was needed for my family - docs uploaded now 2 wks ago - when will verification of docs occur so that enrollment can occur? Thanks!

Answer: You are conditionally eligible now. What that means to you is you will have coverage on Jan. 1st. The conditional part is submitting the required verification documents within 90 days of the date of your application. I guarantee you that whatever you have submitted so far has not even been looked at. So don’t stress. You probably will not get any response to your submittal until well into January.


Applying with 0$ Current Income?

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Question: My son is going to be 26 on 1-3-2014. He is covered on my insurance until 1-31-2014. He is living at home and is between jobs and does not have income. Covered California does not allow him to enter information without showing an income. Also, askes for number of people in household. My husband and I have our own insurance so we would not be applying. How does he fill in this information. He does not need his insurance until 2-1-2014, however, he needs to be covered. We have both tried calling but to no avail as the system is super busy. Please explain how my son proceeds.

Answer: Your son should apply for coverage through Covered California anytime after December 23rd and before January 15th for his coverage effective 2/1/2014. He is a one-person household and since he is estimating his income for 2014, he must enter in income figure even though he is earning $0 today. A number under $16,000 will make him eligible for Medi-Cal. He must promise to file a tax return for the 2014 tax year. (I am assuming that his parents no longer claim him as a dependent.)


Question: I’m little confused about deductible for Bronze Plan.I understand I have to pay $30 each for primary care visit when I choose gold plan. Covered CA website also states that gold plan primary care copay is not subject to deductible. Health insurance benefits chart posted on Covered CA website states that Bronze plan cares copay are subject to deductible. What does it mean? I though copay is cost for services to which deductible does not apply. For example, standard benefits says specialty care visit copay is $70 and deductible is $5,000. Hospital charge me $300 for specialty care visit. Do I have to pay $300 before deductible $5000 met? And then pay $70 for specialty care visit after deductible met? Or do I have to pay $70 regardless of deductible?

Answer: The Bronze plans copays are not subject to the deductible for up to 3 office visits, including pre-natal and post-natal visits, mental health and substance abuse visits, and urgent care visit. What that means to you is you pay only the copay. The emergency room and ambulance copays only come into play once the deductible has been met for a given calendar year. So if you have already spent $5,000 in covered medical expenses for the calendar year and you go to the emergency room, you will pay the $300 ER copay only. Now let’s say you’ve already met the out-of-pocket maximum, having spent $6,350 for the calendar year, you will pay nothing for emergency room services or any other covered expense.


CC Pediatric Dental?

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Question: I’ve gotten conflicting answers about this (pediatric dental). Covered CA rep said they were required to offer it but I was not required to buy it. But Anthem won’t let me buy a policy through them without the added PD policy (its not included in the medical policy). Anthem rep says its the state law & that possibly Covered CA has an exemption even though they are offering identical policies. The State Dept of Insurance could not explain why the difference in answers. What gives!?

Answer: Months ago, Covered California decided not to require carriers seeking to participate in the exchange to include pediatric (-19) dental benefits in their medical plans offered through the exchange. So the carriers set their rates without accounting for pediatric dental benefits. Later, the exchange realized they made a mistake and are actually out of compliance with, at least, the ACA’s intent on this issue. Too late, the rates were set. In the meantime, the carriers’ off-exchange plan offerings learn must include pediatric dental. What a paradox, the exchange is not including pediatric dental and out-of-compliance with the law and the non-exchange got it right.


Question: What do I do if I’ve never accepted my employer’s health insurance and now I want to enroll for 2014 but the open enrollment period isn’t until July of 2014.

Answer: Interesting question! Since you do not have access to employer-based coverage at this point in time and you decided to opt-out of your group coverage before the ACA mandate was fully implemented, I believe that you can apply for Covered California coverage, answering “None of the above” to the question about access to other forms of minimum essential coverage. But remember, to be in compliance with the ACA, you have to accept your employer’s coverage at your company’s next open enrollment period and drop your Covered California coverage at that time.


Question: If my spouse and I each have different needs insurance wise, are we each able to select our own separate plans or must we sign up for the same plan?

Answer: The paper application (page 25) has always had the option for separate selections for each family member. There is no way to do it online. Some have said that a Call Center Rep can do it over the phone, but the outcome is unsatisfactory because the subsidy cannot be distributed properly.


No Invoice?

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Question: I enrolled in Blue Shield Silver PPO 7 days ago and have an applications number and a case number. Have not received invoice from Blue Shield. I called them and they said they have no record of my case and to call Covered CA. I called many, many, many times and they do not answer their phones nor do any of there Certified Counselors answer their phones either. Help!

Answer: It could be that your application data is still “in transit” between CC and Blue Shield. I would check to make sure your CC online account to see if your online application is complete. Login and click on the “Eligibility” tab. You will see a summary of your eligibility status for CC coverage, APTC, and CSR. If that looks OK, click on the “Enrollment” tab and you should see the plan you selected. If your Covered California online application is complete, continue checking with your carrier until they have it in their system. Call your agent if you don’t understand what the heck I’m talking about.


Question: My two sons had been on Healthy Families, their annual review is this month. I submitted proof of income and now received a letter requesting proof of property, and then another stating they have been approved for medi-cal with a $4800 share of cost. Should I not submit the info. they requested and just apply through Covered CA? ( I’m applying for coverage through CC for my husband and myself and the calculator shows they qualify for medi-cal). I’m worried if I complete the annual review we’ll be stuck with that share of cost.

Answer: Right. Ignore the proof of property request from Healthy Families and apply through Covered California for the whole family. The kids will be on Medi-Cal but your assets will not be considered if you apply through CC.


Pay Premium with HSA?

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Question: Can a person make payments of premium of ACA plans through its health saving accounts and claim deduction of its share of premium?

Answer: No. HSA funds cannot be used to pay premiums. HSA withdrawals are not taxed if they are used to pay for qualified medical expenses that does not include insurance premiums.


Question: Is there a tax penalty for opting out of pediatric dental? We have one 2 year old and a baby on the way. We bought the whole family insurance on the exchange but it did not come with pediatric dental. The add-on PPO dental plans are very expensive for what they include and our beloved dentist does not take any HMO plans (which are the cheaper options). It seems it would be far less expensive for us to pay for dental check ups out of pocket than to buy the insurance… at least for the next few years while the kids are very young.

Answer: Insurance works best and rates are lower for all, if everyone is in the pool. That’s the reason behind making pediatric dental mandatory. There is no penalty for not taking it, but you will not be able to get medical coverage without it if you have a child under 19.


Unmarried Parents Household?

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Question: We have a son that is not currently covered, are never married parents living together. Do we have to include both incomes in the household? Or just the head of household?

Answer: It depends on whether you file taxes jointly. Remember, "if you file together, you buy together".


CC Application Pending?

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Question: I submitted my prior year taxes, which do not reflect current income (had some stock sales) but I appended an explanation in the comments. My verification is “pending”. However, it says all documents must be submitted by 12/23 and I don’t know if they need anything else since they have not reviewed it or contacted me. Is it okay to just wait and see what happens for APTC and CSR as long as I attempted to provide supporting documents?

Answer: If your application is “pending” it’s because it’s not complete, not because of verification issues. Login and see what you need to do to complete it. If you need help call one of the agents in our Find-a-Pro Directory. It’s not because they don’t like your verification efforts. I can safely say that the documents you’ve submitted so far won’t be looked at for some time. You actually have 90 days from the date of your application to submit verification documents and you can be covered in the meantime.


Question: Covered CA has a paper app that does not include income info(online you click that you do not want help from the government). If a person bypasses the income information but applies thru Covered CA…can they still qualify for a tax credit at end of the year if their income was such that they would have qualified for a subsidy?

Answer: No. They must provide income information (and verification if requested) in order to be eligible for the tax credits retroactively. So, the long form of the paper app would be required in order to keep the option for tax credits.


Question: Can a senior citizen who is paying for Part A of Medicare because he has not worked in the US cancel Medicare and sign up ACA to take advantage of qualified subsidy?

Answer: This question was answered earlier in the CAHBA Q&A Forum by Premier Agent Max Herr. He is Max’s unedited answer.

Courtesy of the PPACA, persons age 65 and older are now required to enroll in Medicare unless covered by another health plan (generally employer-sponsored). As a result, no one over age 64 is eligible for premium tax credits regardless of income.

The exception to the Medicare enrollment is based on residency. Legal immigrants over age 65 are eligible for enrollment in Medicare if they have been in the US at least 5 years. Prior to that, they must obtain “minimum essential coverage” in some other manner.

Persons over age 65 who do not have fully insured status (40 credits) pay a premium of up to $426 in 2014 (less than 30 credits, the premium is reduced for persons with 30-39 credits). Failure to enroll in Medicare Part A when first eligible (at age 65 for most, or when the five-year residency threshold is crossed if later) means a 10% premium penalty for twice the length of time a person was not enrolled in Part A.

The Part B premium penalty remains a lifetime penalty. The 1% per month premium penalty for Part D is also a lifetime assessment.

So the temporary solution for this German couple, if they have not been in the US for five years is to obtain any form of minimum essential coverage. Once eligible for Medicare Parts A and B, the monthly cost, even at the maximum of $426 for Part A + $104.90 for Part B, is likely to be a lot lower than a Gold plan for a 64-year-old (or older) person.

At $75,000 income, they are well below the joint MAGI threshold for a Part B premium “enhancement”.


Life Triggering Event?

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Question: In final disclosure when purchasing plan, it states that I can’t change plans unless a life triggering event occurs. Does this mean I am wedded to this plan forever or just for the year. Also, what constitutes a “life triggering event”?

Answer: I believe you are referring to a “qualifying event”. Conception would be a “life triggering” event. Just kidding. There are certain qualifying events that must be met in order to be eligible for special enrollment (outside open enrollment) in Covered California. The length of the special enrollment window is 60 days after the qualifying event. If you do not meet one of these qualifying events, you must wait until the next open enrollment period. Here is a list of qualifying events that will trigger (there’s that word) a special enrollment.

  • Lose Minimum Essential Coverage;
  • Gain a dependent or become a dependent;
  • Become a U.S. citizen, U.S. national or lawfully present
  • Cancellation or lapse of coverage in a Covered California is unintentional, inadvertent, or erroneous as a result of an error, misrepresentation, or inaction of Covered California or Health and Human Services.
  • Covered California substantially violated a material provision of its contract in relation to the enrollee.
  • Become newly eligible or newly ineligible for advanced premium tax credit (subsidy) or has a change in eligibility
  • Employer-sponsored plan will no longer be affordable or provide minimum value.
  • A permanent move
  • Recently released from incarceration.

Insure Child Only?

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Question: I want to sign my son up for child only insurance. i cannot find any information on how to do this on this very confusing site.

Answer: Create an Covered California account, list all household members, all members except child decline coverage.


Can I Switch Insurance Company?

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Question: I have completed the CC application process and have selected Anthem Blue cross Silver. Is it too late for me to switch to Blue Shield?

Answer: No. You can login to your Covered California account, withdraw your application, and select another carrier’s plan. You can do this anytime within the open enrollment period.


Mid-Year Household Change?

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Question: My son will graduate from college in June 2014 and expects a full-time job with employer health care. How will this impact my family’s eligibility for ACA subsidy that we otherwise will meet.

Answer: It is your responsibility to notify Covered California when your son has coverage. Covered California will recalculate your subsidy at that time. If your son files his own income tax return in 2014 and you do not claim him as a dependent. You will continue to pay your same “fair share” of the premium for the remaining household.


Fair Share?

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Question: If you look at the income chart on CoveredCA, it looks like a household of 3 will qualify for a subsidy as long as their household income is under $78,120. But only one family member of the household needs coverage. According to the shop and compare tool, this family member does NOT qualify for a premium subsidy. If I recalculate and say that all three members of the family need coverage, then they do qualify for a subsidy. What gives?

Answer**: “Your fair share” of the premium is established as a percentage of your income. For a 3-person household with an income of $78,000, your fair share is 9.5% of income. That equates to about $620 per month. This number is a constant regardless of who is to be covered. If all three members of the household need coverage and the premium is $1120 per month, you’ll get a subsidy of $500 per month to cover the difference. If only 2 people need coverage, your fair share is still $620, and if the premium for 2 people is $720, you’ll get a subsidy of $100 to cover the difference. But if only one person needs coverage, your fair share is still $620, but the premium is only $300. So you pay the $300 without a subsidy.


Out-of-Pocket Maximum?

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Question: Nobody at Covered California can tell me what my out of pocket maximum would be. The website says 2250 per my income and plan choice, but when I call Healthnet directly they told me my out of pocket max could be up to 12K if I go out of network. Nowhere is any of Covered CA does it state that. What is the right answer?

Answer: Apparently your income makes you eligible for an Enhanced Silver Plan with an out-of-pocket maximum of $2250. That's a great deal. If you are smart about utilizing your benefits, you should never have an out-of-network bill of any kind much less have to worry about the out-of-network annual maximum, but the Health Net rep was right, you would have to spend $12,000 out-of-pocket before you are covered 100% out of network.


Can Over-65 Get PPO Off-Exchange?

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Question: Could German couple 79 & 77 making $75k get any subsidies with Blue Shield PPO? would a short term plan make any sense. They’re coming from $1800/mth Health Net 3000ded PPO.

Answer: Based on their income they are not eligible for subsidized coverage in Covered California. I suggest they shop for replacement coverage off-exchange. They can get better coverage with Blue Shield or any carrier including Health Net for less money.


Question: I am at the last stage of the enrollment process and for some reasons I receive a message - “Your enrollment could not be processed at this time. Please try again later.” I have been trying for 3 days now and the problem still remains. Two of my friends also have the same situations. We all choose Blue Shield Silver 70 PPO. We are not sure this is a Covered CA technical issue or Blue Shield related.

Answer: This is definitely a Covered California issue, not Blue Shield. Despite the error message, if you were able to select a plan, it is quite possible that your application is complete. Check with Blue Shield at 855-836-9705.


Question: How and when will I be notified by my insurer in order to make the first premium payment? My Covered California registration for Anthem BC Silver is complete. It says my first premium payment is due December 26. Will Anthem mail me an invoice, or will they contact via email? Since there appears to a noticing backlog to insurance carriers, will the payment date be extended?

Answer: Yes. The initial premium payment deadline for January 1 coverage has been extended to the second week in January. I recommend calling Anthem customer service at 866-820-0765. If you are in their system, they can take your premium payment online.


Covered for 90 Days?

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Question**: If I applied for Covered Ca and came back pending verifications for either Magi or APTC and am told to wait for a letter in the mail. Is it true that I am eligible and covered for the first 90 days and if verifications are not submitted I can will be discontinued?

Answer: Yes. You are approved for APTC for 90 days of coverage. APTC beyond 90 days is contingent on providing the requested income verification.


Will I Have Coverage January 1st?

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Question: Considering that Blue Shield does not know that I selected them as my insurance carrier, what happens come 1.1.14 for those of us who have completed all we’re supposed to do on our end? Hopefully there are no medical issues in early January but with not a lot of time remaining to receive an acknowledgment notice from BS and premium statement to make a payment by the 1st ~ where does that leave us “if” we do need medical services come 1.1.14?

Answer: Although I believe Covered California will find some way to make sure everyone who applied on time is covered on January 1st, nobody can guarantee it at this point. Claims can be handled retroactively if necessary.


Plan Selection Deadline?

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Question: My eligibility results say this: “You must choose a health plan by December 07, 2013.To choose a health plan, click the “Choose a Health Plan” button below.” I do not understand why I have to choose a plan by Dec 7th. I thought the deadline for coverage to start on Jan 1 2014 was Dec 23rd. If open enrollment lasts until March 31st why do I have to choose by Dec 7th? If I don’t will I lose my chance to enroll in a plan for 2014?

Answer: Upon conditional approval, you are given 30 days to select a plan. (That may account for the first date - Dec. 7th). By design, 30 days was thought to be more than enough time to select a plan. Now that the application deadline for January 1, 2014 coverage has been moved back to December 23rd, a person applying today has 16 days to select a plan and complete their application. A plan must be selected before your application data can be forwarded to the appropriate insurance carrier - Anthem, Kaiser etc.. It’s the carrier’s responsibility to collect your initial payment, so they’d like to have that done ASAP. It was intended that your coverage would not start until you had paid your first premium. Given the first month or so of the open enrollment period was FUBAR, the date for collecting the initial premium for 1/1/14 coverage was extended into the 2nd week in January. So, yes you can drag your plan selection to Dec 23rd and be officially covered on Jan 1 (though I don’t know why you’d want to create that kind of stress), but don’t expect to get your insurance card until late January. If you do not complete an application by March 31st you will lose your chance to be covered in 2014.


Question: Can I purchase a qualifying “metal” plan outside of CoveredCA (e.g. directly from a carrier or through a broker) for 2014 and claim a premium subsidy when I file 2014 taxes in April 2015, if my 2014 MAGI qualifies me for a subsidy? May I retroactively claim at 2014 tax filing time a rebate on overpayment of other expenses (copays, deductibles, etc.) on Enhanced Silver plans, if my 2014 MAGI would have qualified me?

Answer: No. A person cannot retroactively qualify for tax credits on a health plan purchased outside of the Exchange. The exchange determination of subsidy eligibility entails more than simply verifying income, for example there’s residency, household size. and employment status as well, things the IRS can’t do as part of your tax return.


Refuse Agent Delegation?

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Question: In terms of paper applications submitted to Covered CA by agents; if the agent doesn’t accept the online agent delegation, will Covered CA still process the application for the applicant minus the agent? We are loosing confidence in CC, and are considering our options including cutting ties, but want to make sure our clients applications are properly processed.

Answer: If you submitted a paper app for a client and then refuse the delegation online, you would be doing your client a great disservice. There’s no telling how long that application would remain in limbo if you refuse to enter it online. Not matter how you feel about Covered California, you know you have to put the client first.


Doctors On and Off-Exchange?

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Question: Some of the doctors listed on Healthnet site say they are only on the ON - exchange Bronze PPO plan, but not on the OFF exchange Bronze PPO plan which is more expensive and the same coverage. Can Healthnet have a distinction of doctors covered if you buy the same exact plan just off the exchange?

Answer: No. Health Net’s provider network for any given plan is the same on-exchange and off-exchange. That’s true of all carriers that are part of the exchange. The provider network issue is like quicksand right now. There’s no solid ground on which to make a decision because carriers are still inn negotiation with medical providers to fill out their networks and like most negotiations, they come down to the wire - Dec 31st. The networks that the carriers are presenting to the public are confusing too. You could be looking at Health Net’s current provider directory and comparing it to their 2014 directory. You can’t get reliable information from your doctor either. For example, you doctor says they are in the on-exchange network, but not the off-exchange network. Do they even know what on-exchange and off-exchange means. They could be comparing their small group network with their individual network. It may be February or March before the providers networks are resolved to the point that a consumer can make an accurate comparison between provider networks among carriers in the individual marketplace. Until then it’s a crapshoot.


Wait for Subsidy?

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Question: With variable investment income, I decided not to wait for income verification. If I pay the full premium thru 2014 and then my 2014 Income Tax Return is below the income level, can I receive the subsidy on a retroactive basis?

Answer: Yes. In fact that would be the ideal way to handle your variable income issue.


How to Handle Paper App Backlog?

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Question: I have submitted over 100 paper applications by mail and fax since Oct 1st. I have yet to get confirmation or any other response from Covered California. What can I do?

Answer: You should start seeing them as new delegation notices in your agent account on Covered California in the next day or so. Covered California staff are are creating online accounts for applicants who already submitted paper applications. All CC is doing is creating the account and delegating the writing agent. The agent will have to complete the applications online from their copy of the paper application. A Covered California spokesperson told me that if delegation notices are not showing up in an agent’s portal by Friday morning, “agents should create a new account for that applicant and enter the entire application online”.


Question: We applied on the CoveredCA website on November 1st and still have not received an invoice from Blue Shield. Should we contact Blue Shield directly or what other actions should we take to determine our status. Covered CA website indicates that our enrollment is complete.

Answer: Covered California has yet to install a working data link to the carriers to transfer applications to them. The carriers get a report from CC on the number of applications processed for them, but CC has yet to send application one. So in your case, Blue Shield does not know that you have applied, much less be in a position to confirm your coverage and send you an invoice. This will get resolved eventually, but it’s a huge bottleneck, particularly because so many paper applications have been submitted.


Don't Want Kids on Medi-Cal?

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Question: I have clients whose kids are ending up on Medi-Cal, but because they are attending college outside the state, they don’t want Medi-Cal. Is there a mechanism by which they can have their kids on their plan and avoid Medi-Cal? Covered California suggested calling the County and refusing Medi-Cal, but most counties have no idea what I’m talking about.

Answer: The family’s household income must exceed 266% of FPL (approximately $52,000 for a 3-person household or $64,000 for a 4-person household) for a family’s kids to qualify for a subsidy in Covered California rather than Medi-Cal. If your 2014 income estimate is under that threshold, the kids cannot qualify for a subsidy in Covered California and are expected to enroll in Medi-Cal. If that is unacceptable for any reason, I think the best way to avoid it is simply not to apply for Medi-Cal for the kids. They can purchase their unsubsidized coverage either in Covered California or off-exchange directly from a carrier. In this example, there is a potential advantage to purchasing through the exchange. If the household income ends up being greater than expected and places the family over the 266% FPL threshold after all, then the family would receive additional tax credits retroactively for the portion that was not advanced for the kids in that tax year.


Question: Has Blue Shield re-priced their Exchange Plans? A month ago their Platinum (aka Ultimate) PPO was $1631/mo. That price was the same, in and out of the Exchange, and was the price quoted to me within Covered CA when I submitted my application. Meantime, I log into Covered CA and guess what - that $1631 is now $1777. It’s still $1631 on the Blue Shield site for the regular market. What’s up with that?

Answer: Blue Shield did not raise its 2014 rates. The first rate adjustment will be 1/1/15. Covered California rates can differ from off-exchange rates in some cases, but that usually involves pediatric dental and if so the off-exchange rate would quote higher not lower. I’m cannot account for the results you describe. Include your email address and personal information - age, zip, number of family member - for a more specific answer and send it to info@cahba.com.


Question: My estimated AGI (2 person household) for 2014 is $20,000. In 2012 I cashed out of an annuity and had an AGI of $70,000. I was considering cashing out of another annuity in 2013 which would lead to a similar AGI. Can I obtain the reduced rates (AGI $20,000) for my 2014 premiums? What's the best way to proceed?

Answer: Since your estimated 2014 income is way less than the 10% allowed without verification, your best option is to submit an affidavit explaining that you will not be cashing out another annuity in 2014. You should also submit documentation showing the annuity income. Feel free to cash another one for the 2013 tax year. It will not affect anything at this point. If you do so, you will probably have to do this again when you renew for 2015 to explain why your income in 2013 if higher than your 2015 estimate.


Question: I read an article in USA today advising that people who do not qualify for subsidies were finding it easier to shop on authorized web-based agent sites. I took a look at www.cahba.com and found 11 CIGNA plans which are bronze/silver/gold compatible, but are not on CoveredCA. They are more expensive than Blue Shield's 2014 plans, but they appear to have the broadest choice of providers I have seen offered. Why are these CIGNA plans not on CoveredCA and is there any danger of being deemed not to have MEC if I buy one?

Answer: Health insurance carriers had to apply and compete to be accepted as qualified health plans offered by Covered California. CIGNA chose not apply, so their plans cannot only be offered off-exchange. However, CIGNA plans offered after January 1, 2014 must be ACA-complaiant. So there is no danger of them not having minimum essential coverage. You are right on about there being no advantage to consumers who are not subsidy eligible to buy through Covered California. In fact, there are more advantages to shopping off-exchange and dealing directly with the insurers. For example, there are more choices off-exchange, like CIGNA plans, and the application process takes only a fraction of the time it takes to enroll through Covered California.


Question: The Covered Calif. application says “Person 1: Has this person been offered affordable full-coverage health insurance for January 2014?” What is the definition of affordable? Will people who answer yes be denied a subsidy?

Answer: People who answer that question “yes” will generally not be eligible for a subsidy in Covered California. To be deemed “unaffordable”, the coverage offered costs an employee more than 9.5% of the annual household income.


Question: In order to prove that I qualify for premium assistance, I had to upload evidence of my income. I uploaded the required documents a couple weeks ago. How long does the verification process usually take? Should I go ahead and “check out” with a health plan even though I don’t know how much premium assistance I will be getting?

Answer: You can safely assume that you will be getting the subsidy for which you were conditionally approved. Go ahead and select your health plan. Covered California could take up to 90 days to “verify” your income estimate for 2014.


Conditionally Eligible for 90 Days?

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Question: My wife & I are retired; most of our income is from investments. We received notification today from CoveredCA that we were approved for only 90 days of coverage until we show proof of income. But we don’t know how to show proof of income, since our 2014 income will be considerably lower than our 2012 or 2013 income. (This is because we had been converting portions of our traditional IRAs to Roth IRAs, artificially raising our income each year.) What are we supposed to do to “prove” our 2014 income? Thank you!

Answer: There’s no app for that :-) I suggest you write an explanation in a bit more detail than you have above and include any documents that back it up - e.g. IRA withdrawals and Roth deposits . If they are not satisfied with that, let them request something specific.


Question: Can I apply for a Children’s Dental plan on the Covered CA site or do I have to call the dental plan company directly? I do not see where to do it on the CoverCA site.

Answer: Covered California just added pediatric dental plan selections to the online and paper applications. You’ll find the “Choose Pediatric Dental Plan” and “Choose Health Insurance Plan” on Attachment D. page 25 of the Single Streamlined Application and in in the enrollment section of the online application.


How to Buy Dental Plan for My Child?

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Question: I would like to sign up for the Delta Dental PPO plan listed in the CovererdCa Dental Plans for Children document. I called Delta, they said they don’t sell it. How do I apply for this dental policy?

Answer: Delta Dental is one six selected companies including Anthem, Blue Shield, Health Net, LIBERTY Dental, and Premier Access Dental - offering dental plans in covered California. You can select Dental Dental’s plan on your Covered California health insurance application either online or by paper application. The dental plan selection was added to the applicaqtion very recently.


Can I Stay on COBRA?

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Question: I enrolled in COBRA when I was laid off from my previous employer in September, 2013. I have received a letter from the insurer stating that my policy will not be available after December 31 as it does not meet new federal requirements for 2014. Employees will be offered a choice of new plans to chose from for 2014. Will I be able to chose from one of these plans as a prior employee with COBRA coverage until my 18 months of COBRA coverage expires? The current premium with COBRA coverage is less than any of the quotes I have received from the current market exchange offerings.

Answer: Yes you can stay on COBRA if you prefer, but you will have to reevaluate your decision once you see the premium for the new ACA compliant group plan you are offered. The rate will probably be higher than the non-compliant plan.


Question: I have been told by Blue Shield that I will be able to stay in it until March 31 2014. The new Bronze HSA plan is 50% more expensive for almost identical coverage to me, so I plan to want to stay in the existing plan. However, as I read the IRS website, that means I could be liable to paying the “individual shared responsibility” penalty for the first three months of 2014, which at my income level would more than offset the premium savings. Can you please clarify whether I would be liable to the penalty or not?

Answer: No penalty. You get transition relief from the shared responsibility payment because your coverage ends in 2014. The transition relief begins in January 2014 and continues through the month in which the 2013-2014 plan year ends, March 31st in your case.


Grandfathered Plan Rate Increase?

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Question: If someone has a grandfathered individual plan, will the rates be locked in till open enrollment next year or can they have increases mid year that may be unfavorable? Which means the client is locked in till open enrollment or does that open a window to make a move to another option?

Answer: Your grandfathered plan rate is only locked in until the policy renewal date, which is the anniversary of the policy”s original effective date of coverage. If that date falls outside off an open-enrollment period, you cannot choose to change plans regardless of the rate increase. That is not a qualifying event. You will not be able to change your plan until the next open enrollment period - Oct 15 to Dec 7 of that year.


Premium Subsidy for Retiree?

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Question: An earlier response here (from Oct.) indicated that retirees under age 65 who are eligible, but not enrolled in employer-sponsored coverage, can obtain premium subsidies in 2014 to purchase coverage through the CA exchange, even though they have access to a employer-sponsored health plan. I would like to take this approach. (I’m 62 and on a retiree plan for 2013 that I can continue next year if I wish. Instead, I’m contemplating a switch in Jan. to a plan on the CA exchange & planning to get a subsidy.) However, in registering, the website asks if I “have or have been offered affordable, minimum standard value health insurance for 2014?” The answer to this is “yes”, but someone at coveredca told me on the phone that if I answer “yes” it will disqualify me from any subsidy. I believe I’m entitled to the subsidy, but it appears the website will not allow it. What can I do?

Answer: If you have access to affordable employer-sponsored coverage, even for retirees, you are not eligible for as subsidy. Look at it this way: since your former employer offers you a group health insurance plan to which they contribute at lease 50% of the cost of coverage, you already have “subsidized” health insurance. Federal subsidies are for people who do not have that option.


Household Size with College Student?

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Question: My son is away at college in New York. I claim him as a dependent on my taxes. He also earns enough to file his own tax return. I would like to purchase a policy for the two of us with subsidies through CoveredCA. Can I do that? Do we report our incomes separately?

Answer: Think of your household as everyone in your tax family. Your son at college in New York, whom you do claim on your taxes, is considered part of your household. And if that son happens to hold down a part-time job while attending school and earns enough money to file a tax return, you’ll need to include his earnings as part of your total household income. So you can purchase a policy for the two of you through Covered California. Your eligibility for premium assistance and cost savings reductions will depend on your aggregate income for a household of two.


Question: I have signed up some clients with incomes that qualify them for Medi-Cal. Since we will receive a $58 commission, I have continued the application process. When I look on my individual listing for these clients they show as “ineligible”. Does this mean they are ineligible for a subsidy? Also, will the application be forwarded to Medi-Cal?

Answer: Yes. If the applicant’s income makes them Medi-Cal eligible the application will be handed-off to the county for further processing. The “ineligible” tag you see in your CC agent account means the applicant is ineligible for Covered California coverage. If your client designated you as agent of record you “should” eventually get your one-time $58 sign-up fee.


Why Are Rates Higher in Northern CA?

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Cost Comparison by Regions.jpg click_image.png

Question: Rates are considerably higher in the northern part of the state than in SoCal. What’s up with that? I understand San Francisco being higher because everything is costlier there, but even the rural areas of the north counties are pricier than LA and Orange County. Can you make sense of it?

Answer: In a nutshell, it’s about population and competition. More population means more hospitals, large medical groups and other providers. That means more competition with more providers willing to contract at lower rates to get a leg up. That translates to a 48% difference in premium rates between San Francisco and Los Angeles for a 40 year old buying the 2nd lowest priced Silver Plan - $373 vs $252.


Why are Networks Restricted?

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Question: There has been much talk about restricted provider networks in the Covered California plans. If the plans have to be the same as those offered outside the marketplace, how are they restricted? Or all all individual plans restricted in comparison to group plans? Can you shed some light on this subject?

Answer: Individual plan provider networks have been "narrowed" for 2014 as a way of controlling costs. That's because a smaller number of medical providers are willing to agree to lower contract rates. Carriers who offer qualified health plans in the exchange must "mirror" those plans (including networks) outside of the exchange, so the individual plan networks are identical in the exchange and off the exchange. Group plans will generally have broader networks than individual plans, if not the same as pre-2014.


Who Sets Prices?

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Question: Does the ACA set prices for procedures etc or are insurance companies allowed to charge anything? Also, which insurance company has the best record for not overcharging for procedures?

Answer: The ACA does not set prices for medical services, nor for that matter does the law set health insurance rates. Insurance companies negotiate with health care providers - doctors, hospitals, etc.- to set a contract rate for each medical procedure or service. There is considerable variance in medical costs between insurance companies for the same service or procedure and also between providers within the same insurance company network, because negotiated contract rates are lower with some providers than others. There is no transparency for the consumer in this system so there is no way to compare the contract rates among carriers.


Continuation of Non-ACA Policies

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Question: I got a letter from Blue Shield that my existing policy would be terminated Dec 31st 2013, and I would be switched over to some new bronze ACA plan for the next year. A few weeks ago I received another letter and that states my current policy can continue until March 31, 2014. What is the significance of March 31st deadline? Has this something to do with the administrative directive Obama administration issued regarding individual mandate? The above letter was before the more recent development of the administration allowing non-ACA policies to continue till the end of the year. In light of that, should I expect yet another letter from BlueShield extending the current policy until Dec 31, 2014?

Answer: It is possible that Blue Shield will extend current non-grandfathered plans for another year. If so that would be a result of the recent mea culpa announcement by President Obama. The initial Blue Shield extension was ordered by the Department of Insurance because Blue Shield allegedly did not give policyholders sufficient notice of cancellation.


Covered Care & AGI

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Question: I’m having a hard time understanding how to enter my income on the Covered Care application. I’m self-employed, so my monthly salary does not include withheld taxes (I pay those quarterly). On the Covered Care application, if I enter the amount of the monthly check I receive, it looks like my salary is greater than it really is. There is no place on the application to enter a yearly AGI. Should I divide my AGI (line 37 of my income tax) by twelve, to show the monthly salary I actually end up keeping? And also, because I have a home office deduction, and there is a place on the Covered California application to list self-employment deductions, am I supposed to enter that amount on the application? Thank you. I’ve tried e-mailing Covered Care, but they still haven’t answered my questions. (You can click the chart to enlarge it.)

Answer: Yes. I think your idea of estimating your AGI for 2014 then dividing by 12 is a good way to report your income on a monthly basis. Perhaps this chart will help to deterring what part of your income counts toward AGI. (You can click the chart to enlarge it.) MAGI Chart.jpg


Get Subsidy From My Carrier?

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Question: In case a participating carrier cancels an existing plan as it does not comply with ACA and offers different plans that comply with ACA to insured, are those offered plans same or different from the plan offered under Covered California. Is the insured entitled to premium assistance and cost sharing help If the insured buys directly from the carrier?

Answer: Insurance companies who participate in Covered California (Anthem, Blue Shield, Health Net, Kaiser), must offer the identical plans off-exchange though you’ll find they use different plan names off-exchange (just to add a bit more confusion). You can select an on-exchange, Covered California, plan from one of these participating carriers after you have enrolled through Covered California and are eligible of a subsidy and / or cost sharing help.


How Do I Submit Proof?

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Question: After 45 days of working my way through a minefield, I was finally able to choose a health plan today and get a confirmation printed out. However, the way I understand it, I will have to submit proof of US citizenship for myself and my wife, either by uploading the documents or by mailing them in. I can’t find the online link anymore, so what would you suggest me to do?

Answer: Try logging in to your Covered CA account and check your “Secure Mailbox”. CC will send a formal request for proof of citizenship, including the reason for the request, examples of the types of acceptable proof and instructions on how to submit it, and your appeal rights. CC does not correspond by regular email for privacy reasons. Unfortunately, they don’t explain this sufficiently and secure mailbox messages go unnoticed.


Question: I just kind of wonder whether I will be able to keep my current non-ACA Anthem Blue Cross insurance plan until the end of 2014 after Obama's announcement today.

Answer: President Obama announced today that he (the federal government) will not require insurance companies to cancel ACA non-conforming individual plans on Jan 1, 2014, but would allow them to continue through 2014. Effectively, this presidential gesture passes the decision to cancel or not on to the insurance companies participating in the federally facilitated exchange. Here in California, where more than 900,000 cancellations have been sent out, Insurance Commissioner Dave Jones called on insurers to extend the policies being scrapped. Neither Obama nor Jones will have the final say, because Covered California requires insurance companies to cancel non-grandfathered health plans on 1/1/2014. The next CC board meeting is scheduled for November 21st and they will probably discuss the option to reverse the cancellation mandate for 2014. It seems unlikely, in my opinion, that they will overturn their mandate. It would cause chaos in the marketplace and they believe that the roll-out is going OK here.


Over 65 No Medicare or Medi-Cal?

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Question: I understand that seniors (new immigrant) over 65 without medicare or medicaid can purchase insurance through exchanges. I assume they won’t be able to get any federal subsidies, right? So should they actually purchase through off exchanges?

Answer: The immigrant you describe would be eligible for a subsidy in Covered California if income is under 400% FPL if “legally present”.


Question: I applied to Covered Cal and am eligible for Medi-Cal in 2014 (just under the income limit). I received nothing for a month until the county uDPS office sent me a note wanting income and residency proof. Is CC forwarding all Medi-Cal apps over to counties and are the county agencies not able to access the Federal Data Hub for verification info?

Answer: Correct. Medi-Cal eligible applications pass through Covered California to the County Office of CA Dept of Health Care Services. Access to the Federal Data Hub may or may not be working right now, but it would be typical to approve an applicant conditionally until proof of income and residency is received.


Anthem BlueCard Access Out-of State?

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Question: In your answer to a question about getting coverage in FL or CA, there was mention that Anthem Blue Cross would not be honoring Blue Card for ACA-compliant plans. However I looked in the brochure for both the on exchange and off exchange Anthem Blue Cross plans and they both mention Blue Card access (Page 4 of PDF mentions accesss to Emergency and UrgentCare coast to coast using BlueCard. Could you clear up the discrepancy?

Answer: Here is the quote from the brochure to which you referred: “When you’re traveling for work or on vacation, going to the ER or urgent care is probably the last thing you want to happen. However, our plans cover emergency and urgent care in every state through the Blue Cross and Blue Shield Association’s BlueCard® Program. This means you and your family have emergency and urgent care coverage from coast to coast.” The fact is that the Anthem Blue Card formerly covered non-emergency care from any BCBS network provider in another state for the same benefit coverage as if the cardholder were in-network in their home state. I would say that Anthem is a bit disingenuous in stating this as an extraordinary benefit since out-of-network emergency care is covered by all plans.


Question: I got notified by Anthem that my plan is canceling on Des 31. I’ve been trying to apply for a new plan at Covered California. So far I have been able to find out that I am not eligible for tax credits and that’s about all. I created an account, but I don’t see why I have to give them my financial information if I know I won’t get a subsidy. Is there another way?

Answer: Without a subsidy, there’s no compelling reason to enroll on the exchange. You should shop for off-exchange plans where you’ll have more plan options and the process is 3 times faster and you won’t be required to disclose your financial information. You can shop and compare off-exchange plans in seconds o this website. Your licensed insurance professional can also provide you with an off-exchange quote, advise you on plan selection, and make your enrollment easy. See Covered California is Not for Everyone


Question I have not been able to find out how the Medi-Cal eligible kids are being handled. An organization that I am working with was instructed by Kaiser to include a denial letter wit the application, if the kids qualify for Medi-Cal. I have not been able to get any information on the plans, who qualifies or what to do with all these kids.

Answer: In California, the income limit for adult eligibility for Medi-Cal is 138% of Federal Poverty Level (FPL) and for children it’s 266% FPL. That’s why you can have parents eligible for a CC subsidy while the kids are eligible for Medi-Cal. If the kids are eligible for Medi-Cal a “denial letter” won’t work. If they pass on Medi-Cal when eligible, they cannot be eligible for a CC subsidy. As for how to handle it? Complete a Single Simplified Application for the family and let CC sort it out. Medi-Cal Expansion Chart.jpg


1099 for Subsidy Income?

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Question: I heard that individuals will receive a 1099 from the Federal govt for any tax credits and/or subsidies they receive and will have to report it as income for state and federal tax purposes. Can you confirm?

Answer: No. The advanced premium tax credits (“APTC”) and cost sharing reductions (“CSR”) are not types of income and therefore are not likely to be reported on a form 1099. However, it is likely that qualifying individuals will receive a statement at tax time reporting any subsidy received. This statement will be used to help reconcile the APTC received (based on estimated income) with the APTC that should be received (based on actual income) at tax filing time. The APTC/CSR are not considered income and are not taxable regardless of how they get reported.

Thank you Steven C Stasoiski, Health Insurance and Tax Professional from Seal Beach, CA for this answer.


Risk Adjustment and MLR?

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Question: The insurance companies do not have any history with the exchange and are probably guessing the risk-profile of the customers. I understand that there is some mechanism built-in to make them whole if they guess wrong and lose a lot of money. (please correct me if I am wrong). My question is, if they find that they were too conservative and make too much profit — i.e. spend less than the stipulated percentage in patient care — are they still forced to give it back. Will it be refunded to the individuals, or to the government, or split equitably based on the subsidy amount.

Answer: The ACA law includes a “risk adjustment” provision that provides a behind-the-scenes mechanism to correct for market imbalances that occur if some insurers attract pools of subscribers whose expected medical costs are substantially greater or less than market-wide averages. It helps to accomplish this by subsidizing insurers that end up with a disproportionate share of high-cost patients and assessing competing insurers that — either through strategy or happenstance — end up with a better selection of health risks. Conversely, there is no mechanism to recover revenue from an insurer who does a better than average job of risk assessment. There is however and Medical Loss Ratio (MLR) regulation in the ACA that requires health insurance issuers to submit data on the proportion of premium revenues spent on clinical services and quality improvement. It also requires them to issue rebates to enrollees if this percentage does not meet minimum standards - at least 80% or 85% of premium dollars on medical care. If they fail to meet these standards, the insurance companies are required to provide a rebate to their customers.


Question: Not knowing what my income is from year to year, I could estimate my income to be lower than the actual amount. If it turns out the IRS says I owe them money because they paid me too much subsidy, will I also be charged interest, penalty, or fine?

Answer: No. There is no penalty or interest, because the IRS will recover the subsidy overpayment as part of your federal tax payment for that tax year. it would not be overdue.


Question: If someone has a giant loss carry forward, like 500K, it’s going to take a while for that to no longer show on line 37. So would that person virtually be on Medi-Cal forever, or for subsidy eligibility, do loss carry forwards only count in the year in which the loss occurred?

Answer: Loss carry forwards do not only count in the year in which the loss occurred. There are two types of loss carry forwards and I am not sure which one you are referring to. A net operating loss (“NOL”) can be carried forward to offset future operating income for up to 20 years following the NOL year. A capital loss can be carried forward to offset capital gains or reduce ordinary income by a maxim