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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.

When Can I Find Out My 2020 Rates?

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Question: I read that Covered California health insurance rates will be about the same for 2020. When can I check my actual rates?

Answer The Open Enrollment Period for 2020 starts on October 15th. At that time you can check your renewal rates or apply for coverage for the first time if you were not previously qualified.

Question: In my area, Covered California only offers one insurance company. I would like to have another health provider. Can I register in another county where they have a choice?

Answer: You should have a choice of carriers next year. Covered California says, “More than 99% of Californians will be able to choose from two carriers or more for insurance in 2020”. That’s because three of the eleven insurers participating in the Covered California exchange, including giant Anthem, will expand their footprint in the state.

Question: As minimum wages increase it puts me in a different wage bracket. Is there going to be a adjustment with Covered CA as wages increase? So many things are going up right along with the wage increase in which I am paying out more and saving less.

Answer: The increase in minimum wage in California for 2020 is $1.00 per hour. Assuming you work a full 40 hours for 50 weeks next year, your annual income will increase by $2,000. Your share of the cost for your insurance premium will go up by about $25 per month if you are a single taxpayer or less if you have dependents.

Question: I've sponsored my parents for green card through my citizenship. They receive total $3,000 per month for retirement from their native country. They are both 65 and over. I understand there is a 5 years waiting period for Medicare. Would I be able to purchase Covered by California for their health insurance needs?

Answer: Provided they are legal residents of California, immigrants are eligible to apply for health insurance coverage through Covered California regardless of age. They may also be eligible for premium assistance based on their taxable income.

Question: I get a subsidy but I still have to pay about $100 a month. How much will it go up next year.

Answer: Your share of the cost may not go up at all. If you are one of the lucky ones, it could even come down. Covered California, the state’s Affordable Care Act exchange, announced some good news a few weeks ago. They said average premiums would rise an average of 0.8% for 2020, the lowest annual increase in its history. In some regions, rates would increase even less or fall. Customers who shop around when enrollment for 2020 plans opens October 15 could reduce their premiums by as much as 16.5%, depending on where they live.

Question: If i am out of a job, with no income, can i get Covered California insurance, as long as I can pay the premium?

Answer: Absolutely, you may even be eligible for a subsidy to help pay the premium if you lost your employer coverage due to job loss.

Have you ever stepped up to the pharmacy cash register only to learn your new prescription will cost you hundreds of dollars — instead of your typical $25 co-pay — because your insurance doesn’t cover it? Or received a painfully high bill for a medical test because your health plan didn’t think it was necessary? Most people have, but only a tiny fraction ever appeal such decisions. In 2017, for example, enrollees in federally run Affordable Care Act marketplace plans appealed fewer than one-half of 1% of denied medical claims, according to an analysis by the Kaiser Family Foundation.

If you do appeal, your chance of getting the health plan’s decision overturned is a lot better than you might think. “About half of appeals go in favor of the consumer,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a healthcare consumer advocacy group.

There’s no sugarcoating it, though: Getting to “yes” with your health plan can be an ordeal, and you may need help from friends, family members, your doctor, insurance counselors, even legal aid societies. In California, health plans are supposed to help facilitate the appeals process. When they deny coverage, they must inform members in writing how to appeal. And when they receive enrollee complaints, they are required to acknowledge them formally, which sets the clock ticking on a series of steps to resolve the dispute.

Regardless of the type of insurance you have, you can do several things to strengthen your position even before you file an appeal.

Get organized You will need up-to-date medical records, as well as all communications with your doctor and health plan and any other paperwork that might bolster your case. “Don’t do anything over the phone. Do everything in writing. You need a paper trail,” says Maria Binchet, offering her hard-earned wisdom from the trenches. Binchet, a resident of Napa County, has a rare, disabling illness called myalgic encephalomyelitis, or chronic fatigue syndrome. Because none of the doctors in her Medicare HMO network has expertise in the disease, she says, she has requested referrals to outside specialists on numerous occasions over the last 22 years, been turned down each time and appealed nine times. After one of those appeals, the health plan allowed her a single visit to a specialist — but he wasn’t taking new patients.

“You have to be persistent and resilient,” she says. Binchet also advises that you request from customer services the unredacted notes of the health plan’s internal discussion about your case. The notes can help you determine how extensively your case was considered, who made the decision and whether that person was medically qualified to do so. A letter or phone call from your doctor to the health plan can provide valuable support. “It’s important that you get someone involved who can talk about the medical evidence, because that’s what this is really about,” Fish-Parcham says. Clock is ticking When your paperwork is ready, you must appeal first to your health plan. For most private plans, your deadline for filing the appeal will be 180 days after care is denied. The insurer then faces a deadline — usually 30 days — to render its decision. If it upholds its initial decision or doesn’t meet the deadline, you can take the matter to the agency that regulates the plan within 180 days. If your health is in imminent danger, you can generally get an answer in a matter of days rather than weeks. Unfortunately, different plans have different regulators, with varying appeal procedures. If you don’t know who regulates your health plan, call customer services and ask. A large majority of Californians have policies regulated by the Department of Managed Health Care, but millions of others are in plans regulated by other state agencies, such as the California Department of Insurance or the federal government. A good place to start is the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov ). Even if it is not your regulator, it can direct you to the right place, Rouillard says. If you are one of the 26 million Californians in plans regulated by the department, you can request a free review of your case by outside medical experts if your appeal to the health plan failed or was not answered by the deadline. These independent medical reviews are for cases in which a health plan doesn’t think a type of treatment is medically necessary or refuses to cover it because it is experimental — or won’t pay for emergency medical services after the fact. An archivewebsite on the department’s allows you to search past decisions for cases like yours. The summary language in those decisions might help you frame your arguments. You can also request an independent medical review through the California Department of Insurance (800-927-4357). If you are one of the 5.5 million Californians in a federally regulated employer plan, your regulator is the U.S. Department of Labor’s Employee Benefits Security Administration (866-444-3272 or askebsa.dol.gov ). Help is available As you wade through this process, there are organizations that can help. One of them is the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org ), which can assist people in public and private health plans. It offers free advice, can help you get your documents in order and provides legal services. Medicare enrollees can receive free assistance from the Health Insurance Counseling and Advocacy Program (800-434-0222 or cahealthadvocates.org /hicap ). Wolfson writes for Kaiser Health News, an editorially independent publication of the Kaiser Family Foundation.

Do I Have to Reapply?

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Question: Do I have to apply again to Covered California or simply continue to make same payments and same coverage I had last year, if my income has not significantly changed from last year.

Answer: You are probably automatically renewed, but there is an exception as follows: If you enrolled in 2018 by special enrollment and have not selected a 2018 health plan prior to December 13, you will not be automatically renewed. You must select a 2018 health plan and then actively renew that plan for 2019 coverage to avoid a break in coverage.

Question: I have enrolled in Blue Shield Trio 70 HMO for 2019. How can I choose a primary care doctor?

Answer: Blue Shield will issue a member ID number as soon as they receive your initial payment. Once you have an ID number, you can register on the Blue Shield website (blueshieldca.com) and select or change a Primary Care Physician. If you can't do it online, call Blue Shield member services.

Married Filing Separately?

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Question: I'm recently married and will be filing married/separate tax returns for 2019 tax year as he owes the IRS. However when applying to renew my covered cal insurance it states I must file married jointly. I've had covered cal insurance since it was offered and received the tax credit towards my premium and filed and paid taxes every year.

Answer: You will be ineligible for premium assistance if you're married and file separately, no exceptions.

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