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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.


July 2012 Archives


Question: I had health insurance coverage on my son when I was working for 2 years. In March I resigned from my job… filled out paperwork (to be added to father’s group coverage) on 6/30. The HR Department said that he will not be added to the insurance until the 1st of the year. Everyone is telling me that he should qualify for “special elections” and there is no time limit on that. Is this true? I think the employer is trying to say we waited too long to add him to his dad’s insurance.

Answer: Yes, apparently you did wait too long. You may enroll a dependent during the period beginning 31 days before and ending 60 days after a qualifying event. That would make May 31 the deadline adding to his father’s plan


Question: My employer offers me health insurance for me and my family, however the cost deducted from my pay check is outrageously high, were talking about $500 a pay check. I can’t afford that payment, and on top of that, the coverage is horrible. It would be far cheaper for me to purchase an insurance policy myself though a company outside of work, at half the cost, and with far better coverage. However all insurance companies I’ve called have denied coverage because my employer offers me insurance. Is this a law that Insurance companies can’t offer insurance for individuals who are given the option through their work?

Answer: You cannot be denied individual health insurance because you have group health insurance available. I don’t know why you were told otherwise. Perhaps, you are being denied individual health insurance because you do not meet the underwriting requirements - most frequently for preexisting medical conditions.


Question: I had a chiro adjustment 4 times, and electric stimulus and my insurance paid. Then for the next three, exact services, they denied. Then 4 times after the denial they paid again for same service. I appealed but they denied. Why would they pay for a service, then not pay, then at later date pay again. I’m confused. If I bring this to their attention, can they go back and deny the previously paid claims?

Answer: The most frequent reason for claims payment variations is the service codes the provider enters when submitting the claim are incorrect. You can also have errors in the carrier’s claims department. That may account for the hit or miss nature of your chiropractor claims. First of all, you need to know your coverage. Call your member services hotline. The number is on your insurance card. Have them explain your chiropractic coverage so that you know it. If you have been paid for benefits you are not due, you will probably want to keep quiet. If they owe you, raise hell.


Question: I’m currently 24 years old and my parents include me on their health insurance. There insurance renews in October. If I get married after October, will I still be included on their insurance through October 2013?

Answer: Your marriage does not affect your parents’ right to include you as a dependent on their health insurance coverage to age 26. Your husband, however, may not be included on your parents’ coverage.


Question: Child with born with health issues. So this child already has preexisting conditions from birth and her parents can”t pay the bills.

Answer: A newborn with preexisting conditions has a couple of options to obtain coverage: child only individual coverage and the Preexisting Conditions Insurance Plan (PCIP). Neither of these options will help the parents pay the baby’s medical bills while uninsured, but will cover medical expenses going forward regardless of preexisting conditions.


HIPPA Plan and Exchange

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Question: If you are currently under existing HIPAA individual plan can you then change to the new insurances to be offered by the Exchanges effective Jan 1, 2014?

Answer: Yes. HIPAA plans will phase out after the Affordable Care Act (ACA) becomes fully implemented in 2014. You will be able to purchase individual health insurance in the Exchange or the private market that costs less and provides better coverage than your current HIPAA coverage.


Question: How do I become an exchange navigator in California?

Answer: In California, Navigators and Assisters are essentially the same thing. Their roles and responsibilities are virtually the same. Both Eligible Navigators or IPAs must be affiliated with an Assister Enrollment Entity. Assister training and certification will begin in August 2013 so that IPAs are ready to assist with Covered California enrollments beginning October 1, 2013. Navigator certification will not begin until November 2013 because the exchange will need time to conduct an analysis to determine where enrollment assistance gaps occur (geographic areas or targeted market segments) then grants for the Navigator Program will be awarded to enrollment entities to fill-in the gaps. Navigators are expected to begin enrollment assistance in December 2013.


PCIP and CA Exchange

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Question: If I am currently enrolled in CA PCIP program, will it be necessary to then reenroll for new insurance via the new exchange? Also, there is a 6 month period where you cannot be covered by any insurance to enroll in PCIP. Will there also be a similar waiting period of non insurance for those ins plans offered by the exchanges? Will there be any pre existing condition exclusions allowed under the insurance co that will be in the exchanges?

Answer: Yes. You will want to enroll in a qualified health plan in the California Health Benefit Exchange or the private market outside the exchange in January 2014 when your preexisting conditions are no longer a factor. The coverage and rates should be better that PCIP. There will be no requirement that you be without health insurance for at least 6 months. The Affordable Care Act does not mention a waiting period and it is unlikely the California Exchange would require one. There will be no pre-existing condition exclusions in any plans after January 2014, either in the Exchange or the outside market.


Question: My daughter who is 23 and is a covered dependent on my husband’s insurance policy is pregnant and Maternity is excluded on the policy. My question is that in California Maternity Benefits are now mandatory as of July 1, 2012. Would this apply to her as well? If so, who do I contact to get her covered? Thanks so much!

Answer: Yes. Maternity coverage is a mandated benefit in California on new plans issued after July 1, 2012. However, your husband’s coverage was issued prior to that date. It does not automatically include maternity coverage now. If his coverage is part of an employer sponsored group health insurance plan, maternity coverage will be included at open enrollment, when the entire group renews or moves to a new plan. If your husband’s coverage is an individual plan, he would have to reapply for a new plan effective July 1 or later and go through the underwriting process. Your daughter’s pregnancy is a preexisting condition that will result in the application being rejected. I’m afraid there is no way your daughter’s prenatal and normal delivery expenses can be covered now. However, her current policy will cover medical complications during pregnancy and delivery should that occur.


Affordability and ACOs

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Question: What, if anything, will the Exchange do to promote Accountable Care Organizations (ACOs)?

Answer: So far, the California Health Benefit Exchange Board has not discussed ACOs in public meetings. Yet, the Exchange must address affordability in order to meet the goal of increasing healthcare coverage. Affordability is often facilitated through innovation of benefit plan design and creative thinking about provider networks and delivery systems. ACOs offer significant potential for new forms of value-based plan designs which support affordability and quality of care. The exchange should consider working with California health insurance carriers to support this innovation.


Assister Training Adequate?

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Question: How can a two-day training course prepare so-called “Assisters” to help people choose the right health insurance coverage? I am a licensed agent with eight years experience selling both individual and small-group health insurance in California and I am sometimes confused by the endless benefit choices and financial trade-offs?

Answer: I share your concern. Covered California just published a draft of the training curriculum for assisters. While the outline certainly looks comprehensive, I believe the proficiency of the assister will vary greatly depending mostly on their after-training experience. At one end of the spectrum, you have the assister who goes to work in a call center surrounded by experienced assisters and supervisors and deals with many applicants every day. Obviously, this assister will retain and put into practice much of what they’ve been taught. At the other extreme, an assister who only works with a handful of applicants in the first few months after training will retain very little of the training. The same could be said of agents. An agent who typically works with small groups will be in a whole new world when it comes to assisting enrollments in Covered California.


Question: I am self-employed. My spouse’s dependent coverage is too expensive. Will I be able to purchase insurance through the exchange?

Answer: Absolutely. You will be able to apply for coverage in a qualified health plan through the California Health Benefit Exchange starting in October 2013 for coverage effective January 1, 2014. You may even qualify for subsidized health coverage calle advanced tax credits in the Exchange, which is the exclusive channel for these tax credits. Those individuals and families with incomes between 138% and 400% ($92,200 for a family of four) of the Federal Poverty Level (FPL) will qualify for subsidies.


Question: Will Brokers need to contract with the Exchange to prove that we are licensed and insured? Any other requirements to get paid through the Exchange?

Answer: The California Health Benefit Exchange categorizes brokers as Assisters - along anyone else that wants to facilitate an enrollment in the Exchange. All Assisters will be certified through the Exchange after completing required training. Certification will be renewed annually. Currently, the Exchange is saying that Assisters should complete at a minimum a two-day Assisters Training. The Exchange has given flexibility for program sponsors to consider an abbreviated version of the training program licensed agents. Assister training and certification will begin in August 2013 so that IPAs are ready to assist with Covered California enrollments beginning October 1, 2013 Keep in mind that agents are not paid by the Exchange, but by the carriers offering qualified plans through the Exchange, Contracting with carriers will still be required.


Change in Coverage

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Question: I was scheduled to have gastric bypass surgery July 31. My surgeon’s office contacted me and told me coverage was denied. My employer will add the coverage effective Sept 1, only if they do not have to cover every employee (we total under 10). Does my employer have to cover every employee or can she just cover me since no one else is obese?

Answer: While it was generous of your employer to offer the additional coverage for bariatric surgery for you, the coverage change would have to be added to the entire group.


Question: I am 21 years old and on my parent’s insurance. I just got a job that offers insurance but it is not as good as my parents. Can I deny my employer’s insurance and just stay on my parents?

Answer: Yes. You may sign a WAIVER OF GROUP HEALTH INSURANCE COVERAGE. The waiver says something like this, “I hereby certify that I have been given the opportunity to participate in the group health insurance plan provided by my employer through XYZ Insurance Company and have been informed of the consequences of not enrolling in such plan at this time. I understand that if I reject the group health plan on behalf of myself and/or my spouse or other eligible dependents, the group health plan will not provide any benefits on behalf of those individuals for whom I have waived coverage. With this knowledge, I decline to enroll.” You will usually be asked to list your current coverage.


Newborn Coverage Options

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Question: I am married but am still covered under my mothers group insurance plan. I have maternity coverage but I am wondering if the insurance will cover the baby after birth and for how long. Also if my husband does not currently have medical insurance will his employer still have to open his enrollment after the baby is born?

Answer: Generally, your insurance coverage will cover your newborn for the first 30 days after birth, but please confirm that with your insurer to make sure. Your husband apparently waived employer-sponsored group health insurance and will not be able to enroll until the his employer’s next open enrollment period. The baby’s birth is not a “qualifying event” for your husband. It would be a qualifying event for the child were your husband insured. You can purchase an individual health insurance plan for your baby in the meantime.


Question: I currently am 100% covered by my employer but will be going part-time My employer will not pay any of my health insurance costs as a part-time employee. To make ends meet I will need to also be self-employed. I have a pre-existing condition that requires very pricey drugs. Is my best option to elect COBRA and hope that they don’t repeal the health care act so that I can get affordable coverage in 2014?

Answer: Yes. Your best option is to elect COBRA. It will cover you until you can enroll in guaranteed health insurance coverage available through your state health insurance exchange in January 2014. If your income is still on the low side by then, you will probably qualify for a subsidy to help pay your premium. And of course, your preexisting conditions will no longer affect the availability or cost of health insurance.


Exchange Coverage Cheaper?

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Question: Will i get cheaper coverage from a state health insurance exchange?

Answer: No and yes. In general qualified health plans sold through the state-based exchanges starting in 2014 will be higher-priced than the average plan today. That’s because they must contain a minimum of essential benefits which today’s cheaper plans do not cover. However, many millions of Americans will qualify for “advance tax credits” which are federal subsidies for the purchase of private health insurance available only through the exchanges. These subsidies are based in income and are quite generous. For example, subsidies will be available to a family of four with annual income up to $92,000.

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