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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.

New Covered California Rate Calculator Available

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Question: So far all we have is “teaser” rates for single 40 and 25 year olds. When will we be able to get quotes for actual household sizes?

Answer: Right now. Covered California introduced a new rate calculator on their website yesterday. Something to watch out for: they only show 4 plans in their comparison and not always intyellegintly. For example, in my region the show 2 Anthem plans and no Kaiser plan. As for the rates, I’ll let you form your own opinion.


For Region 7 (Santa Clara County), I found in the CoveredCA 2015 shop and compare tool


the Kaiser Bronze HSA option for 2015 is no longer present (only regular Bronze shows up). The HSA plans was present in 2014.

However in the 2015 CC health plans PDF for region 7, they list a Kaiser Bronze HSA in their comparison chart (on page 67, PDF page 35)


I’m trying to get to the bottom of what is going on. Whether it was an oversight that the Kaiser Bronze HSA was left out of the shop and compare tool, whether things are still being negotiated, whether the plan will only be offered off-exchange, or whether the plan is being canceled.

Do you have any insight into what is going on?

Normally I would just assume everything will show up eventually on Nov 15, but an associate recently received a letter from HealthNet that their 2014 PPO Exchange plan would no longer be offered on exchange so they would need to sacrifice their subsidy and purchase off-exchange, switch to a HealthNet HMO plan, or switch to another carrier.

If something like that would be happening with the Kaiser Bronze HSA, I’d rather know sooner than later so I can research alternatives before the phone lines become 4 hour holds.

Recently I spoke to a Kaiser direct insurance agent who insisted their exchange plans did not need to be offered off-exchange.

I have been under the impression that if an insurance company offers a plan on the exchange, they are required to provide a “mirror” plan with the exact same network/premiums off-exchange.

Their inventory of products off-exchange could however be larger because they are allowed to offer off-exchange plans which they do not sell on exchange.

I’ve been using the CoveredCA shop and compare tool as a proxy for my directly purchased (mirror) plan’s rates because it seems to get updated quicker.

Is my understanding of the mirror plans correct?

My wife and I currently have medical insurance though my union (Iron worker 229). I am going to be retiring this coming April. My question is what kind of medical insurance do I qualify for and what are the costs. I have blue cross now but want to know what insurance will benefit me most for me and my wife, and what do they cover and cost.

If your employer offers coverage to you, they probably have to offer coverage for dependents as well, so you would have to enroll them in your employer’s plan.

If not, then the best course of action would be for the custodial parent to make the application for health insurance through CoveredCA, and if ineligible for Medi-Cal, then to select the health plan that best meets their needs and have you pay the premium.

Although you could make the application for them, you might not have the supporting documents required for eligibility determination, which could delay the process.

I am divorced and have two kids in my ex wife’s custody. Son is 14 years old and daughter 17 1/2 years. They were covered under healthy families and now I have been asked by court to pay for health insurance. Can I have health insurance for them to cover under Covered California?

Yes, if insurers fail to meet the 80% MLR figure, excess premiums (not “profits”) collected must be refunded on a pro-rata basis per health plan sometime around June-July of the following year.

Insurers must maintain profitability to remain in business, the problem is that the 80% MLR is measured on a calendar year basis and provides little flexibility for insurers to look at the long-term actuarial cost of providing “unlimited” lifetime medical care and adequately set aside reserves for that purpose. Insurers may deduct certain costs of doing business, such as licensing and other regulatory fees (which are hefty under the ACA), before calculating loss ratios, but set-asides to reserves are not one of them.

My bad. Legislation was signed in May that prohibits premium increases in CA for reasons other than age, geographic region, and number of insureds. Just another example of bleeding-heart liberalism managing health care in the face of actuarial reality.


tobacco users are not subject to higher premium in California to my understanding.

Am I wrong?

If insurers make excess profits, it must be rebated under Obamacare. Is this not going to happen?

Well, 70.5% is pretty close to 72%. But what we don’t know is whether Maura is a tobacco user or not. If she is, a large part of the increase is the 50% surcharge insurers are permitted. We also don’t know Maura’s age, and insurers are entitled to charge up to 3x the age 21 rate for a person age 64, so that could explain part of the increase.

No one should be surprised at all by significant rate increases. Why not? Because your insurance company needs to remain profitable in order to continue covering your claims without annual or lifetime dollar limits (at least those which fall under the banner of the ACA — not all claims do). Kaiser once paid agents respectable commissions, but beginning 1-1-2014, a new sale = $100. Period. Medicare Advantage? $0.

Kaiser has a good system, and they have almost total control of their costs. They are also one of the more expensive issuers — and anyone who has received a bill from Kaiser for their care (such as in a third-party claim following an auto accident), knows that they value their care highly. Their rates may be an indication that they don’t want significantly more business, and that they might want to reduce their member census some as well. Premium increases are an effective tool to achieve that result.

Congressional leaders listened to the insurance companies with whom they met and came to a “gentlemen’s agreement” about the PPACA prior to passing the legislation. But they stabbed the insurance companies in the back by passing legislation that was entirely different than what they had come to an agreement about. Turn about is fair play.

California’s legislature — which has passes all manner of nonsensical legislation in 2013 — has repeatedly failed in the past three years, however, to give the Insurance Commissioner authority — as allowed in the PPACA — to reject rate increases. Why? A closer examination of their campaign finances and donations may reveal the answer.

You can’t blame the insurance companies entirely for this mess, although they deserve some of the credit. The work of your elected representatives is largely to blame. If you don’t believe they represent your beliefs, why do you keep reelecting them?

Regarding the 72% rate increase, in the brochure from Kaiser I received last week, Kaiser has increased the amount I will pay out of pocket for my $4500 deductible plan, from $275/month to $469/month effective 1/2014. This is the 72% increase.

Is the assumption that the Fed subsidy will cover the difference? I.e. that the taxpayers will fund Kaiser’s extortion?

I will not be able to afford health insurance without a subsidy covering the difference and will probably opt for the $95 penalty.

What’s going on?


It is my understanding that tabacco users will not be subject to a 50% rate increasein California? Has something changed?

In regards to the 72% rate increase, I am comparing my current rates plus 9% expected increase for 2014 to the Silver plan. I have a $2700 deductable and a max out of pocket of $5000 which includes the deductable. The silver plan is $2000/$6450.

I had an cat scan done this year and my plan charged me $150 but under the silver plan ,the will cost is $250.

We can go through details but it means very little. Now thanks to Oabamacare, I have to pay 72% more in premiums. Frankly, all I care about is the premium, deductable, and max payment. The charges over the years for proceudres have always surprised me being very very reasonable.

I am going to call my current insurance company and find out if my plan makes be responsible for 40% or 30% of the medical costs.

As far as the apple to apple comparison, I as any other sound person cares about how much more I have to pay. Now, we know why Covered Californai useed an apple to orange comparison when they first rolled out and touted rates going up only 33%: it is smoke and mirrors.

Obamacare from my point of view is not affordable. In fact, it is an outrage!!!!

“My rate has gone up 72%”

There may be some truth to this, but no insurance company has asked for a 72% general rate increase. Thanks to our do-nothing state legislature, however, the Insurance Commissioner still does not have authority to reject rate increases — he can only label them excessive … he cannot stop them.

But is is known that CA health insurance rates, for the most part will be going up for most age groups. Older persons, should see slightly lower rates for some plans in certain areas, due to the 3x age 21 rate cap. Unfortunately, tobacco users will see up to a 50% increase over those rates.

However, there are no specific details provided above. It may perhaps be a comparison of dissimilar plans — a bronze equivalent compared to a platinum equivalent. I don’t know the answer to that.

Thanks for the long follow-up.

I’ve known the $46,000 MAGI is not one’s face salary. Still, the sudden cliff vs a more gradual drop in subsidy seems perverse and may induce strange motivations for some to stay just under that level of MAGI.

I’m curious about your following statement

“The annual credit is figured as 9.5% of MAGI. At 400% FPL in 2013, the maximum subsidy would be $4,366 (or $363.83 per month) for a “household of one”

In SF Bay Area at age 64 with $45,959 MAGI, I would get a $483 subsidy on a Kaiser Silver plan according to “shop and compare”. My premium before subsidy would be $865 and my cost would be $383 monthly.

If I was age 64 in the San Francisco Bay Area and only made $16,000 per year, the Silver Plan from Kaiser would be priced at $865 per month but my tax subsidy would be $802 per month, putting my monthly premium at $64. BTW, the Blue Shield option would cost ZERO as the subsidy equals the premium. Or so says the Covered California “shop and compare” calculator.

I understand how Affordable Care Act works as I have been following it closely.

My “surprise” was the cost of the top end plans from Kaiser that are comparable to the current top end “self pay” grandfathered plans I see in the 2013 Kaiser rate book, for the SF Bay Area, for a 64 year old, with a 7% adjustment added for the expected 2014 premium increase.

I do realize that the ACA plans give a “free” annual exam, and have some differences.

I believe the key feature is that there are no pre-existing conditions. The long standing Kaiser member is unlikely to need a triple bypass next year, while the guy who has just been hanging on until January 1st, uninsured, may join up on January 1st and present with the need for a bypass within a couple months. Kaiser collects $$850 to $1140 and has instant costs of $50,000.

** One interesting side note about the Covered California “shop and compare” calculator.

If you are age 50 or 64 (perhaps other ages) and you put in a income of $22,981 or more, you are shown Bronze, Silver, Gold, and Platinum. But if you put in a income of $22,980 or less you are only shown Bronze and Silver as your options.

Seems they are making a assumption that you wouldn’t want a better policy. After all, you could have a million dollars in gold coins sitting in your safe deposit box and yet still have a income below $22,981 a year MAGI.

Wow!!!! My rate has gone up 72%. We are seriously considering living without insurance for the first time in 20 years.

So much for affordable care. Obamacare is itching but a middle tax class tax .

I hate Obamacare

I should have added that if a person does not qualify for the premium tax credit, they don’t have to purchase a health plan through the Exchange. It could very well be that lower cost plans exist off the Exchange, but one must be sure that they are “qualified” — which means that they must meet the “minimum essential coverage” requirement (all of the essential health benefits must be covered with at least 60% “actuarial value”) in the ACA in order for a taxpayer to avoid the “Shared Responsibility Payment” tax penalty the IRS will collect.

“But if you make $46,000 you get ZERO subsidy and must pay the entire $1,052.

Talk about a going off a cliff. Costs you about $5,800 for making an extra $50 in income.”

What we don’t know is whether Wayne is describing his gross income or his Modified Adjusted Gross Income (MAGI). His complaint could be legitimate or a mistake.

What must be remembered is that the subsidies are ONLY for persons whose MAGI is between 133% and 400% of the Federal Poverty Level. In 2013, the 100% FPL for a “household of 1” = $11,490. Therefore, 400% FPL = $45,960. A MAGI of $46,000 is $40 too high to receive a subsidy.

The real problem is that, for most taxpayers, MAGI is going to be HIGHER than the AGI figure at the bottom of one’s Form 1040 tax return, because things like pre-tax deductions from pay for 401(k) or 403(b) plans, non-taxable interest, and certain other deductions from income must be ADDED BACK into AGI under the MAGI calculation.

The annual credit is figured as 9.5% of MAGI. At 400% FPL in 2013, the maximum subsidy would be $4,366 (or $363.83 per month) for a “household of one.” If the average national cost of the second lowest Silver plan is $8,909, the credit represents 49% of that cost. See the online credit calculator here http://kff.org/interactive/subsidy-calculator/

What Wayne forgets (or does not know), is that the “affordable” part of the Affordable Care Act never promised that health insurance premiums would actually be affordable. It did not promise that the premium tax credits would cover 100% of the premiums one would have to pay. But preventive care and contraceptive drugs are “free” courtesy of your insurance company.

The ACA simply provides that no one may be turned down for coverage, and that there can be no annual or lifetime limits imposed by insurance companies for coverage of the “Essential Health Benefits” — that’s the “affordable” part. But I doubt that many people in America would consider $6,350 in actual annual out-of-pocket expenses (or $12,700 for a family) ON TOP OF premiums paid to be “affordable”. It does represent a significant cap on the cost of a catastrophic event.

IMHO, the American people did not receive what was “sold” to them by their elected representatives. After all, the final agreement was negotiated by a small group of legislators behind closed doors on a Sunday afternoon. Who among those that voted for the Act in the next day or two actually read all 900+ pages? And, even if they did, who actually understood it?

But persons with preexisting conditions will have coverage available to them beginning 1-1-2014. It will necessarily be “subsidized” by generally higher costs for insurance imposed on healthy persons, since no one can be charged a “substandard” premium (but tobacco-users will pay up to 50% more).

As for the reply above that says the online plan comparison tool at Covered California “show only 4 plans” … that’s what I thought, too.

* However, if you click on the two or three “dots” below the list of four plans, then you will magically be shown the rest of the plans available to you in your region. * All of the available plans from Platinum down to Bronze are there.

This is a fundamental design flaw in the site that does not clearly indicate that other plans can be viewed. They should have embedded clickable arrows to the right or left of the list. Maybe they’ll correct this, maybe not.

You can also download the “Get Covered” app for Android or Apple iPhone smartphones and tablets. I don’t have either of those “toys”, but I have do a free program called “BLUESTACKS APP PLAYER” ( http://www.bluestacks.com/ ) (and their companion program called “CLOUD CONNECT”) installed on my Windows-OS laptop that allows me to download Android apps from the Google Play store and run them on my laptop. The advantage to me and my clients … a 17.3” screen instead of a 4” screen.

Regarding rates. WOW

I can only speak to the ages of 63 and 64.

Assuming that Kaiser’s self insured rates would have been raised about 7% in the coming year.

I was on a $50 co-pay, no deductible, no drug coverage plan. That was $610 for a 63 year old and $622 for a 64 year old. A grandfathered plan. With a 7% boost for 2014 that would have become $652 and $655.

I switched in May to a $5,000 non-deductible non-grandfathered plan for $337 which next year, say, would have become $367 at age 64.

So looking at those and also, I have the rate sheet for current grandfathered Kaiser top plans with co-pay $25 and $40, both with drugs.

My comparison for those with NO-Subsidy, meaning income of $46K or more, is that Kaisers rates for these plans are substantially higher than they currently are in 2013.

At the top end, $25 to $40 co-pay Kaiser plan for next year it would have been about $835 in a mix of those two, with a 7% hike in rates. That for a 64 year old.

The similar Covered California plan looks to run about $1091 if you have no subsidy. (a mix of Gold and Platinum)

About 130% of what I would have expected if they were equal. 30% boost..

Obviously exact comparisons are difficult and I have no idea how it looks at the lower end of the age brackets.

Wow, if you make $45,950 you get a $483 subsidy towards a $1,052 Gold plan age 64.

But if you make $46,000 you get ZERO subsidy and must pay the entire $1,052.

Talk about a going off a cliff. Costs you about $5,800 for making an extra $50 in income. If you are self employed, take a extra week of vacation.

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