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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.


September 2013 Archives


Agent Agreement Available Today!

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The agent agreement is available and Covered California is notifying those agents who have completed training and passed the exam with the following message by email.
Agent Agreement Final Instructions.pdf


Question: I didn’t quite understand your recent answer regarding Medi-Cal and kids. My daughter is 18-1/2 and I would prefer her to be covered under the same plan as the rest of the family. If I declined Medi-Cal for her, would we simply pay the un-subsidized price for HER, or would the whole family become ineligible for receiving a subsidy ?

Answer: You would pay the un-subsidized rate for your daughter only. The rest of the family can be eligible for a tax credit.


No Agent Agreements Yet?

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Question: Since we have no agreements available to sign yet, will agents still be able to sell come tomorrow? (October 1st?)

Answer: As it stands now, no agent is fully certified to sell on Covered California because the official agent agreement is not ready. The Exchange says that they will provide an agreement for signature and bill the $58 fee to all agents who have completed the training and passed the exam, about 1,500 agents, this week. In the meantime, the only method available is ton complete a paper app and hang on to it until you are certified.


Dropping Retiree Health Plan

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Question: I am a dependent on my wife’s retiree health plan. Can I drop that coverage and get a plan on the California Exchange? Can I qualify for a subsidy based just on my income, or is the subsidy based on total household income even though the insurance would be just for me.

Answer: Assuming your spouse’s retirement plan is a group health plan and since have access to an employer-sponsored plan, you are not eligible for a subsidy in the Exchange. You may however choose any exchange plan of off-exchange individual plan you wish.


Question: Is there a penalty for under-projecting the income? Are they planning to charge interest on the subsidy difference? All I have heard is that one has to replay the subsidies, but nothing the interest or penalties. Also. I understand that in addition to the direct subsidy on the premium itself, one may qualify for a reduced co-payment and deductibles based on income. Assuming that is true, how will they claw that back if the actual income turns out to be more than the projected income. Based on the answers for the above, wouldn’t it make sense to always undershoot?

Answer: Correction: (I misread this question first time around.) There is no penalty for taking more advance tax credit than you are eligible for except to repay the excess advanced. The cost sharing reductions are not subject to repayment.


Provider Networks?

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Question: How do you compare plans? I cannot find any info as to if my primary is in network or not?

Answer: Covered California will have a consolidated provider directory on their site at some point. Individual carriers will have provider directories on their sites as well. Some carriers have still not finalized their networks so there will be some gaps when this thing launches tomorrow.


Must My Kids Take Medi-Cal?

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Question: If a family of four has an income of $32,735 - $58,875 they seem to fall into a bracket where the parents would have an exchange plan with subsidy and the children would be offered Medi Cal. In this scenario is it mandatory for the children to be placed on Medi-Cal, or can they opt to be included with their parents on a family exchange plan with subsidy?

Answer: If the any family members (children in your scenario) are eligible for public insurance they may choose not to apply for coverage and enroll in Covered California, but they are ineligible for a subsidy because they have access to public health insurance.


Question: I can’t find this anywhere! My brother will be in China this school year, including the first half of 2014, which is what the financial assistance for premiums will be based on. He didn’t have any other income in 2013. His income in 2013 will all be excluded because he pays taxes to the Chinese government as a teacher and he is under the $90k or so foreign income exclusion limit. Yet, he’ll be low income, probably fitting in the less than 200% of the FPL. We can’t figure out if he qualifies for the financial ACA premium assistance. Most people drop insurance when they go work overseas, but since he is returning and wants to remain with the HMO and his doctors, he wants to pay while he is teaching this school year in China. Thanks.

Answer: Your brother is exempt from the mandate to purchase health insurance while he lives out of the country. He couldn’t enroll in Covered California while out of the state anyway. When he returns, he will qualify for a special enrollment period and can enroll in the exchange. His eligibility for a premium assistance at that time will be determined on his projected income. He can probably find a plan that will include his current providers if not the same carrier he has now.


Dissolve Small Business Coverage?

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Question: I am a small business with under 40 employees who has always paid 100% of employee and family medical coverage since 1977. With the changes in healthcare coverage would it be more beneficial to me to have my employees go individually under California Coverage or would it be cheaper for me as an employer to continue cover them as a business under my current provider?

Answer: You’r right to reconsider the decision you made in 1977. Things have changed. There are so many elements to be considered that this decision lends itself to the classic Ben Franklin weighing of pros and cons. If you continue to provide a group plan with 100% coverage for your employees you get loyalty, employee good will, easier to recruit new employees, a big tax-deductible expense. On the con side a you get a huge business expense that will only continue to grow beyond your control. If you dissolve your group plan, there are many other considerations. How many of your employees will qualify for subsidies in the individual exchange. Will you provide extra compensation to “sweeten the deal” particularly with your higher-paid or key people? What are the tax consequences to your business and your employees? It’s complex and illustrates why you need a knowledgable professional insurance broker to guide and advise you.


Question: I own two homes in two different states (California and Florida) - and I live at each one 50% of the time (this is how I file my California State Income Tax - Florida has none). Which state health exchange do I purchase? How can I ensure that I am able to see Doctors in both states?

Answer: (1) It sounds like you probably are not going to be eligible for a subsidy based on income, if so there is no reason to enroll through the exchange in either state. (2) The best way to get access to in-network providers in both states is to purchase a Blue Shield of CA plan or a BCBS of Florida plan that will provide access to the “Blue Card” which is the BCBS national coverage plan. At no extra charge, it will allow you to get in-network coverage in both states. Anthem Blue Cross in CA will not honor the Blue Card for individual ACA-compliant plans.


Question: How will covered California know if your employer offers coverage?

Answer: The employer is not required to provide that information in 2014, so there is no routine way for the Exchange to verify access to employer-based coverage. If you’re thinking you get a free pass to subsidized exchange coverage in 2014, you may want to consider this: the IRS will have access to that information for the 2015 tax year and could possibly check your status in 2014…just saying.


Can Rates Be Changed During the Year?

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Question: Because the (plan, rate, network) information is going to be made available only at the time the website is going to open for business (Oct. 1), my guess is that they are going to be quite a bit off (up or down)in their projection regarding the number of sign-ups in each bucket. Can the insurance companies revise the prices up or down going forward?

Answer: No. The rates both on exchange and off-exchange are now set for 2014.


Any Private Insurance Left?

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Question: After Jan 2014 will there be any private insurance left to choose from, or is everything under Covered CA and do we know if our doctors will be on any plan we choose and will they be required to accept all insurance plans?

Answer: Covered California has contracted with 12 private insurance companies to offer plans in the exchange marketplace, so all Covered California plans are private insurance as opposed to Medi-Cal which is public insurance. Covered California says it will have a consolidated provider directory including all private insurance company networks on their website on October 1 so you will be able to see which private plans include your doctors.


Question: I read … that Blue Shield has significantly reduced its doctor network (shrunk around 50%) and excludes the UC system (UCSF, UCLA) for their ACA/metallic/exchange plans. Those UC medical centers are available to me in my current non-grandfathered plan … If I am unable to keep my existing non-grandfathered plan, how do I keep my existing network?

Answer: Blue Shield refers to it’s existing PPO network as the “legacy” network. Your description of the new Shield individual network is accurate. Members on non-grandfathered plans can keep their plans with legacy networks until the next plan renewal date. Small Group plans will continue with the legacy network. Incidentally, Covered California says it will have a consolidated (all carriers) provider directory on their website on October 1st.


Question: I pay 20% more because I have a preexisting condition. If I decide to keep my current plan into 2014, will they take off the extra premium in January?

Answer: No. If you choose to keep your current plan until the renewal date rather than enrolling in an ACA-compliant plan during the open enrollment period, your plan will continue to have pre-existing condition rating until its renewal date.


Can I Still Buy a Child-Only Plan?

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Question: I live in Nevada and pay for health insurance for my 8 year-old who is living with my ex in California. Will I be able to buy Obamacare for my kid? Also can I get a subsidy?

Answer: Yes. You will still be able to buy child-only Covered California coverage for your child in California. She may be eligible for a subsidy depending on the income of the household of which she is a part.


Question: If my Cobra coverage ends during the year, what proof would I need to show to be able to get coverage in the subsidized exchange? Would I be able to seamlessly have coverage start the day after Cobra coverage ends?

Answer: When your COBRA coverage expires you will receive a certificate of creditable coverage from your COBRA insurer. That will serve as proof. You will then qualify for a Special Enrollment Period (SEP). You will be able to coordinate the effective date of your new coverage on the first of the month after the end of COBRA coverage. By the way, if you are eligible for a subsidy, there is no need to wait for the expiration of your COBRA coverage. You can enroll in the “subsidized exchange” during the initial open enrollment period.


Does He Lose Grandfathered Status?

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Question: If a family is on a grandfathered plan and the 26-year-old ages off to his own policy with same plan, does he lose grandfathered status?

Answer: Yes. Because grandfathered plan status in the individual market is based solely on effective date of coverage. It must be before March 23, 2010. In your example, when the 26-year-old purchases his own policy, he will have a new effective date. Likewise, any plan transfers or plan downgrades since March 23, 2010 would have resulted in new effective dates thus loss of grandfathered status.


Question: Regarding premium costs, do you know the difference and the meaning of the ‘8% of income’ rule, and also how different than the ‘9.5% of income’ rule?

Answer: The premium threshold for an exemption from the individual mandate is 8% of income, while 9.5% of income is the “fair share” premium threshold for premium assistance.


Income Under 400% FPL But No Subsidy?

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Question: I plug-in earnings of $45,000 for the year. Age 46, in Los Angeles county region 16 (zip 90036). Covered California calculator says I am not eligible for a subsidy. The note says: “For your income, age, and location, the cost of health insurance is below the “fair share” amount called for under the Affordable Care Act. This means you will pay less for coverage than people living in areas with higher insurance costs or people who have higher costs due to their age.” Do you know what “fair share” is and if indeed this “fair share” also affects my subsidy eligibility?

Answer: The ACA considers your “fair share” to be anything less than 9.5% of your income. This converts to $356/mo. for an income of $45,000. The premiums for a Silver Level plan in the scenario you provided are below $356/mo., so even though your income is less than 400% FPL, there is no subsidy available because the premiums are low enough for your fair share.


Can I Upgrade My Coverage?

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Question: If I purchase Covered Cal PPO insurance and I find that I am not covered enough due to a horrible illness, can I then purchase private PPO insurance or will I be denied?

Answer: You cannot upgrade your coverage, either in-exchange or off-exchange, once the initial open enrollment period ends on March 31, 2014, until the next open enrollment period beginning 10/15/2014.


Question: Wondered if you watched the webcast of yesterday’s Covered California Board Meeting. If so, anything we should know about.

Answer: I did but I was late tuning in. Readers should comment with takeaways of their own, particularly in the first hour or so. Anyway, Here are a few items I picked up on.

  • Quality Ratings could be included by the Exchange as early as mid-November. Kaiser is pushing for it as they look good in the data. Other carriers who don’t look so hot say no “the data is old and no longer relevant”. I believe consumers would be well served to have this information included in the decision making process, no matter how imperfect.
  • Agents may be paid for Medi-Cal sales. Peter Lee is behind it, so I’d say it’s likely at some point.
  • Single Streamline Application is 35 pages long. The Exchange says that only 3 pages need to be completed by a single applicant. Check it out. Single Streamline Application.pdf

Rate Increases after Jan. 2014?

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Question: How often can a carrier raise rates? Will in be only during open enrollment or any time during the year provide they give a 60 day notice?

Answer: Rate adjustments will occur once a year with the new adjustment coming in January 1 each year going forward. Also, an adult having a birthday during the year, will see the adjustment in January as well.


Can We Split Our Family Enrollment?

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Question: … if one person in a three person family unit decides to opt for insurance without any subsidy inside or outside the exchange, do the other two automatically forfeit any subsidized insurance through the exchange because of that fact? Does it matter what the family income level is?

Answer: The eligibility for premium assistance in this scenario would be based on the income for a household of three. If the household is eligible for a subsidy, two members can enroll in Covered California while the third chooses unsubsidized coverage off-exchange. If not eligible for a subsidy, you could also enroll two members on exchange and one off-exchange, but there would be no benefit in so doing. In this case, it would be easier for all three family members to enroll off-exchange and split the enrollment among family members in any which way.


Worried About Clawback

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Question: Let’s say - A household’s current income is at 150% FPL and takes the advanced subsidy through the Exchange. During 2014, the income dips below 138% but they forget to apply for Medi-Cal when this happens. Will they be subject to “clawback” come tax time since they qualified for Medi-Cal but has taken the subsidy instead (in which case the charge back amount can be substantial)?

Answer: There is no reimbursement or “clawback” required in this scenario. Remember it is your responsibility to notify Covered California of changes of income.


Question: My work provides medical insurance for families (3+ persons), however the rates are going up for 2014 and I will have to pay the difference. Can my 22 year old who works move to a Covered California plan, thus reducing my cost at work for 2 people only?

Answer: Your 22 year-old dependent can opt out of your group plan to purchase individual health insurance in Covered California or off-exchange, but she will not be eligible for a subsidy because the she has access to group health insurance through your employer.


Question: Will this new Technical Release stop me from offering employers with less than 50 employees a reimbursement plan for their employees to buy subsidized coverage in the exchange?

Answer: Yes. To quote the DOL Technical Release #2013-03, “…an employer-sponsored HRA cannot be integrated with individual market coverage or with individual policies provided under an employer payment plan, and, therefore, an HRA used to purchase coverage on the individual market under these arrangements will fail to comply with the annual dollar limit prohibition…”. HRA’s integrated with fully insured small are still in compliance.


Can Married Couples Apply Separately?

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Question: If there is a married couple with out children, each has their own income, can they apply as singles? If so then as far as income verification is it just their own income not household income?

Answer: No. Household income is the usual rule. A married couple would have to show that they lived apart for the entire year to qualify separately.


Question: A recent news release from the DOI quotes Insurance Commissioner Jones saying: “The license approval for Covered California also provides a more efficient way for licensed agents to help consumers and businesses purchase health insurance through the Exchange, by allowing the agents to affiliate with the Exchange as opposed to obtaining appointments from each carrier selling health insurance products through the Exchange.” That seems so say that agents don’t have to worry about getting appointed with some of these lesser known carriers. Can you confirm?

Answer: Unfortunately I can’t confirm your assumption. I believe the Commissioner was referring to the SHOP exchange in the news release from which you quoted. In the SHOP, the Exchange pays the agent directly, so it stands to reason that being appointed with them is all you need. It would be tremendously helpful if the exchange provided a single path to appointments with all carriers in the individual Exchange as well. In fact, I’m pretty sure they said they would do so, but it was some time ago and I haven’t heard anything since.


Question: I am single making $50,000 ( I do not work) and the insurance cost is $7320 which is 14.6 percent of my annual income. The 14.6 percent exceeds the 9.5 percent affordability rule yet I am not eligible for tax credits as my income is a bit too high. Do I misunderstand something, or are options available?

Answer: While you are not eligible for a subsidy because of your income, your lack of affordable coverage does provide you with another option - access to a Catastrophic Plan, which is normally reserved for individuals under 30 years of age.


Provider Networks Ready?

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Question: Many have asked when Covered California provider networks will be ready for publication.

Answer: Here’s The exchange’s answer to that question posed by Chris Price via Twitter:

Provider Networks.png


Question: My income is very low right now as I am only able to find part-time work. I hope that will change sometimes but i don’t know when. How can I keep from owing them money at end of the year?

Answer: You can avoid advance tax credit repayments by reporting income changes as soon as possible. the government figures if no families report income changes during a single year, 38% of those receiving subsidies would owe the government a median of $857 each. If families report income changes in a timely manner, only 23% would owe money to the government and those that do would pay a median of $343 each.


Do I Have to Apply as a Family?

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Question: Currently I have my son on a child only plan, so that he can be on a richer plan than me and my wife. We are on a bare bones high deductible plans — that too individually thanks to the grotesque state of current individual insurance market place. We had to take what we could get. All the calculators I have seen so far want to treat the three of us as a group. When the exchange finally opens up are we going to have a chance to buy ala carte? How will the subsidies be calculated and applied? Thanks, Bated Breath.

Answer: If your household income qualifies you for premium assistance, you will have to choose family coverage in the exchange, but if you are not eligible for a subsidy, you can buy your coverage off-exchange and choose different coverage for each family member if you wish.


Question: I was totally confused and frustrated by the exchange certification process, pre-registration, registration, pending, and so on. Now I’m finally ready to take a class and there’s nothing available until the end of the month. What if I can’t get certified by October 1?

Answer: Covered California will temporarily certify all licensed agents for the month of October. That’s because the Agent Agreements won’t be ready for signing until sometime in October.


The Affordability Test for Families

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Question: If I include my wife and children on my employer’s health insurance, the annual premium will be above 9.5 percent. If i drop my employer’s plan and purchase my own for the family, am i still eligible for tax credit?

Answer: No. The 9.5% affordability test applies to the net employee-only cost of coverage. It does not include the cost of insuring spouse and or children. Therefore, you or your family members are not eligible for a subsidy in Covered California. This is not a Covered California decision. It is an IRS rule.


A Plain Vanilla Marketplace?

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Question: If all of the plans on and off the exchange are the same - benefits and rates, then there’s no competitive advantage except in the networks. Am I right?

Answer: You’re partly right. If a carrier participates in Covered California, they must also offer the same plans or “mirror” those plans off-exchange. But, participating exchange carriers can also offer some alternative plans. For example, Anthem will offer 8 Bronze plans and 4 Silver plans off-exchange that do not mirror the exchange plans. Of course, they still have to be ACA-compliant and conform to the actuarial values for each level. Blue Shield, on the other hand, will be offering no alternative plans off exchange, only mirrored plans. Cigna, who does not participate in Covered California, will be offering only alternative plans off-exchange. So, the 2014 marketplace is not quite a plain vanilla as we first thought.


Question: I have a small group client with key personel working for the company living in another state. How will we enroll these types of groups?

Answer:If this small group is off-exchange, nothing changes. Remember the group has to have 51% of eligibles residing in California. As for the SHOP, where the employees have a choice of carriers, the out-of-state employees would obviously have to choose a SHOP carrier with a presence in their state. The best choice will generally be Blue Shield, as they have the best national coverage through the BCBS Blue Card Program.


Dependent in Another State?

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Question: Parents with dependent. Parents claim on taxes. Dependent is 23 and out of state. How to handle this? Insurance where parents are or kid? Separate? State or fed program?

Answer: As mentioned before, Covered California has yet to publish comprehensive guidelines for “household” determinations, but I’ll go out on a limb for you. If your “kid” is a full-time resident of another state, he or she may apply that for state’s exchange coverage and be eligible for premium assistance. You would not count this kid as part of the household in California regardless of tax status. Your kid must be a full time student or disabled to be claimed as a dependent over age 18 and that expires in the year he or she turns 24.


SHOP Agent Commission

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The following is the schedule of agent commissions for new SHOP business effective January 1, 2014 and later.

  • 1st Year 6.5%
  • 2nd Year 6.2%
  • 3rd Year 5.9%
  • 4th Year 5.6%
  • 5th Year 5.3%
  • 6+ Years 5.0%

MAGI and HSA contributions

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Question: I have had an Individual HSA plan for years and probably will select one if available in Oct. When I estimate my MAGI for 2014, should I include my annual HSA contribution in the figure or will this not be tax deductible anymore?

Answer: Thanks to Max Herr’s very informative comment on my previous HSA entry. I have your answer. Your 2014 HSA contribution will be added back onto your AGI to make up your MAGI for the purpose of calculating your tax credit. That will lower your credit and may even cause it to disappear. So I’d recommend that you do not take your tax credit in advance and you may find that you have an unused tax credit once you do your 2014 taxes. That pleasant surprise would be easier than paying the tax man a surcharge.


HSAs and Subsidies

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Question: If I select a HSA individual plan can I also qualify for a subsidy for the premiums?

Answer: I haven’t read anything definitive on this question from the IRS. If anybody else has please let me know. You have the option to apply your subsidy toward the purchase of a Bronze plan which the HSA is, but I doubt the IRS will not allow a double tax benefit. They may come to some accommodation for a partial reduction of the HSA contribution.


2014 Commission News

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Question: I saw where Blue Shield announced agent commissions at 4% on individual business. Any news on other carriers?

Answer: Yes. Shield announced 4% first year and renewal for ACA-compliant individual business effective 1/1/14. Anthem also disclosed their commission: $18 per member per month first year and $12 pmpm renewal. Looks like Kaiser will be staying at a $100 flat fee. Anybody heard from Health Net?


Question: I don’t understand how you will quote plans available for Oct, Nov, Dec effective dates, while also quoting ACA compliant plans with a January effective date. It could be very confusing. Any ideas?

Answer: Carriers are taking steps to handle the potentially confusing overlap you described. Blue Shield announced today that they will stop accepting online applications for their current portfolio of plans on September 25th and will begin displaying and quoting ACA-compliant metal plans on September, 26th, with October 1st the first day to submit applications for ACA-compliant plans. Only paper applications for the existing portfolio will be used between 9/26/13 through 11/15/13 with the last effective date 12/1/13.


Can Spouse Opt Out of Group Coverage?

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Question: I work for a public school in which my employer pays for my health insurance. My wife is a homemaker and is on my insurance, but I pay the entire premium. My gross income last year was 27,000. Can my wife leave the insurance she currently has and shop on the exhange?

Answer: The IRS has ruled if one has “access” to employer-sponsored coverage they are not eligible for premium assistance in the exchange. So your spouse can opt out of your group coverage and shop at the exchange, but she will not be eligible for a subsidy.


Household 4, Insured 1 or 3?

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Question: My husband is on Medicare. I am not. In addition we have, twin sons age 20 who are college students and have student health insurance. The boys live with us. Our household income is about $50,0000. Do we count the household income if only I need coverage? Can my sons stay on their college insurance after January 1, 2014?

Answer: Yes. The household income is used regardless of the number of members to be covered and you can enter only one person to be covered. Your sons can stay on their college insurance because it qualifies as minimum essential coverage. Go to the Covered California Shop and Compare calculator enter 4 for number of people in household, household income of $50,000 and for our example enter zip code 90045. Enter age 50 for our example and leave the number of people to be covered at one. The options presented at the Enhanced Silver level have net monthly premiums ranging from a low of $256 to a high of $289 after premium assistance. But wait we’re not done. As an added bonus, we’re going to add your 2 sons to the same Enhanced Silver coverage absolutely free. That’s right, you can cover 3 family members for the same cost as one person. How in the world is that possible? Because of the little known fact that there is a premium limit is based on income. What that means to you is the amount you pay is set by your income, in this example approximately 7% of $50,000 - or $290 per month. What happens is the subsidy increases to cover the added gross premium for 3 family members versus one. Wow! What a deal.


SHOP Options for Employees

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Question: If my employer chooses a Bronze anchor plan with Kaiser can the employee pick a Gold plan with Anthem and pay the difference?

Answer: No. The employees may select from any plan, including different carriers, but only from the metal tier selected by the employer - Bronze in this example.


Question: My significant other & I share a home. We have income of $11,000/yr. I believe that qualifies us for Medi-Cal but we have substantial assets for our retirement. Are you still eligible for medi-cal with over $750k in bank accounts and mutual funds for retirement?

Answer: Yes. You are eligible for Medi-Cal. Assets are no longer considered in determining your eligibility.


Can Group Dependents be Subsidized?

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Question: Are small & large employers required to offer coverage to dependent children under 21? I know they don’t have to offer to spouses so they could go to the exchange, but if they are required to offer to dependent children then that could mean alot of children who’s household incomes above 250% could be with out coverage since they would not be eligible for tax credits on the Covered California Exhchange, therefore the parents may still not be able to afford coverage for their children.

Answer: Neither small nor large employer-sponsored groups are “required” to offer coverage to dependent children, but currently all small groups in California do and most large groups do as well. The same is true of spouses. And, yes, since spouse and dependent coverage is “offered”, even without an employer contribution, the family is not eligible for premium assistance in the exchange. This is an IRA ruling not a Covered California decision.


Employee/Single only coverage?

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Question: Will employers be able to elect to provide employee only coverage in the SHOP Exchange so spouses/dependents can go to the individual exchange and be eligible for a premium subsidy?

Answer: At least one of the major carriers is considering it and that would be for off-exchange small groups as well if it does happen.


Why No Training Date?

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Question: I called Covered CA—told to wait for e-mail you mentioned last week. So far, no e-mail to pick in person training. What can I do?

Answer: I’ve had some agents tell me that their status had changed from pending to eligible but they have not received the login info for training. In the meantime, here’s the training schedule. Click image to enlarge.

Agent Training Schedule.png


Opt Out of Student Insurance?

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Question: I am a graduate student and wondering if I can waive the plan offered by school and purchase outside. I have about 22000 income this year which should be qualified me for some subsidy. School plan is not my best choice because it is way more expensive. My question is will the school plan an accessible coverage for me which might prevent me from buying one outside myself ?

Answer: Yes. You can waive the plan offered by your school and enroll in subsidized Covered California coverage. Having access to school coverage will not disqualify you from receiving premium assistance in the exchange. At MAGI of $22k, your subsidy will cover approximately 50% of the Silver Plan premium.


Tax Credits with No Income?

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Question: My wife and i draw a salary from our s corp Total salary 24,000 for both in a year. Our adjusted gross income on tax return is a loss. Do we qualify for credits?

Answer: No. Since you are eligible for Medi-Cal, you do not qualify for advance tax credits.


When Will Coverage Begin?

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Question: If I apply during open enrollment, for example on January 22nd, and go to the the doctor that same day, will be my coverage begin that day? Will that doctor visit be covered? Or, does coverage always begin on the first of the month following application?

Answer: The earliest coverage will start is the first of the following month, but you must enroll by the 15th of the previous month. In your example, enrolling on January 22nd, your coverage would not start until March 1st. Any medical expenses you would incur between January 22nd and March 1st would not be covered.


Mom and Pop Business

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Question: I am the sole shareholder and employee of my home-based marketing services business, set-up as an S-corporation. I pay my husband, as an independent contractor, sales commission (about $30k/yr) for projects he brings to the company. I have been buying individual medical insurance for our family of 4 (incl 2 small kids) from Anthem. For 2014, should I buy insurance through the small business exchange, or as individual insurance? I am confused as to whether the small business tax credits are a better “deal” than the subsidy. I anticipate a $50k 2013 household income and perhaps $60k for 2014.

Answer: Your only option is the individual exchange. Covered California SHOP has ruled that at least one employee must be on payroll to be eligible and that employee cannot be a family member. See comments for additional details.


Question: If the difference between PPO and HMO is diminished, it seems the choice among various insurance plans comes down to one important factor: network. But this piece of information is nowhere to be seen. Certainly Covered California already knows what they are, so what’s the delay?

Answer: Right. Provider networks and price are the only differences among plans on the exchange. When can we see them? Certainly by October 1st. Where? Definitely on the individual insurance company websites and hopefully it will be available during the plan selection phase of the enrollment process on the exchange.

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