Speak with a Covered California certified agent! Call (888) 413-3164 or Shop Online Now

Shop and Compare

California Health Insurance Plans and Rates

It's easy. Just enter your zip code.

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.


Must My Kids Take Medi-Cal?

By on | 25 Comments

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.

25 Comments

Actually if you have or need specialists it isn’t that hard to run into this problem. Specialists can be hard to find with the best insurance plans and if you have a rare condition- it’s entirely possible you may find there are NO providers in your area that accept any form of Medi-Cal. Especially if it requires regular care- Medi-cal simply isn’t designed with disabilities, chronic conditions or anything more then an annual check up and ‘sick’ check ups in mind.

Question: A family of 5 ( 2 adults and 3 young kids) have an existing grandfather PPO individual policy with Anthem. We want to just do a change of the coverage with Anthem to another EPO plan with them. Our income qualifies us as a family of 5, to get a premium subsidy with an Anthem plan on the exchange. We do not want to enroll the 3 kids in Medi-cal which according to income we qualify for. We want to get on the exchange a plan just for the 2 adults only- with Anthem, to change the existing coverage and transit to another EPO plan with Anthem. Also we want to do off the exchange- another change of coverage plan with Anthem- and transit to another EPO plan just for the 3 kids. In other words: We want to split our existing ppo grandfather policy into 2: One plan on the exchange for 2 adults to get the premium subsidy. The 2nd plan off the exchange, directly with Anthem just for the 3 kids. We wanted the Enhanced silver plan on the exchange for the 2 adults, and for the kids plan EPO with Anthem silver plan. HOW DO WE DO THAT? It does not give many options on the on line application. Please advice us. Thank you very much.

If I’m enrolled in Medi-Cal can I still choose to pay for my services with cash?

Cynthia, These children should not have been issued Blue Shield coverage through Covered California. They can’t have both Medi-Cal and private coverage, but it’s only been within the last few days that the CC enrollment system was capable of instantly identifying applicants already on Medi-Cal. If they applied today, the children would be ineligible for Covered California coverage until they were off the Medi-Cal system. However, for the time being, as long as you can verify coverage at Blue Shield, I’s say go ahead and bill them as I assume they pay better than Medi-Cal. And yes both boys would use the same Blue Shield card as they are both on the same policy.

Question for insurance agent or representative.

I am a therapist and have two children that I’ve seen through Blue Cross managed Care- A Medi-Cal plan.

The parents told me the children still have Medi-Cal and the parents also purchased a Blue Shield plan through Covered CA for their children only as the parents are covered through the father’s employee plan. The children have autism & qualified for Medi-Cal

The parents visited a Covered CA agent who sold them a Blue Shield “Family plan” for their two children only. The eldist boy is listed on the insurance card and they indicated the younger sibling is under the older brother’s plan with the same ID number since it is considered a “family plan” even though it is for the children only.

I am not sure how to bill for this or if it is true that a sibling can fall under another siblings “family plan” when the parents are not enrolled with only a single ID number. Also the parents state the kids are still eligible for Medi Cal and still have their plan. The Medi-Cal plan has covered some therapy but they want to add additional visits under this new plan— I called the insurance number but was on hold for over an hour and could not get to a representative. So Can the children have both Medi Cal and the other Covered CA Blue Shield plan? Can a child have a “family plan” with a sibling listed under their ID? Help appreciated!

Be careful not to jump to any unfounded logical conclusions here (as I almost did.) When expecting to just use Medi-Cal for your qualifying child as a form of “high risk/catastrophic/hospitalization” plan, be aware of the unacceptable, unintended consequences. I fell into this logic trap today when I preliminary decided that we’d just pay for checkups/medical services out-of-pocket, (rather than pay $2050 on a separate, unsubsidized Anthem BC EPO/PPO plan and just accept the coveredca.com assigned Medi-cal as a sort of “catastrophic / hospitalization” plan for our healthy 8-year old daughter. [Since history suggests we have never, ever paid her pediatrician’s medical group/pharmacy anything close to $2050 for normal checkups/medicine, etc per year]. ) But fortunately, my wife was more through and actually called our pediatrician’s billing department. If your child’s doctor/medical group doesn’t accept Medi-Cal, than if your child needs to be hospitalized, her doctor cannot order the hospitalization because they don’t accept Medi-Cal. If hospitalization were necessary, a new Medi-cal accepting pediatrician would need to be contacted to complete the order. (Lord only knows how long that process might take.) As I see it, this really only leaves two options for opting out of the (likely dysfunctional) Medi-cal program: Purchasing a separate, un-subsidized policy through a carrier/agent or insuring my daughter separately under the actual Catastrophic (High Deductible) Plan available to individuals under the age of 30, and to those whose insurance was cancelled due to ACA requirements for 2014. The latter solution is likely only available for 2014. This dichotomy of eliminating premium subsidies due to increased eligibility for children from Medi-cal seems like an unintended consequence of the ACA implementation, which is a a very new, very complicated Act. If competent pediatric physicians believe that they cannot run their practice on the rates set by Medi-cal/Medicaid, than they cannot accept Medi-cal/Medicaid. The only mitigation for this sizable worm hole in the ACA is that most children don’t need much medical care and therefore their unsubsidized policy rates are somewhat reasonable, but otherwise, this is a unacceptable weakness in the ACA as currently enacted.

Going back to what Amy said on Oct 5th. Its not that we cant find a pediatrician that accepts medi-cal, its the fact I dont want to change the doctor for my kids. Max, what is the mechanism that can pay the doctor that does not take Medi-cal?

Insurance carriers have been put first, rather than insureds’ care. That’s what’s happened.

I never thought single-payer would work until someone pointed out that Medicare works very well.

Oh yeah…

We will have to get a family plan on the exchange to have coverage in 2014. None of our Doctors who we currently access through a Blue Shield PPO plan are on Blue Shields EPO network. I just saw my family doctor and was told they were still on the PPO network for 2014 but were not on the EPO network. But getting insurance through Covered California, I don’t have a choice but the EPO network. None of our doctors on Blue Cross either, PPO or EPO. I’ve checked the providers lists on both Blue Shield and Blue Cross to verify this. Oh - and Covered California says to ignore the list on their web site as it is not accurate! Oh - and if we qualify for Medi-CAL, we will lose our doctors as none take Medi-CAL. Meanwhile, Blue Shield tells me that my son attending college in LA (we are in SF) will have to come back to SF for routine medical care as the EPO network is only local to the Bay Area. So, we get affordable health care (which we don’t really have right now) but lose all our doctors in the process. What happened to “if you like your doctors you can keep them”?

this is hard. ya’ll know what your doing so be a good Samaritan and help me! we are a family of four. about 50,000. in the 93446 area code. it says we qualify for the silver plan(adults) and the kids qualify for medical. now what? the deductible is about 147 for us and I assume the kids are free. how do I enroll. if I chose a plan can I change later? how come there are only two providers? blue cross and shield? how do I find out if there is a doctor in my area that takes those insurance? I have never bought insurance and we just pay 50$ for a visit to a clinic usually when we get sick. do we apply for our insurance then the kids separately? or is it all in one packet. when you reply( and please do) dumb it way down my friend!! I am very intimidated by this whole thing as are many of my friends. and pleas tell me if you feel its better to buy the bronze with a 60$ copay and 19$ prescription and a monthy fee of 65$ or would you but the silver with a 160 monthy premium and a 20$ copay? we go to the doc about once a year. maybe we would go more if it didn’t cost too much but honestly I don’t think we would take time out of the week it always takes forever by the time we get in the back room our fever broke and were better! and do we get the balance credited to us each month before the bill comes or do we have to pay the whole bill and get the credit back on taxes? also on one of the bronze plans there is a tiny “2” and at the bottom it says this not subject to detectable for first two visits, if that means you don’t pay the 60 dollar deductible the first two times you go only after that then that is great but i’m not sure what it really means. thank you and pleas some one respond!

Under Medi-Cal, if you cannot find a provider willing to accept Medi-Cal patients, then Medi-Cal has a mechanism to pay the expenses anyway.

“I can’t find any in my area.”

Unless you reside in one of the most remote areas of California, you should be able to locate a Medi-Cal provider without as much trouble as you claim.

In SoCal, for example, we have Molina Healthcare and LA Care which are HMOs that specialize in enrolling Medi-Cal patients and Medi-Medi Seniors. Obviously, they have networks of providers who accept Medi-Cal patients.

This action relies on an assumption that a child on Medi-Cal has the same availability to health care as a kid on a private plan. For instance: my kids’ pediatrician does not accept medi-cal. So right there, I lose him. Then my speech therapist for my son does not take medi-cal - so I lose that too. I’m sure I’ll be directed to a county-run service? A pediatrician …somewhere? Assuming we’ll be “thrilled” with free medi-cal assumes we’ll be “thrilled” with whatever services accept medi-cal and so far, I can’t find any in my area.

Hello F1 VISA student.

You are eligible for Medi-Cal with modified adjusted gross income under 138% of the Federal Poverty Level (FPL).

I am a F1 VISA student. I have SSN, and I submit tax report, in which my income is very low or none every year because a F1 Student is not allowed to work or allowed just under 20 hours a week. I know F1 VISA is qualified for marketplace coverage; however, am I eligible for subsidy or Medi-CAL if my income range is under 138% of FPL?

“Covered California which verified that the entire family is not eligible for a subsidized Covered California plan if the kids do not take Medi-Cal”

Yes, as I tried to explain at least once or twice.

“the parents WILL still get a subsidized Covered California health plan with a total subsidy based upon a household size of four, and based upon total household MAGI.”

Now you’ve heard it from me at least three times, and from Covered California at least once. Should be enough to satisfy your curiosity. But your remarks about whether children have separate coverage via IFP or Group is wrong. Responsible insurers and agents are not supposed to enroll any person in a health plan if that person is eligible for Medi-Cal. Which of us would risk losing our license over your desire not to have your kids on Medi-Cal?

Additionally, How would children have coverage under a group plan? Only through their parent(s), and if a parent has group coverage, then the household is ineligible for a premium tax credit unless the employee’s self-only cost exceeds 9.5% of MAGI.

Yes, you can probably manage to purchase child-only plans (and you’d have to misrepresent your income to do so), but personally, I think that would be foolish. You will end up with three plans (you and your wife, child 1, and child 2 = three plans), each with sizeable deductibles (no family deductible except for you and your wife). Choosing all silver level plans, you could be facing up to $25,400 in combined deductibles — $6,350 per person times four — instead of the family maximum of $12,700. How does that sound? And that’s on top of your premiums, subsidized with tax credits or not.

In my opinion, you would be making a big mistake to go that route instead of taking advantage of Medi-Cal and its virtually non-existent out-of-pocket expenses. But what do I know? I’m only one of 24 licensed Life & Disability Insurance Analysts in the state of California. My daily work involves “the numbers.”

Sweet! Looks like we find some common ground.

Looks like Phil’s original answer has led to some misunderstanding. He suggested “If 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.”

I took his reference to “they” and “they are ineligible” to mean JUST the KIDS that do not take Medi-Cal are ineligible for subsidy, yet his inference was/is that parents would still be eligible for subsidy. I then posted query in response. I assumed Phil also meant (as he wrote) that the kids could opt out of tax credit subsidy coverage with Covered California, yet still have option to enroll in Covered California or non-Marketplace IFP plan coverage, yet also parents could still get a subsidized Covered California plan. I understand generally too that family members can enroll in differing Marketplace health plans.

I just called Covered California which verified that the entire family is not eligible for a subsidized Covered California plan if the kids do not take Medi-Cal. I think this is what you are saying Max.

However, Covered California also just told me (per my inquiry) that should the kids have other coverage elsewhere (regardless if IFP or group), such as having non-subsidized non-Marketplace IFP coverage, then the parents WILL still get a subsidized Covered California health plan with a total subsidy based upon a household size of four, and based upon total household MAGI. Hope their answer is correct and reliable.

So, here we would have a situation where the kids do not take Medi-Cal and the parents DO still get tax credit subsidized Covered California plan coverage. Ah ha! It is possible, so today says Covered California.

Max also: The words ‘Subsidies’ (as in tax) not the same as the word ‘Subsidized.’ I should stop saying what I say…? I was fairly clear in explanation too.

As for who is to “blame” is not my concern. As a consumer, and from a consumer point of view, seeing what is and is not available in terms of providers for available health plans is what matters. Access to providers via carrier networks WILL change and lessen significantly compared to plan networks today. Not sure why you said plan networks will stay the same. As to why or whom is to blame or whose decision it is, is irrelevant to making the choices for coverage moving forward. Knowing about these provider network changes relevant for the available Covered California and non-Marketplace plans is important in making a decision to enroll in a health plan.

If a person attempts to enroll through the exchange and the software determines that the person (i.e., children but not adults) is eligible for Medi-Cal, that person cannot be enrolled in any plan through the exchange, but will instead be directed to Medi-Cal (Medicaid). That’s was has been drummed into us as agents in the Covered California training, and its what I wrote in National and State Training manuals that I developed for a national training provider which are currently being used in other states such as Nevada, Missouri, Wisconsin, and Montana. That information was fully vetted by those other states, believe me.

“if the kids do not enroll in Medi-Cal, the kids will not be eligible for subsidy”

If you don’t want your children enrolled in Medi-Cal, then you may choose any health plan of your desire OFF THE EXCHANGE and forgo the premium tax credits entirely. The tax credit numbers I posted earlier (based on Los Angeles Region 16) are what the Covered CA credit calculator returns for your FAMILY OF FOUR with your children enrolled in Medi-Cal. You can believe or not believe whatever you choose, but STOP USING THE WORD SUBSIDIES in relation to Medi-Cal and your children. It is confusing you, and it has no application.

As for hospitals being part of a network in 2013 vs 2014, that is simply a choice of hospitals to be part of a network or not, and is purely an economic decision. Insurance companies are under a heavy federal mandate to meet 80% Medical Loss Ratios, and still earn enough of a profit to stay in business. One of the ways to do that is to pay hospitals LESS in 2014 than they were paid in 2013. Medicaid/Medi-Cal is doing the same.

The hospitals you mention are choosing to opt out of certain Medicare Advantage networks as well in 2014. This has nothing to do with Covered California specifically, as much as is has to do with Medicare and Medicaid reimbursement schedules. I don’t blame those hospitals one bit. But you are confusing apples and oranges when you try to equate changes to 2014 hospital providers (since you apparently don’t see physicians as a larger component of provider networks) as having something to do with the exchange more than other economic factors.

UCLA and Cedars-Sinai have narrowed their involvement in certain insurance company networks to very small geographic regions rather than being open to folks network-wide. Why? Because they can afford to with their PPO and private-paying patients. Want to be able to access them? Enroll a PPO (and pay the higher out-of-pocket costs) or move into one of their narrowly defined coverage regions.

Blame Congress for all of this. It’s their plan, and it’s not what most Americans wanted or thought they were getting.

Max, if you are correct, and I believe you believe you are, then what a deal to get doubly subsidized, with premium tax credit money for a health plan for two adults as based on a family of four (greater MAGI allowance), while kids also get free (subsidized) Med-Cal to boot.

As for provider networks staying the same as today, you’re dead wrong.

Blue Shield today provides in-network access to UCLA and UCSF, yet (as arranged today, subject to change) Blue Shield will not have UC school providers for their IFP plans come Jan 1st, 2014. In Los Angeles, likewise Blue Shield provides in-network access to Cedars, yet come Jan 1st, 2014, all Blue Shield IFP plans won’t have Cedars either.

And likewise with Anthem. Current Anthem IFP plans provide in-network access to UCLA and Cedars, yet come Jan, 2014, Anthem will no longer provide in-network access to Cedars, yet the UC schools medical providers will still be there with Anthem.

As I also understand it, Medi-Cal is not a mandate. One will always have opportunity to enroll in an unsubsidized IFP plan, whether inside or outside of the Marketplace. If one is eligible for Medi-Cal, one is never forced to enroll. Millions are currently eligible for Medi-Cal and are not enrolled. These people were not mandated to enroll, as you claim. Come Jan 2014, situation will be the same; millions more will be eligible, yet will not enroll (mainly because they won’t know about Medi-Cal or Covered California).

If one is eligible for Medi-Cal, then Medi-Cal is the only free or low-cost (subsidized) health plan option. One may always elect to forgo enrolling in Medi-Cal to take an IFP plan, yet the selected IFP plan will will not be subsidized. Medi-Cal eligibility precludes and thus excludes tax credit subsidy for an IFP Covered California Marketplace plan. One will still be able to enroll in a Covered California or non-Marketplace IFP plan, however, and not enroll in Medi-Cal.

So, my question of scenario has been:

—- if the kids do not enroll in Medi-Cal, the kids will not be eligible for subsidy, yet the family of two adults IS eligible for subsidy. But if family is given subsidy as based on MAGI for a household size of four (4) family members, then… the kids indeed WILL effectively be subsidized under their family’s Covered California IFP plan, contrary to their subsidy ineligibility per the kids not taking their eligible Medi-Cal. That’s effectively what you are saying will be the case; that kids will get free money (costs covered, in-full or partially = a subsidy, whether through taxes or not) either way. If so, sweet! Kids will be subsidized either way. But also doesn’t seem quite right, considering the kid’s would be passing up Medi-Cal, which actually precludes and thus would make them generally ineligible for IFP Marketplace plan subsidies.

We are obviously on a different ‘page’ and of different understanding on this, as you are adamant that Medi-Cal is a mandate (and not a form of subsidy), in this case, for the kids. As relayed here I disagree. Medi-Cal is definitely a form of subsidized health care. If one is eligible for and Medi-Cal enrollment is passed up, there is generally no tax credit subsidy available for a Covered California Markplace plan, as Medi-Cal IS the subsidy option. I also know Medi-Cal is not a mandate if one is eligible. No one is forced to enroll in a health plan.

If I am (or were to be) Medi-Cal eligible, I am or would choose to be buying a non-subsidized IFP plan off the Marketplace. It’s worth my money to have access to providers I want.

I thought I was very clear. But, I’ll try one more time.

Does the size of your household change because one of your kids decides to eat at McDonald’s while the other three members eat at Jack in the Box? Of course not.

Your household size is determined by the number of adults and children residing there as one distinct family unit. Four = four = four. It does not change based on who has insurance or who has Medi-Cal. If you used the online “Shop and Compare” tool, that would be clear to you also.

Please!! YOU MUST STOP using “subsidized” when talking about Medi-Cal. No one but you considers Medi-Cal a “subsidized” program. It is paid for about 75% with cash-based IOUs from the federal government, some 25% administrative money from the states, some of it IOUs, and little else. As taxpayers, we all pay for Medi-Cal with our income taxes and federal and state debt.

Enrollment in Medi-Cal is, essentially, a requirement under the ACA, for all those who are eligible. It is NOT a subsidy, but a mandate. Except that there is no charge to be enrolled.

You and your wife are also under a mandate to have a qualified health plan, and if not eligible for Medi-Cal based on income, you remain eligible for premium tax credits based on a HOUSEHOLD SIZE OF FOUR as long as your household MAGI is between 100% and 400% of FPL, which FOR A FAMILY OF FOUR in CA is a maximum of $94,200.

End of that discussion.

The credits for a household of two or more persons are payable to the person(s) who file a JOINT FEDERAL TAX RETURN in 2015 for 2014. They may be received in advance in 2014 based on estimated 2014 income, but will be reconciled in 2015 when you file your tax return, and you could owe some money back or have more money coming. You could completely forgo the credit in 2014 and receive it as a “refund” in 2015. That’s your choice.

“The Covered California and mirrored off-Marketplace health plan provider networks are being slashed big time Max!”

Please!! Tell us EXACTLY what authority gave you that information. It’s just not true. Have you asked your doctor that question? Have you asked ANY doctor that question? Those are the persons who know the truth.

So Max…. you still did? and did not? address my question/concern!

Sounds like… you’re suggesting that the subsidy for this family of four will be provided as based on a household of four, AND the kids can take subsidized Medi-Cal.

I would like to know for certain. Phil can you help, and do you know?

Max, of course Medi-Cal is subsidized: that’s why it’s free. In fact, generally, those on Medi-Cal have Medi-Cal as their ONLY subsidized health plan option as tax credit subsidies through an optional Covered California plan are not available for Medi-Cal eligibles and members.

Thus my inquiry about this family: whether there will be tax credit subsidies as a family of four with two kids also on Medi-Cal, or whether there will be tax credit subsidies based on family size of two adults only; as the kids already have subsidized health plans with no-cost free Medi-Cal.

And you saying that provider networks will remain unchanged (“there will not be differences…” and will be the same for Covered California plans as compared to the provider networks of current non-ACA-compliant plans is silly! The Covered California and mirrored off-Marketplace health plan provider networks are being slashed big time Max! Covered California health plans will have substantially smaller carrier provider networks as compared with current non-ACA-compliant plans today. Hence potential benefit to find a non-Covered-California plan with full provider networks, which we hear will be available from Anthem for IFP plans. Small group market plans will have full provider network health plan options, at least we know with Blue Shield, and I would imagine with other carriers too. We’ll find out real soon!

Yes, of course family size is a determiner of FPL, but the size of your family does not change based on who may be eligible for Medi-Cal enrollment.

I thought that was made clear in my response above — “As an example, let’s say Michael’s MAGI is $33,000 — or about 140% FPL for a family of 4”.

You wrote: “Afterall the kids are already getting a subsidy from being on Medi-Cal”. This is, technically, incorrect. There is no cost for Medi-Cal, only out-of-pocket expense. No cost does not equal a “subsidy” as subsidy is used to refer to premium tax credits.

Health care providers are justified in refusing to accept Medi-Cal patients thanks to the low reimbursement rates. However, your statement “Same reason for not taking a subsidized Covered California plan; that the provider(s) that an enrollee wants may very well no longer be a part of a carrier’s network” and “Rumor is that Anthem will be providing additional IFP plans with wider networks than plans with Anthem’s Covered California or out-of-Marketplace mirrored IFP plans” is just that, an unjustified rumor. There will not be differences between existing HMO/PPO networks and networks for Exchange-based plans (except for any providers whose contracts are not renewed by the insurer or are terminated voluntarily by the provider, as happens naturally every year).

“this is why one would be willing to pay more for health plan coverage.” Fine. Your decision to obtain health insurance is entirely one of free choice. Nothing prevents you from doing this OFF THE EXCHANGE. But off the exchange, you are ineligible for any premium tax credits. If you need the tax credits, you must enroll in an exchange-based plan and if your children are Medi-Cal eligible, they WILL BE enrolled in Medi-Cal. In that, you have no choice.

If you don’t like that, then vote for other Congressional representatives who think like you, because it was Congress that established the onerous requirement to obtain one’s health insurance through the exchange in order to obtain a premium tax credit, instead of making it available to all citizens and nationals without restriction.

Finally, “Anthem seems it will be carrying the UC Medical network of providers”. This is not Anthem’s decision alone, but that of each of the individual UC medical centers, just as it is of every other hospital in California. There are plenty of hospitals and physicians that have ceased contracting with Anthem as a result of its “heavy handed tactics” when it comes to provider contracts.

Hi Max.

What you say I misunderstand does not address with explanation the nature of my inquiry.

Also, tax subsidy is NOT based solely on just MAGI income. Tax subsidy is ALSO based upon FAMILY SIZE.

I also do not think the tax subsidy is doled out per person.

Here’s the rub of my question: If the two kids go on Medi-Cal is the subsidy then based upon family of four or family of two?

Subsidy is based upon whether the family MAGI income is under 400% of the Federal Poverty Level (FPL)(which is correct, as you say), yet is based ALSO upon the total number of members of the household.

400% FPL threshold for household of one (1) is $45,960K, while 400% FPL threshold for household of four (4) is 94,200K. So, of course the number of household members makes a difference! A family subsidy for a household of one with MAGI of $45,900 will be much lower than the subsidy for a family of four with MAGI of $45,900.

Yet again, if the two kids go on Medi-Cal as they may be eligible, is the family subsidy then based upon family of four (4) or a family of two (2)? Afterall the kids are already getting a subsidy from being on Medi-Cal, and so to not double-up, it seems the household tax subsidy might likely be based upon a household of two (2), computed for just the adults. Yet, if the tax subsidy is based upon a household size of four (4) then the family will get a great deal; effectively, the kids will be provided double subsidies.

Wondering also if the Calculator and CalHEERS enrollment process will address this?

And the reason why parents may NOT want their kids on Medi-Cal, even though subsidized, is because of the limitation of providers under the Medi-Cal HMO plan. Same reason for not taking a subsidized Covered California plan; that the provider(s) that an enrollee wants may very well no longer be a part of a carrier’s network through the new health plans as offered through Covered California. And so this is why one would be willing to pay more for health plan coverage.

Rumor is that Anthem will be providing additional IFP plans with wider networks than plans with Anthem’s Covered California or out-of-Marketplace mirrored IFP plans. That will spice things up a bit. Anthem could make itself the go-to carrier if it also included the national BlueCard Program. Especially that Anthem seems it will be carrying the UC Medical network of providers.

Michael, you misunderstand the nature of the premium tax credit. The tax credit is the tax credit. It is based solely on household MAGI — it is not calculated or doled out on a per-person basis.

If the children qualify for Medi-Cal Kids, there is no need to purchase insurance for the children. The full tax credit remains available and would be applied to the parents’ premiums. The good news is that at 140% FPL, the available options are “enhanced”.

The question is simple: Why would someone choose to pay money for children’s coverage when essentially the same coverage is available without charge? To do so makes no sense.

As an example, let’s say Michael’s MAGI is $33,000 — or about 140% FPL for a family of 4. Michael and his wife are ineligible for Medi-Cal by a few hundred dollars per year in income, but the children are probably eligible for Medi-Cal Kids (under what was formerly SCHIP, which has been subsumed into Medi-Cal), so there is no need to pay premiums for health insurance for the children.

Michael and his wife could purchase an “Enhanced Silver 94” plan at a net cost of about $40 - $140 per month, depending on the insurer, with most plans in the mid-$90s. This includes a estimated $359 monthly premium tax credit.

If, instead, Michael’s MAGI were $60,000, the children would not be eligible for Medi-Cal, the monthly tax credit would be about $60 less at about $296, but the after-tax credit premium for an “Enhanced Silver 70” plan would jump to between about $325 - $525. The kids’ premiums account for between $285 - $385 per month (not to mention a significant increase in annual out-of-pocket maximums).

Complex? Of course. Who can help you sort out your options? Only a licensed and “certified” insurance agent.

So, is there then to be a calculator, or some means to determine total family plan premium, if the family, inclusive of the kids, takes a family policy, yet only the adults get a subsidy and the kids do not? How is the subsidy calculated, and communicated to the Covered California applicant, for just the adults’ coverage, and exclusive of the kids’ coverage, in order to determine total health plan monthly (or annual) premium costs?

This is a great Q&A. It should be apparent that one of the objectives of the PPACA is to enlarge the number of folks — including children — who are beholden to the federal government for their health and welfare. This does nothing to reduce the cost of health care in America, which is what the PPACA was supposed to be all about.

It is well-known that health care providers are not properly compensated for services rendered to their Medi-Cal patients. With more folks joining the ranks of Medi-Cal, to whom will hospitals and doctors turn to make up the difference between what they need and what they are paid, if not to their insured patients.

Is it a good thing that folks who are not on Medi-Cal today might find their way to it come 1-1-2014? Who knows? Remember, when the PPACA was passed into law, there were close to 50,000,000 uninsured persons in America, and the Congressional Budget Office estimated that over the next ten years, only about half of those would end up insured. Why Congress chose to overhaul an entire system instead of simply addressing the uninsured in America is beyond me.

The PPACA has forced insurers to face certain realities, including providing coverage to persons with preexisting conditions. That is something that could have been easily addressed legislatively. The insurance companies will learn that these folks do not necessarily cause huge claims. But only at the expense of unlimited lifetime care. That will be hard to predict from an actuarial perspective. It already doesn’t work with Medicare.

Quite the conundrum.

Leave a comment

Do You Have California Health Insurance Questions?

Ask An Expert

View Previous Questions
Call Us at (888) 413-3164


© 2019 California Health Benefit Advisers, LLC
Home / About / Start Shopping / Ask a Question

“Covered California,” “California Health Benefit Exchange”, and the Covered California Logo are registered trademarks or service marks of Covered California, in the United States. This web site is owned and maintained by California Health Benefit Advisers, LLC, which is solely responsible for its content.