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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.


February 2014 Archives


Coverage for Dependent Parent?

By on | 2 Comments

Question: My mother (64) is an immigrant and lives with me and my family, and makes 0 income. I have claimed her as a tax dependent on my 2011 and 2012 returns, though she files her own returns with 0 income. When I created a CoveredCA account for her, I used MY income as the household income, which precluded her from receiving subsidized insurance either through the exchange plans or through Medi-Cal. The definition of household income here is unclear. Any insight on what's the right definition here for household income?

Answer: Assuming your mother has legal resident status, she is eligible for Medi-Cal. Her application has to be changed to a 1-person household with $0 income and she has to agree to file a tax return in 2014 as "single" status. You need to stop claiming her as a dependent. You can't have it both ways.


Undocumented DACA Immigrants?

By on | 1 Comment

Question: I have a two-year work visa under President Obama’s DACA law but I am not a citizen and do not have a green card. Can I get California Covered?

Answer: You are definitely eligible for Medi-Cal, not sure about premium tax credits and or cost sharing reductions in Covered California. You have legal status under the Deferred Action for Childhood Arrivals (DACA) program and as such are eligible for Medi-Cal in California. Background: In 2012, President Obama developed DACA, which grants undocumented children legal status and authorization to work in the United States for two-year periods. To be eligible for the program, children must:

  • Have arrived in the U.S. before age 16;
  • Be under age 31 as of June 2012; and
  • Have continually lived in the U.S since 2007.

While the expansion of Medicaid under the ACA specifically excludes undocumented residents, California ruled that DACA residents are eligible for Medi-Cal.


Change Plans Now?

By on | 9 Comments

Question: I began coverage on 1/1/14 on the Blue Shield Bronze PPO. Can I change to the BS Silver PPO now or do I have to wait til next year?

Answer: You can change plans until March 31st. After that you will have to wait for the next open enrollment period.


Question: My doctor wants to know how to get into the Covered California network.

Answer: Once again, there is no Covered California provider network. Your doctor must contact the provider services department for each qualified plan within Covered California - Blue Shield, Anthem Blue Cross, Health Net, Kaiser, etc. The Blue Shield Provider Services phone number is 800-258-3091. I try to get the other carriers’ numbers and post them here.


Deductibles Individual or Aggregate?

By on | 7 Comments

Question: There are 2 members in my family, a 59 y/o and an 18 y/o out-of-state college student. We are looking at the BS Silver 70 PPO plan. If one of us is hospitalized, is the deductible $2,000 (individual) before the 20% starts or would it be $4,000 since we are a family? Likewise, is the same true for maximum out-of-pocket expense? If it is the $4,000, it seems wiser to go with the Gold 80 plan at $100 more per month rather than risk the deductible. Your thoughts?

Answer: Nearly all of the ACA-compliant individual plans (the only plans you can buy now), have individual deductibles. So in your example (if one of us is hospitalized...) once the $2,000 deductible is met the 20% coinsurance goes into effect. The Bronze HSA plan is the only plan in the new portfolio where the deductible is collective or aggregate, meaning the family deductible of $10,000 would have to be met before the 20% coinsurance goes into effect. The out-of-pocket maximum is individual as well. Also, the Blue Shield PPO is the only Covered California qualified plan that will cover your college student "in-network" while out-of-state.


Question: Hi Phil, if a husband is offered insurance through his job (employee portion paid at 100%) and the wife/kids waive because they are on Medi-Cal, would they be required to leave Medi-Cal immediately (or would they have to notify them) because they are offered affordable insurance through the husband's job? Or would they just wait until Medi-Cal says something?

Answer: Medi-Cal beneficiaries are obligated to inform that agency of any changes of status that will affect Medi-Cal eligibility. So yes, you would have to notify them though I don't think that being offered employer-based spouse and dependent coverage would exclude you from Medi-Cal eligibility by itself. But then I'm not a mediCal expert. Keep an eye open for comments to this post as I'm sure some of our Medi-Cal gurus will provide added perspective.


Covering Child with 50% Custody?

By on | 3 Comments

Question: If a person has 50% legal custody of a their child, can the child be covered by both parents that live in different states?

Answer: No. The child cannot be covered by both parents. The child should be covered by the parent who claims the child as dependent for tax purposes.


Question: I (age 27) make 23K a year and I claim my Mom (age 58, 0 income) as dependent in my tax. Do you know why I am eligible for the plan(silver 94) but my Mom is not ? She was transferred to MediCal.

Answer: That's interesting. It seems that even though you claim your Mom as a dependent, her eligibility was determined on her $0 income rather that yours. Yet your benefit level (Silver 94) is based a 2-person household. In that case, it seems as if they are regarding her as if she were a dependent under the age of 18. Might be worth filing an appeal if your Mom wants off of Medi-Cal.


Income changes and CSR?

By on | 6 Comments

Question: I'm currently on a Silver 94 PPO with Blue Shield. I'm sort of expecting to make more money than I anticipated around midyear. The way I understand it is that I have to report changes on income to Covered CA. Will this bump me out of the Silver 94 plan and force me to a plan with full deductible at mid year whenever I make the change?

Answer: Yes. Higher income will change your eligibility for cost sharing reductions (silver plan benefit enhancements) as well as advance premium tax credits (subsidy).


No Prior Tax Returns?

By on | 8 Comments

Question: My daughter has not made sufficient income to be required to file tax returns. She is enrolled with a plan but has received a Covered California request for a copy of her W-2 or prior tax return, her birth certificate and social security card. We have the card and birth certificate. How do we respond to the request for proof of income?

Answer: I'm surprised they didn't ask for her high school transcripts? I mean, these CC requests for verification are wildly off the mark. Here's the scoop. You have 90 days to comply. Wait until you can get through to CC on the phone without waiting 30 minutes or more to talk to someone - probably another month. Once you can conveniently talk a CSR, he or she will sort out what you really need to provide and tell you how to submit it. They will also remove the unnecessary requirements from your account. As for your daughter not filing taxes in the past, that's not a requirement. She only has to agree to file taxes for the 2014 tax year and beyond.


Getting Off Medi-Cal?

By on | 2 Comments

Question: I got onto Medi-Cal last year becuse I lost my job. My income will soon go up and I really want to sign up for Anthem or Kaiser, etc. My agent says CC will NOT let me sign up for a plan unless I "disenroll" first, from Medi-Cal. Is that true?

Answer: Yes. The CC system can now instantly access Medi-Cal data during the application process. Applicants currently on Medi-Cal will automatically be found ineligible for Covered California coverage, with or without advance premium tax credits. The individual(s) must get off the Medi-Cal system before becoming eligible for CC coverage.


Negative AGI?

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Question: How about a loss carry forward that comes from a theft loss? This creates a net loss on line 37 of our 1040. How do we enter it on the Covered California website or the Medical website. It doesn't allow us to enter a negative number for AGI.

Answer: The CC application asks for your current income whether W-2 employed or self employed. Jeeze Louise! What did you make last month? If you start making a lot more, or a lot less, you can correct later. After personally assisting on over 300 CC applications, I can tell you that for most people, the whole AGI thing makes things more complicated than they need to be. Fuhgeddaboudit!


Employer Mandate Delayed?

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Question: I read in the news that the requirement for employers to provide health insurance has been delayed another year, but when I got into the details I just got more and more confused. Help?

Answer: Under the latest regulations, only employers with more than 100 full-time workers will have to pay fines next year and only if they do not cover at least 70% of their workers. In 2016, when the full mandate takes effect, employers with more than 50 full-time employees will have to provide insurance to at least 95% of their employees.


Question: When I enrolled in Covered California Anthem Gold PPO in December, I first called all my doctors offices, twice, and asked what CC plans they would be participating in. Each time they all told me if I picked a “Blue PPO” I’d be fine. As Anthem is the only PPO available in Alameda County (Blue Shield is an EPO), I signed up for Anthem. Yesterday I looked on the website and my large internal medicine group had dropped. I emailed them and my doctor confirmed, saying it would “Be Prudent” for me to find a new doctor ASAP. What are my options? I could try to get back on my HealthNet high-risk pool plan ($1080/mo, $4000 deductible, cancelled Nov. 1 then reinstated, but it’s so infuriating when I’m eligible for a significant subsidy on the exchange. I work 3 jobs to be able to pay for health insurance. What do you recommend as a pathway to finding the cheapest insurance that does cover Alta Bates Medical Group, Hills Physicians Med Gp, Sutter East Bay Med Fndn, or multiple of those groups)? Advice welcome.

Answer**; You seem to be someone who is receiving ongoing treatment for multiple conditions. So I understand that changing providers is a bitter pill to swallow. However, think of it as a trade-off. You couldn’t even get regular health insurance a couple of months ago because of pre-existing conditions - paying over $1,000 monthly for a high deductible risk pool plan. Now you can get covered for the same rate as a triathlete. Now you are “eligible for a significant subsidy” making a no-deductible Gold plan available at a fraction of what you were previously paying for substandard coverage. Narrow networks are necessary to keep costs down - one of the trade-offs for all the good stuff you now enjoy. You welcomed advice - pick new providers in-network for the plan you selected and move on.


Question: My husband and I are both self-employed so our income varies. Likely we will fall around the $60,000 mark for 2014 and qualify for a subsidy. The problem arises because we would like to choose two different plans based on different medical needs. Both plans are offered on “Covered California.” We want to choose a bronze plan for him, and a platinum plan for me. According to some info on the web, this should be a possibility, if so how would we do it?

Answer: The CC online application allows for multiple plan selections for households with 2 or more applicants when applicants are eligible for CC coverage without subsidies. Ths plan selection screen Plan Selection.png (click image to enlarge) is in the Enrollment Section. This would require overestimating your income on the application so as not to be eligible for advance premium tax credits and getting full tax credit due when your tax return for 2014 is filed.


Question: There are 2 members in our household. I am self-employed, with an 18 y/o dependent, with an AGI of $55,000. My 18 y/o attends college out-of-state and has no income. She will turn 19 October 2014. My understanding is she will be covered out-of-state under a family plan if I purchase BS PPO Silver 70. What happens mid-year when she turns 19? Does she have to go on Medi-Cal? If so, will it cover her out-of-state? Would it be better to purchase a catastrophic PPO policy for her now and for me to get my coverage through CC?

Answer: No worries. Your income $55K is high enough that your dependent under 19 will not be eligible for Medi-Cal and your Blue Shield Silver 70 PPO Plan will provide her with excellent coverage out-of-state. When she turns 19 she would be ineligible for Medi-Cal in any case as long as she is included in your household as your dependent. If your income was below $38,775 (250% FPL), she would be eligible for Medi-Cal until age 19 with only emergency health care coverage out-of-state.


I need to change my plan. How?

By on | 4 Comments

Question: I signed up for Blue Shield enhanced PPO through CC. But, my OBG does not seem to be getting paid from them so they do not take this insurance. How do I change my plan so I am covered with her? She is in the Cedars Network I believe.

Answer: From what you've said, It's possible that your doctor is in the Anthem Pathway network. In any case, you have to find your doctor in the right network before you change carriers. At this point-in-time, it is difficult to search the right carrier networks for a doctor. No offense, but you are not likely to do it right. You could use the assistance of a Certified agent. Go to coveredca.com, select "Find Local Help", then select, "Agents".


Catastrophic Insurance Over 30?

By on | 7 Comments

Question: I am eligible for catastrophic insurance due to my old plan being cancelled and my inability to find a plan that I can afford. I have been trying since December to find someone to quote me a price for catastrophic coverage and have yet to find anyone who can do that. Any suggestions on how to break through the Obamacare firewall and access these plans?

Answer: No over-30 rates or online applications available yet. Carriers are just beginning to set up application processes to open off-exchange catastrophic plans to new or current individual members, 30 years of age or older to apply if the attest to their plan being cancelled due to the ACA, and finding other plans unaffordable. So far, no news from Covered California about opening on-exchange catastrophic plans. Background: In late December, HHS released guidance that allow individual plan members with discontinued policies to be eligible for a hardship exemption from the individual mandate and enroll in catastrophic plans that were previously only available to individuals under 30.


What's a Physician to Do?

By on | 5 Comments

Question: I work for a private physician's office, and we have multiple patients switching to CC. How do we know if we can still see these patients? Do we need to contract? If so, how do we do that? Also, how do we set a reimbursment rate? None of this is clear on the website. Is there even a providers line to call?

Answer: Providers do not contract with Covered California directly, but with each individual carrier selling plans through CC. So you need to contact Anthem, Blue Shield, Health Net, etc. and inquire about getting included in their 2014 Individual and Family Plan networks.


Medi-Cal Asset Recovery?

By on | No Comments

Question: I am hearing contradicting statements as to whether or not the new recipients of Medi-Cal are subject to recovery of assets upon death. Is there a definitive answer and how would it apply to a child only Medi-Cal recipient if the parents qualified for a subsidy while the child was placed on Medi-Cal.

Answer: Read the comments to this previous post on this question to get as definitive an answer as is possible at this point.


SSN Doesn't Match? Impossible

By on | 2 Comments

Question: Why do I get a letter telling me that my husband's social security number doesn't match what they have on file? How can that possibly be?

Answer: At this point, Covered California's requests for verification are often nonsensical. I advise you to ignore this request for 2 or 3 weeks when hopefully you will be able to get through to Covered California on the phone and to remove this requirement from your record.

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