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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.

Employer-Paid Coverage and Medi-Cal?

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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.


“Employers who buy small group coverage through the SHOP are offered the choice of NOT offering coverage to spouses and dependents.”

I’m not currently working in the SHOP market, and may never work in it. My reading of the Insurance Code, which closely follows the PPACA, does not match this statement.

If this is what SHOP is doing, however, then it is a complete contravention of the PPACA, which REQUIRES coverage for dependents to be OFFERED. The PPACA does not REQUIRE employers to PAY for dependent coverage, so while the employer may choose to pay up to 100% of the employees’ self-only cost, the employer can pay $0 toward the dependent cost.

CA law changes the definition of “dependent” to include the spouse of the employee. The PPACA specifically excludes “spouse” from the definition of dependent.

Employers who buy small group coverage through the SHOP are offered the choice of NOT offering coverage to spouses and dependents. Since no California small group carrier offers this option yet, this is a strong selling point for the SHOP. Employers with low-income workers should jump on this.

Max, as I understand it, if the employee has access to ‘affordable coverage’ and this affordable coverage is available to the child(ren) and spouse, then the child(ren) and spouse DO have access to ‘affordable’ coverage and are therefore not eligible for tax subsidy or subsidized Medi-Cal.

The child(ren) of the employee, therefore always has/have access to affordable coverage if the employee’s premium cost is under 9.5% of the employer’s lowest-cost employer-sponsored group plan.

If the spouse does not have access to the employee’s ‘affordable’ employer-sponsored group plan, then the spouse can go to the Marketplace to acquire tax subsidized coverage, subject to total household income eligibility criteria.

Yet, as you have said, that in California the spouse is required to be offered coverage under the employer-sponsored group plan, further suggests (if, as my initial above understanding is correct), that the spouse too, in California, with access to ‘affordable’ coverage, will likewise not have eligibility for tax subsidized coverage through the Marketplace.

Effectively further, Med-Cal is not (would not be) available to household members with access to ‘affordable’ coverage; inclusive of the child(ren).

“Max, are you saying the child’s Medi-Cal eligibility is based upon the “household income” irrespective of affordable employer-sponsored group coverage available to the parent-employee?”

Not exactly “irrespective” as I try to understand the “rules”. The “rules” indicate that a child will be eligible for Medi-Cal when the household income is at or below 266% FPL. The ACA (and CA law) requires group plans to “offer” coverage for “dependents” (ACA excludes “spouse” from the definition, CA law includes the spouse as a dependent).

Premium tax credits are not available for anyone who “is eligible” for “minimum essential coverage” (MEC) — which could be a Qualified [Individual or Group] Health Plan, and includes Medi-Cal or Medicare. That’s the only thing really spelled out in the ACA.

So the criteria for Medi-Cal eligibility is completely dependent on “household size” and then “household income” in relation to the size. The employee will never be eligible for Medi-Cal if employer-sponsored coverage is offered AND the “self-only” cost is less than 9.5% of household income (“affordability” for determining eligibility for premium tax credits begins at 8.5% of income).

The spouse is eligible for premium tax credits, but not Medi-Cal, if the household income is above 138% FPL and at or below 400% FPL. The children are eligible for Medi-Cal simply on the basis of household income (as stated above) … the employee is not required to cover his/her children through the employer. The “taxpayer” is simply required to provide each member of the household with MEC at least 9 months out of the year to avoid the “shared responsibility payment”.

When household income is above the “bright line” of 250% FPL, there is a $13/month per child premium for Medi-Cal (maximum $39/month in a household). (see http://www.dhcs.ca.gov/services/medi-cal/eligibility/Documents/12-33.pdf)

For more information about determining household size and household income in relationship to eligibility for APTC or Medicaid (Medi-Cal), there is a very good presentation here: http://www.cbpp.org/files/Household-Definitions-Webinar-7Aug13.pdf

The bottom line is this: The PPACA was intended to put as many people (adults and children) onto government-sponsored health insurance as possible in lieu of forcing all persons into a single-payer system. It is one of the largest welfare programs ever enacted in US history. Once you have millions of people dependent on the government for their health care, they will begin demanding government assistance for other aspects of their lives. And, ultimately, the only way to make that work is to force everyone else to accept the government’s “assistance” — like it or not.

Those who advocate for the single-payer system (you can see it on this website in some of the other threads) are mostly asking for the government to provide them with free health insurance. Government cannot provide anything for “free”, even though it may try, because it has no ability to overcome the long-term cost.

Such social welfare programs ultimately lead to the collapse of an economy because fewer people work and pay taxes to support the government that has chosen to support them. Look at the collapse of the Soviet Union more than 20 years ago, and how the people who were instantly freed from socialism (with no “Plan B” in place) now long for the return of the old days when the government took care of them. This is Putin’s impetus to try to re-form Russia into its former personna. Will the people be happy when they once again are paid with toilet paper and brassieres when the government cannot afford its “plan”?

Look also to Greece where more than 50% of the population are beholden to the government for (a) employment, (b) social services, or (c) both — and what it has done to their economy, where the public debt reached a high of more than 170% of GDP in 2012, but was once as low as just 22.6% in 1980.

Now look at the US, where our $17.5 trillion of admitted public debt is currently about 108% of GDP and rising. For three years or more, Obama has asked Congress to give him an unlimited debt ceiling, and his 2015 budget proposes to add more than $8 trillion in new debt while only raising $1.6 trillion in new tax revenue — a 5:1 debt-to-revenue increase. That’s unsustainable.

And none of it even begins to account for the $128 trillion long-term unfunded liability of Social Security and Medi-Care, which was only $87 trillion in 2004. No one is paying attention to this at all.

Yet, if the employer also establishes the employer’s group plan coverage as available to the employee’s spouse, even if the employer offers a 0% spousal premium contribution, then the spouse will likewise have access to ‘affordable’ coverage, and will NOT be eligible for a premium tax subsidy should the spouse purchase an individual plan through the Marketplace.

I believe the employee’s children also have access to affordable coverage once the parent-employee has access to affordable employer-sponsored coverage. How is Medi-Cal eligibility established for the child when the parent has access to affordable employer-sponsored group coverage? Max, are you saying the child’s Medi-Cal eligibility is based upon the household income irrespective of affordable employer-sponsored group coverage available to the parent-employee?

From the DHCS 2014 “playbook” for Medi-Cal:

” … one parent may be eligible for Covered California without subsidies because they have access to affordable coverage through their job, while their spouse is eligible for premium assistance tax credits through Covered California and the children are eligible for Medi-Cal.”

Hello Phil, I am an agent that is running around in circles please help. I insured a family with 2 parents and 2, 4 year old children through Covered CA with Blue Shield. The mother told me that at that time none of them had any insurance. After qualifying all four of them for a subsidy we applied for all four of them only to find out a month later and several hundred dollars in doctor costs that the children where on Medical therefore turned down by CC. Neither I or them got a letter from CC that the children are not insured. The mother called Medical and was told that she had to terminate the children from Medical and since we can only add them to CC on April first the children would be uninsured for a month.That was also the answer from CC. Very bad situation leaving children uninsured.I talked with CC twice and got two different answers as to add the children. One customer service rep told me to TRY and add them to the existing policy not knowing how to do it and the other said the parents had to also terminate their policy leaving them uninsured for 2 weeks and write a new application to CC. Your thoughts on how to do it without laps in coverage. Thank you

I think one of your difficulties is that you blame your situation on others.

You could enroll just your wife into an individual medical plan.

You could not write off as much business expenses and losses if the health tax credit you would get is better than the savings realized from taxation. You’ve got 10 months still in 2014.

You could realize this health insurance model has been around and offered for years by both Dems and Repubs.

Five months of waiting for a Medi-Cal doctor suggests you were on Medi-Cal prior to Jan 2014, where Medi-Cal rules were based on assets and income, rather than just on income as it is now.

Sue, go to coveredca.gov. Fill out the forms there and they’ll stick you into medi-cal whether you want it or not.

As for me and my family, we’re screwed. Our business is operating at a planned loss due to reorganization and as a result we’ve been told we’re only eligible for medi-cal or $1100 (600% increase) a month plans with unbelievably high deductibles and copays from our old insurer or a similar exchange policy without subsidies.

We had no trouble affording our old plan which let us see the doctors we needed to see. We can’t even get an appointment for our new medi-cal assigned doctor to stick and we’re no longer allowed to see specialists without a referral from said doctor. We once had an appointment for late march, which we arranged back in late january when our enrollment packet finally arrived after nearly 5 months of waiting, but the doctor appointment has been put off indefinitely until at least may due to the doctor being ‘too busy’.

My wife was supposed to see her specialist for crucial, ongoing care that no one else in the county is qualified to provide, but that doctor is not covered anymore. And since we can’t even see our new primary for some kind of referral to some kind of specialist, we’ll just have to see how long she survives. We saw 6 different doctors, including 2 specialists before getting directed to the most qualified one, so I’m doubtful an ER doctor or gynecologist will be of much use, though they’re the only other doctors we’re allowed to see freely under medi-cal without our primary’s referral? I’m thinking I might need to go to a gynecologist for a recent ligament injury myself if I can’t get into my primary soon…how sad is that for a guy?

Next year, if we survive and are healthy enough to keep our business going, we’ll be operating at a net profit again and we’ll be back in normal health insurance, but we’ll never forget what the Democrats did to us against all of our protests (I filed 6 protests at covered california alone for being forced off of health insurance and into medi-cal).

Runaround Sue -

You applied for Medi-Cal under the NEW 2014 Medi-Cal income eligibility rules, and as you say, you were approved for Medi-Cal.

Therefore (if indeed approved) YOU ARE COVERED under Medi-Cal RIGHT NOW, and for all of January, 2014, and moving forward.

When you say your Medi-Cal was discontinued on Jan. 31st, it seems to me this is the prior-year 2013 Medi-Cal you had, which ran one month into 2014 and then became discontinued because of Medi-Cal’s older 2013 asset eligibility rules where your $3,000 in assets took you above the old 2013 asset limit of $2,000, which then led to the discontinuation. But there are new income-only Medi-Cal eligibility rules which started Jan 1st, 2014. No more asset rules for Medi-Cal eligibility.

Sounds like Medi-Cal simply did not know, and still may not know, about your new January 15th Medi-Cal enrollment through Covered California.

Medi-Cal has to get word from Covered California. Medi-Cal would not have received word from CovCal about your new 2013 Medi-Cal eligibility and approval with only 15 days of January left.

And processing of Medi-Cal through Covered California is taking some time. My pre-Thanksgiving Medi-Cal enrollee client in Alameda County just got her Medi-Cal welcome kit and cards two days ago on Feb. 19th. That was about three months to get her Medi-Cal cards.

But while it is currently taking time for Medi-Cal to contact you, and to get your Medi-Cal enrollment finalized, you actually ARE COVERED by Medi-Cal, starting Jan 1st, 2014, because of your Medi-Cal enrollment approval through Covered California on January 15th, 2014.

When you log in to Covered California, you should likely see the main page say “You’re Covered as of 01/01/2014.” If not, you likely still need to upload your proof of eligibility documents (such as proof of income) through the ELGIBILITY page. To do so, scroll over the ELGIBILITY green box with white checkmark on the main page to get to the ELGIBILITY page, so you can then upload your proof of income or other proof of eligibility documents from your computer into the Covered California system via clicking the ‘Submit Documents’ blue link on this main ELGIBILITY page. Also, on this same ELGIBILITY page you should see the health plan you are eligible for, such as Medi-Cal. If it’s Medi-Cal, the page may say you are conditionally eligible for Medi-Cal…. subject to proof of income, proof of your CA residency, etc.

And as you are covered under Medi-Cal now (as I see to be most likely) you actually can go to a Medi-Cal doctor, pay for services or ask to arrange billing at a later time, and Medi-Cal will reimburse you for those doctor costs once your Medi-Cal enrollment is finalized. You must see a Medi-Cal provider for Medi-Cal to reimburse you.

How do I know this? I spent a lot of time finding out for my clients by calling Medi-Cal offices and other things because Covered California and Medi-Cal have left them high and dry for a couple months not knowing anything as they wait and wait without any solid sense they actually have coverage.

Hope this helps.

On the odd chance that you indeed are not currently covered under Medi-Cal, and if you were in fact not approved by Covered California for Medi-Cal for January, 2014, then log in to Covered California, and apply again, and/or select a traditional health plan for which you would otherwise be eligible. If you apply again and are approved for Medi-Cal based upon your household income, you will be approved with coverage the day of the CovCal/Medi-Cal application submission, and your coverage with Medi-Cal will start right away. But again, from what you’ve conveyed, it seems you likely already are covered with Medi-Cal and simply need to wait it out more (and the CovCal system would not let you apply again).

You can designate me as your Covered California Certified Insurance Agent when you’re logged into Covered California. Via the blue “Find Help Near You” link at the top of the page (to the upper right of page) go through the simple steps to designate me your agent. Then click ‘Find Agents’, search my name, Michael Freedman, get to the final step to ‘Confirm,’ and I’ll let you know about your enrollment and status, etc. Call me too.

All the best.

I had medi-cal last year due to pregnancy. This year, I renewed but got denied. The only reason is “I have more than $3000 saving.” Jan 15: I applied CC online and CC rep. told us that we are eligible for Medi-cal and new Medi-cal is no longer count the assets. Then, I called my medi-cal social worker again he said he doesn’t have knowledge about new Medi-cal and doesn’t deal with it. After several attempts, I had a chance to talk to his alternate supervisor. He sent me a form to fill. I received the form yesterday and it is CC application which I did online a month ago. I need to follow up my health issue with doctor this month. My medi-cal was discontinued on 01/31/14 What should I do next? Please help.

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