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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.


Special Open Enrollment

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Question: If a person is enrolled in an individual health insurance plan (not employer sponsored) outside the exchange and currently does not qualify for any subsidies because his or her income is above the threshold; what happens if he or she loses their job, becomes unemployed and now qualifies for subsidies, would this person be able to join Covered CA under the special enrollment rule and be eligible for advance tax credits?

Answer: Since your individual coverage is independent of your employment, losing your job will not trigger a Special Enrollment Period. If you were to apply for coverage through Covered California during open enrollment - by March 31st - even though your income makes you ineligible for premium assistance now, you could be eligible if you do lose your job later in the year.

14 Comments

Enrollee means a qualified individual or qualified employee enrolled in a QHP. Enrollee also means the dependent of a qualified employee enrolled in a QHP through the SHOP, and any other person who is enrolled in a QHP through the SHOP, consistent with applicable law and the terms of the group health plan. Provided that at least one employee enrolls in a QHP through the SHOP, enrollee also means a business owner enrolled in a QHP through the SHOP, or the dependent of a business owner enrolled in a QHP through the SHOP. Definitions 155.20

(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions. (i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; (ii) The enrollee’s dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; or §155.420

Covered CA says that you have to already be enrolled with Covered CA to get a SEP for a decrease in Income. My question is, how does HeatlhCare.Gov interpret the CFR?

Covered CA cites their webpage and says change in income is only if you are already enrolled in a Covered CA plan. Email dated 11.14.2016 3:35 PM

45 CFR §155.420(d)(6); 10 CCR – CA Code of Regulations – Special Enrollment Periods § 6504(a)(6). Note that Covered California interprets this to only allow for changes in plan, not to newly enroll based on language in the state and federal regulations referring to the enrollee rather than the individual as in other sections. Thus, if you are already in a plan you can change to a new plan but you can’t newly enroll in a plan when your income decreases. Western Poverty Page 5.215

45 CFR §155.420(d)(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions.

(i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions;

(ii) The enrollee‘s dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; or

(iii) A qualified individual or his or her dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.

(iv) A qualified individual who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100 percent of the FPL and who, during the same timeframe, was ineligible for Medicaid because he or she was living in a non-Medicaid expansion State, who either experiences a change in household income or moves to a different State resulting in the qualified individual becoming newly eligible for advance payments of the premium tax credit;

No. It is not necessary to have applied with Covered California during the open enrollment period. A subsequent change if income that would make you eligible for premium assistance is itself a qualifying event that make you eligible for a 60-day special enrollment period.

“However, if a consumer enrolled in an off-exchange plan and later experienced a change (decrease) in income, then would the consumer be allowed to exercise a SEP and enroll in an exchange-based plan and obtain PTCs and CSRs?”

As long as the “life event” is one defined under HHS/IRS regulations, the answer is YES. Premium tax credits will be prorated to only the months of eligible coverage.

I understand that it is necessary to enroll in an exchange-based plan to preserve eligibility for PTCs and CSRs.

However, if a consumer enrolled in an off-exchange plan and later experienced a change (decrease) in income, then would the consumer be allowed to exercise a SEP and enroll in an exchange-based plan and obtain PTCs and CSRs?

Only qualified health plans purchased through a Health Benefits Exchange, such as Covered California, are eligible for premium tax credits. A person enrolling through the Exchange due to a “special enrollment period” will receive pro-rated tax credits based on the number of months of actual exchange-based coverage.

In other words, based on income, a person might be eligible for $5000 in “annual” premium tax credits, but if enrolled in an individual QHP effective December 1, they would only receive PTC for one month = $416.67.

Can you confirm that it is necessary to enroll via Covered CA to preserve eligibility for subsidies in the event of a change in income or any other qualifying event that triggers a SEP?

If you did not live with your husband at any time in 2013, you may list your filing status as SINGLE.

I have been separated from husband for years but not legally divorced. He claimed married filling jointly with the IRS and now I’m being told I don’t qualify for coverage. I’m in the process of amending my status with the IRS but it can take up to 4 months. I’m currently on Medi-Cal but that ends the last day in March and because my daughter aged out. I don’t wish to lose coverage and wanted to know if I can apply for covered ca as married filling SEPARATE until the matter with the IRS gets resolved. Also, I noticed there is no option for “Separated” I understand I’m legally married although he does NOT support me in anyway and we have not lived together in years.

Annette … It would have been helpful if you mentioned what type of file you were trying to upload. I have uploaded hundreds of PDFs or JPGs without such a message. HTML might not work. GIF, TIF, or PNG should work, but I have never tried to upload those.

Dear “Cluster” …

Did you apply on your own or did you use the assistance provided by a Certified Insurance Agent? Paying your first premium on 3/7 provides no point of reference — it could simply be the premium due for an April 1 effective date, in which case, your ID cards will probably show up in your mailbox within a few days. Or it could be the first payment for a March 1, in which case, your ID cards will probably show up in your mailbox within a few days.

If you enrolled on your own, you should call the insurance company whose plan you chose. They will have you in their system and can tell you what you need to know. If you used the assistance of an agent, call the agent and ask him/her to do this for you.

Mostly, I don’t see any valid complaint in your rant. Yes, CoveredCA has never had sufficient personnel to handle the volume of telephone calls they receive, but that was to be expected — they are paying exorbitant salaries to senior/top level management and don’t have a commitment to fund from the bottom up.

We’ve all experienced hours on hold and received useless, or nearly useless information from time to time. I now have a list of 150 individual applicants, and long ago lost track of the number of hours I’ve spent on hold with CoveredCA.

But some of the CSRs I’ve dealt with in the past couple of weeks are either more experienced or are just better at what they are doing, so I would say certain aspects are improving.

After 3 months of calling, systems down, & finally paying my 1st payment on 3/7/14 I have not received anything further? Paid for the best that I have no idea if it’s actually active & I can visit my doctor? What’s the next step since other requests for help have been ignored? This has been the biggest cluster *&@$ since ObamaCARE kicked in. All lies especially since I was not able to keep the insurance plan I had already!!!

I am trying to upload documentaiton showing proof of income and proof of residency. I keep getting an error message: invalid file type. Can you please tell me the file type and the file size specifications for uploading files? Thank you for your help! (BTW: Other than this issue for uploading files - I thought teh site was incredibly easy to use)

Phil is correct. By enrolling in a CoveredCA health plan, you preserve any eligibility for premium tax credits that will be availabble when you “reconcile” your 2014 income in 2015. Failure to enroll by March 31, 2014, will eliminate any possibility of obtaining the credits for 2014.

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