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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.

CC Enrollment with Medi-Cal Opt-Out

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Question: Family of 4 with an agi of $45,000. The Covered California online application says the children qualify for medi-cal. Family wants to pay the premium for their daughters. Can they still apply in Cover California for the four of them? If they receive medi-cal can they use it as a supplement for their Cover California policy?

Answer Yes. This family should apply through Covered California because the husband and wife will get a substantial subsidy. Be careful to indicate that the children do not want coverage, otherwise they will automatically be enrolled in Medi-Cal. Then they can apply for the children off-exchange in the plan of your choice. Yes you can have both Medi-Cal and private coverage.


You can estimate any amount of income for 2014 that you care to. It will all be “reconciled” in 2015 when you file your income tax return. You may have to add “unrealized” income to both realize your tax credit and remain outside the Medi-Cal program in 2015.

I want to get my income level up so family can receive CC. Can I use independent contracting work for relative,gambling winnings, gift from relative, deferred inheritance paid/made/earned in 2014? Income from 2013 on tax filing 12K too low. Thank You,

Problem is they (the CovCal application system) gave my client only Medi-Cal, when she earns over Medi-Cal income threshold. I got them to fix this and she enrolled with the subsidy calculation given and reduced from her monthly premium (she made binder payment). Now account says only Medi-Cal (go figure) with no history of her ever signing up for her subsidized EPO plan. And no option to do so now.

Like almost everything else, CoveredCA CSRs and their supervisors and managers spew out all forms of misinformation. And it’s obvious, because they each recite their answers nearly verbatim.

Medi-Cal is Medi-Cal is Medi-Cal. An adult/household with income over 138% FPL = NO Medi-Cal … pregnant or not. AIM is not Medi-Cal, but is available to women with household MAGI up to 200% FPL.

Anything to the contrary stated by anyone at CoveredCA is BS.

There is a learning curve to all of this, but CoveredCA is far behind the crest of the wave.

Yes, that’s what I told Covered California, yet they see it the other way. They say pregnancy means Medi-Cal.

Why do you think they (on the application) ask each woman question on the application whether she is currently pregnant? I’ve been told by Covered California that pregnancy condition determines Medi-Cal egligbility. I said, are you sure, I don’t think so, and that makes no sense? I went to managers, etc., yada yada. “Yes,” “yes,” “yes,” was the same answer.

And if eligible for Medi-Cal, then not eligible for tax credit subsidies, as you say.

Michael …

Pregnancy alone is NOT a qualifier for Medi-Cal. Other than for long-term care resources, Medi-Cal is strictly income-based at 138% FPL or below (with the singular exception of persons 19-25 who were in foster care on their 18th birthday, and children under age 19 at 266% FPL). So if your pregnant client’s household income (pre-baby) is more than 138% FPL, she is NOT Medi-Cal eligible.

Pregnancy (not over 30 weeks gestation) is the qualifier for AIM (Access for Infants and Mothers) which is based on 200% of FPL (after deductions, but an applicant for AIM whose income falls at or below 138% FPL will be enrolled in Medi-Cal). AIM does not constitute “minimum essential coverage” under the ACA, because it is limited specifically to pregnancy-related expenses. It provides certain out-of-pocket limitations to prenatal, labor and delivery, and post-natal health care services and expenses until the baby is 12 months of age.

There is a “total cost” for AIM based on 1.5% of MAGI (and they offer a $50 discount if full payment is sent with the application). See http://www.aim.ca.gov/Costs/#what


This ties in with my client’s issue. If being pregnant makes one eligible for Medi-Cal, yet one’s AGI is above the Medi-Cal threshold, is the tax subsidy NOT available because of Medi-Cal eligibility?

Pregnancy, condition of, is reason for discrimination? Women are, discriminated against due to whether they are pregnant or not?

Of all ‘medical conditions’ to ‘force’ someone onto a type of medical care, and to preclude them from financial access to doctors of their choice.

The war business is much more profitable than the life business, isn/t it? Ah, such intelligence.

“You can have Medi-Cal and private insurance.”

This is an apples-and-oranges discussion. Yes, a person can have health insurance and Medi-Cal. Just as a person can have health insurance and Medicare. The government takes a backseat on the payment for services bus.

But the “family of four” will not receive a full subsidy as a family of four when the children’s coverage is purchased off the exchange and they are eligible for Medi-Cal.

Please read IRS Notice 2013-41, first paragraph under the heading “Background”:

“Beginning in 2014, eligible individuals who purchase coverage under a qualified health plan through an Affordable Insurance Exchange are allowed a premium tax credit under § 36B. Under § 36B and § 1.36B-2 of the Income Tax Regulations, in general, an individual (who may be the taxpayer claiming the premium tax credit or a member of the taxpayer’s family) may receive health insurance coverage subsidized by the premium tax credit only for months the individual is enrolled in a qualified health plan through an Exchange AND IS NOT ELIGIBLE FOR OTHER MINIMUM ESSENTIAL COVERAGE.” (emphasis added)

This is as I posted previously. It does not say ENROLLED, it merely says “ELIGIBLE”. In California, children are ELIGIBLE for Medi-Cal with household income up to 266% FPL. They don’t have to apply for Medi-Cal to be eligible, they have to apply to be enrolled.

I don’t know how the IRS intends to sort this all out, or how they will even know, but the facts are the facts. Medi-Cal + Health Insurance = YES, Medi-Cal + Premium Tax Credits = NO.

Delete your web browser’s cookies and cache. This usually makes the difference when the CovCal site in actually working and not down, but has been down when you previously tried to log in without success.

Obviously, I could be wrong, but my understanding is that persons who are enrolled or ELIGIBLE to enroll in Medicaid cannot claim the premium tax credits. According to a document posted at http://www.cbpp.org/files/QA-on-Premium-Credits.pdf

“Premium tax credits are available to individuals and families with incomes between 100 percent of the federal poverty line ($23,550 for a family of four) and 400 percent of the federal poverty line ($94,200 for a family of four) who purchase coverage in the health insurance marketplace.”

“They can’t receive premium tax credits if they are eligible for other “minimum essential coverage,” which includes most other types of health insurance such as Medicare or Medicaid”

Coverage for the children purchased off the exchange is obviously not going to be subsidized, but when the children are “eligible” for Medi-Cal (household income up to 266% FPL), that statement says to me that they will not qualify the household as a family of four. Or if they qualify the family as a household of four, that the tax credits will be reduced considerably.

One way or the other, I believe there is a real downside to the recommendation that needs to be clarified.

I’m always afraid to say you’re wrong, Max, because I fear starting an extended pissing contest. However, my experience has been that the subsidy calculation is based on the entire household size regardless of whether one or more members opts out of coverage.

When adding a household member, the 4th question asks,”Does this person want health insurance?” Answer, “no”.

re: Family of 4 with Medi-Cal eligible children. Premium tax credits may be adversely affected by enrolling children in an off-exchange health plan. The household will likely only be counted as a household of two, not four. If the children are enrolled in Medi-Cal alone, the household of four will be preserved, even though the children may or may not be paying a premium for Medi-Cal.

Phil: In your response, you state to “make sure the family indicates they Do NOT Want Medi-Cal and want to pay for thier children’s coverage at a subsidized rate.” Where is there a box on the application or webstie to indicate this? I’ve been hoping to find where this is, as many of my clients don’t mind paying for their kids instead of having them go to Medi-CAL. Please Advise in steps one which section on line or on the paper app. this is?

Thanks Dan. here’s the pertinent text: “A Medi-Cal beneficiary may have both private health insurance and Medi-Cal. As a Medi-Cal beneficiary, you must report any private health insurance you have to your county social services office. If your private health insurance is through a Prepaid Health Plan or Health Maintenance Organization (PHP/HMO), you must go to your health plan to receive health care services. Medi-Cal may not pay for services available through a PHP/HMO plan if you choose to seek treatment elsewhere.”


You can have Medi-Cal and private insurance.

I am as assister and have not been able to log into Covered CA for 2 days - is anyone aware of any issues with the site. I called CoveredCA and they say the site is working fine. HELP!!!!

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