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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.


Qualifying Events?

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Question: Back in December, I applied for an off-exchange Blue Shield plan because our household income was well over the income range for subsidies. But now we definitely are eligible for a subsidy, because my husband just lost his job a few days ago. Can I still apply through Covered California.

Answer: Yes. A change of income that affects your eligibility for a subsidy is considered a qualifying event that make you eligible for a special enrollment period of 60 days from the date of the change - in this case his employment termination date. Here is a list of other qualifying events:

  • Getting married
  • Gaining a dependent or becoming a dependent through marriage, birth, adoption, or placement for adoption
  • Permanently moving to a new area that has different health plan options
  • Losing other healthcare coverage that is considered minimum essential coverage.
  • A change in income that would affect an enrollee’s eligibility for financial assistance
  • Becoming a U.S. citizen
  • As a result of an error, misrepresentation, or inaction by a QHP or agent

2 Comments

This is the same situation I am in, with a new client. I was not the agent originally, in fact the client went directly to Kaiser, the client has English as a second language. As she spoke with kaiser they told her they could not help her, but would enroll her into a off-exchange plan. At that point she was confused. Kaiser enrolled her into a plan that was $1400. a month. She can not afford that premium and feels she was mislead. her income is only $33000 annually for a family of 4. So I did apply for covered Ca. and signed her up with Kaiser for $222.40 per mo. Am I going to have a problem? ,

I think this issue was discussed before and the answer was determined to be NO.

With respect to being newly eligible for a subsidy such as the advanced premium tax credit (APTC) and cost sharing reduction (CSR), the regulations provide for a special enrollment period if “an enrollee, or his or her dependent enrolled in the same QHP (qualified health plan), is determined newly eligible or ineligible for APTC or has a change in eligibility for CSR.”

The key word in this case is “enrollee” - the special enrollment period is granted only if the person had previously enrolled on the exchange (Covered California). In this case, the person stated that she had enrolled in an OFF-EXCHANGE Blue Shield plan and would seem to be out of luck.

Now, if she had previously asked about enrolling thru Covered CA and was misinformed (e.g. was told that it made no difference whether she applied on or off the exchange), she could argue that her failure to previously enroll was due to misrepresentation or error. In that case, Covered CA could decide on a case-by-case basis that this person’s family should be granted a special enrollment period.

I would personally encourage her to review the circumstances which led her to enroll off-exchange instead of thru Covered CA. If there was anything which could be construed as misinformation, I would then encourage her to apply thru Covered CA and be ready to explain why she is filing outside the open enrollment period.

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