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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.

Lost Medi-Cal for the Kids. SEP Eligible?

By on | 3 Comments

Question: My two children are currently on medi-cal, but our income went up and they are no longer be eligible (annual review is pending, but I know they will be dropped). Will this be a triggering event for covered california just for the two of them or for the whole family? I ask because without the entire family enrolling, we don't qualify for premium assistance, so it becomes very expensive just to enroll them now separately. We are a family of 5 and made 92k last year. My husband has covered through work (self employed, but had to enroll himself to be able to get his employees covered), and myself and newborn daughter have private insurance. Thanks!

Answer: Yes. You and your children will be eligible for a Special Enrollment when they loose Medi-Cal coverage due to your income change. Your Covered California share of the net (after subsidy) premium for an adult and 3 children will be about $725 monthly for a Silver Plan. Interestingly, your husband could be added to your Covered California family plan at no additional cost. I suggest he re-examine the rationale behind participating in or even having a employer-based health plan for his business.


Yes, Lisa is correct. With your husband having access to affordable minimum value health insurance coverage through his employer (which is himself through his own business) he and you as the spouse and your kids will NOT be eligible for any health premium tax subsidy assistance through Covered California. This is the general rule per the ACA; that one’s access to affordable minimum value coverage through one’s employer precludes tax subsidy assistance eligibility.

Phil’s suggestion for your husband to reconsider offering group employer health insurance is a good one, as it may in fact be financially better (if not much better) for your family, and as well for his employees, to enroll in an Individual/Family health plan through Covered California with Advance Premium Tax Credit subsidy.

Many small businesses across the state have terminated and are terminating their employer/business group health insurance policy, in exchange for a Covered California health plan with advance premium tax credit subsidy assistance. It is often less costly for the business, AS WELL AS ALSO less costly for the employees, to rather enroll in and acquire coverage through Covered California, with a health plan and advance tax subsidy, than for the employer/business and its employees to keep paying more for the group employer coverage.

And to Mary who also responded here, Phil and this cahba.com website, of course, is/are independent from and is/are NOT Covered California. The ACA was written and crafted a certain way, the IRS, Dept of Labor. and Supreme Court have further ‘guided’ implementation, and this is indeed how the health insurance landscape is currently.

As well, I am a licensed independent California health insurance agent, and able to assist clients as will work best for them, and for their families and businesses.

What is wrong with this statement?? CoveredCA is suggesting this employer stop coverage for his employees? I thought the whole purpose of CoveredCA/SHOP/Obamacare/ACA is to get coverage for everyone. You’re suggesting perhaps the employees in question all receive a subsidy instead of their employer playing their premium? Employer vs. taxpayers?? This really is upsetting and I’m sure I’m not the only one to feel this way.

Actually if her husband is offered coverage (or enrolled in employer coverage) they do not qualify for premium assistance.

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