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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.

July 2015 Archives

Private Insurance for my Child?

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Question: I am self employed. Acceptance by physicians for Covered CA plans are different for me and for my 8-year-old child: my child's physicians do NOT accept ANY Covered CA plans, while mine do. Can I stay on my Covered CA plan and purchase an off-exchange plan for just my child? We don't qualify for a subsidy.

Answer: Yes. You can do that during open enrollment - November 1, 2015 through January 30, 2016 - when you may update your Covered California account to indicate that your daughter, though part of your household, is not requesting coverage. Then you can apply for coverage for her directly with an insurance carrier effective January 1, 2016.

Question: what is the penalty if any for someone who claims more income than they actually achieve? If someone earns a income that qualifies them for Medi-Cal but they inaccurately predict a income that would qualify for a substantial subsidy, then what is the practical outcome of this error? What is the maximum that someone would be penalized for after overstating their income? I doubt that there would be any practical penalty. Prove me wrong.

Answer: In the scenario you describe, you would be liable to repay no more than $300 for the year. The following is a more complete answer to the "clawback" question provided here in October 2013:

The consumer is liable for repayment of any excess tax credit received in the calendar year. However the amount of the "clawback" provision is limited by the household income according to the ACA law. If the household income (expressed as a percent of poverty line) is :

    Less than 200% FPL, the amount of the clawback is limited to one-half of $600
    At least 200% FPL but less than 300% FPL, the amount of the clawback is limited to one-half of $1,500
    At least 300% FPL but less than 400% FPL, the amount of the clawback is limited to one-half of $2,500.

Question: I now have temporary residence in Chile. I will maintain my citizenship and will file federal taxes. Will I need to continue my medical insurance in the US?

Answer: No. You do not have to maintain health insurance coverage in the US while living abroad.

Question: Husband on Medicare. Wife on CovCA. Income forecasts show we will be over the CovCA limit. Want to drop the Blue Shield plan (via Cov CA) and purchase new independent individual plan as wife's employer does not provide insurance. Can we do this? How? When? I assume deductibles won't be carried over (except for another Blue Shield plan maybe?)

Answer: Your question highlights a couple of common misconceptions about Covered California coverage. The fact is that you can keep your Blue Shield coverage through Covered California even though you are no longer eligible for premium assistance. Just change your income with CC so that your subsidy gets turned off. During open enrollment, November 1, 2015 through January 30, 2016, you can drop your CC coverage and apply directly with an insurance carrier, like Blue Shield. However, there is no real benefit in doing so, as the rates and plans are the same when you go directly to the carrier. Additionally, should your income drop again, you would have to reapply with Covered California to get subsidized.

Big Income Change?

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Question: We're a household of 3, husband at 55, wife at 46 & son at 14. My husband is quitting his job by the end of Sept 2015. YTD income at that point is $250K+ but the last quarter will be zero. Because he's starting something on his own, he will have zero income in the coming year or so while starting something from scratch. We probably opt out of using COBRA (too expensive). Here are my questions: 1. Given we have high income for 3/4 of the year but zero for the last 1/4, will we qualify for Cvered CA? If not, any other option? 2. If we can apply for the last 1/4 of the year for Covered CA, will we get premium assistance now that we are at zero income level? 3. For next year 2016, my husband will continue having zero income while I will try to get "part-time" job. Do we need to report any new income in mid-year once I find a part-time job? Basically, how it works when our income change during the year? Thanks for your advise in advance.

Answer: When your employer-based health plan terminates - let's say September 30, 2015 - you can sign up for individual health insurance through Covered California even though you will not be eligible for a subsidy in 2015. Then, sometime before December 15th, you will adjust your household income at Covered California to estimate your 2016 income. If that estimate falls within the premium assistance range ($28K to $80K for a 3-person household), you can receive a subsidy to help pay your premium until your income is once again beyond subsidy range. Your 2016 estimate does not have to be accurate, any excess subsidy you may receive will be returned when you pay your 2016 taxes and vice versa. In this case, you could really use a good agent to help you with the application process and subsequent changes as proper timing is key to maximizing your benefits and avoiding any gaps in coverage, not to mention a potential nightmare of governmental proportions if you do things incorrectly.

Dropping COBRA?

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Question: My wife's company is going to pay the COBRA premium for six months as part of termination agreement which is very expensive. Can I apply for individual coverage once they stop making our COBRA payments?

Answer: You would not be eligible for a Special Enrollment Period simply because your employer stops paying your COBRA premium. However, you can apply for individual coverage either through Covered California or directly with an insurance carrier during open enrollment starting November 1, 2015 through January 30, 2016. As luck would have it, you should be able to take advantage of the former employer's largess for most, if not all of the 6 months before open enrollment closes.

Question: My employer mandates insurance to all employees, however I am already covered by TRICARE when I retired from the military. I don't want my employers insurance and want my health and welfare portion to go into my retirement account. This adds up to over $8,300 a year which I feel I am entitled too. Can you please advise me.

Answer: You can opt-out of your employer-based coverage option in favor of your Tricare coverage, however your employer is under no obligation to pay you the unused premium.

Application for Dependent Only?

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Question: My son recent lost his eligibility for medi-cal Now I need to enroll him in a plan. Can I get him enrolled in a plan without also enrolling me and my husband? When I go to my account, I only get options for family enrollment plans.

Answer: When you enroll through Covered California, you will enter information about your husband and yourself as well as your son and any other household members. Further in the application process, you will indicate that only your son wants coverage. His eligibility for premium assistance is based on your household income.

Question: What will my maximum Out of Pocket expense be for a knee replacement surgery? I am 64 years old. I have Covered CA Blue Shield Silver Level health insurance. My deductible is $5,000.00 I look forward to your answer. thank you.

Answer: You can figure about $6,400, which is the maximum-out-of-pocket expense. Once you have paid out $6,400, your covered medical expenses are 100% paid by the plan. One thing to watch out for is extra charges for durable medical devices. In the case of a knee replacement, you are advised to go home with a device that flexes the repaired knee automatically. Make sure that the device you choose is covered by your plan.

Change Insurance Plan Now?

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Question: I am not happy with my Blue Shield of CA Platinum PPO insurance plan and I want to change to a less expensive plan and/or a different insurance company. I signed up for my plan directly with BlueSheild of CA not through the Covered California website (because it wasn't letting me due to computer glitches). I know you can terminate your plan through Covered California, but I'm not sure how to do it if I'm outside that system? Also, if I'm allowed to terminate my coverage with BlueSheild can I do so outside of the open enrollment period(now), and can I then enroll in some kind of other insurance through covered CA (also outside of open enrollment). Thanks so much for your help!

Answer: If you were to cancel your Blue Shield coverage you would notify Blue Shield (customer service number on your insurance card) since you bought directly from them. But you cannot get replacement coverage until open enrollment, so you are pretty much stuck with what you've got until January 1, 2016.

Question: Is income between 138-150% of FPL is the only condition? Would there be a problem that the person is 68 years old and does not qualify for Medicare? How is the 138% calculated ? Is it based on raw income or after tax income or else?

Answer: If the person in question is not eligible for Medicare at age 68 and has legal status, then this individual is eligible for Covered California coverage. The income calculation is an estimate of 2015 adjusted gross income (AGI) (see line 37 of last 1040 tax form to help estimation). If the estimated AGI is over 138% federal poverty level (FPL) and less than 400% FPL, this individual could be eligible for premium assistance. Whether, he or she can buy coverage now or wait for open enrollment is dependent on other factors.

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