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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.


December 2015 Archives


Over 65, Never Paid into Medicare?

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Question: I have a special needs brother who just turned 65. He has been getting medical insurance through Medi-Cal, but was told that now he is 65 he can no longer be covered unless he gives up all but $2,000 of his assets. He never paid into social security or medicare. Could you please provide some information on eligibility for those over 65?

Answer: Your brother is eligible for Medicare even though he never paid Medicare taxes. People with less than the requisite 40 credits​ ​must pay the premium for Part A​ - $411/mo​ for those with less than 30 credits. Part B premiums are $122 per month for most people.​ Go to medicare.gov for more infomation.


Obamacare Deadline?

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Question: My fiancé was unable to apply by the deadline yesterday because the computer gave an error message when he tried to submit online. He doesn't want to get hit with the penalty, and he wants health insurance. Is there anything he can do?

Answer: The Obamacare deadline for coverage effective 1/1/2016 has been extended two days - through midnight December 17th.


Question: What is the advantage of signing up directly with Blue Shield PPO, as opposed to signing up through Covered California?

Answer: Covered California is the only place to enroll for health insurance coverage if your household income makes you eligible for premium assistance. When you apply through Covered California you agree to file taxes each year and to allow Covered California to access your tax records through the IRS. When you apply directly through a California health insurance carrier like Blue Shield - referred to as an off-exchange enrollment - you are not asked to provide any income related information whatsoever. Off-exchange, you will find plans that mirror the covered California plans exactly in benefits and rates, but, you'll find plans that are unique to the off-exchange-market as well.


Premium Assistance Now or Later?

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Question: Will the premium assistance lower my monthly cost or simply give me a tax credit at the end of the year?

Answer: Most people who receive premium assistance take it each month to reduce the net premium they have to pay. But that's not the only way to do it. You can also take a lesser amount monthly or none at all. In the later case, you will receive the remainder of the premium assistance you are due when you file your tax return for that tax year.


Best Out-of-Network Coverage?

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Question: I make about 18,000 annually and live in the 90021 zip code. I am looking for a plan that will give me the most out of network benefits, because I need a spinal surgery, and my surgeon is not part of any networks. Personal pay and medicare only. Can you tell me of any plan options that include out of network benefits?

Answer: To receive out-of network benefits you must select a PPO plan. In your zipcode, there are two carriers offering PPO plans, Anthem Blue Cross and Blue Shield of California. Their out-of-network benefits are identical. Your income makes you eligible for a Silver 87 Plan with enhanced benefits, so here's how your surgery would be paid for. For all in-network costs - like hospital, drugs, and physical therapy - your in-network maximum-out-of-pocket expense will be $2,250 (Silver 87 plan). The out-of-network cost for you surgeon will probably meet the separate out-of pocket maximum of $9,250. Your total cost for this surgery will run $11,500. If you can find an surgeon in-network with whom you are equally comfortable, your total cost would be $2,250.


Covered California and SIMNSA?

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Question: My present insurance coverage is under Covered California through Health Net. My husband is the primary owner to this account but at this time he is unemployed. My employer is offering me a SIMNSA Insurance which has an office in Chula Vista California. The provider services are based in Tijuana, Mexico. I do not speak the language nor familiar in the Tijuana area. Crossing the border from U.S. to Mexico is a nightmare (the minimum is 2 hours going and 2 hours coming back in the U.S. This makes me uncomfortable since I don't speak Spanish. My question is can I legally reject/decline to the offered insurance? What will be the consequence in my part if I do reject this offer? (Note: SIMNSA is the only insurance company offered by the employer.) Will I lose my Health Net insurance since this is subsidized.

Answer: SIMNSA plans offered in the US are ACA compliant and meet the meet the minimum value and provide essential health benefits. Most services require no co-payment at the time of treatment. Some select services require a $5 to $10 co-pay, after which all services are covered at 100%. Unfortunately. you have to cross the border into Mexico to see a provider (except for emergency coverage in the US). You can opt out of the SIMNSA offer from your employer, but you will no longer be eligible for premium assistance (subsidy) through Covered California because you have access to employer-based coverage. Assuming your employer pays all or most of your monthly premium, I advise you enroll yourself and your husband in SIMNSA and plan on using it for any major medical expenses that may arise. If you prefer, you can pay cash to see medical providers in the US side for routine care. That expense would be much less than carrying an additional health insurance policy without premium assistance.


Must Dependent File Taxes?

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Question: My family of four is covered under Covered California with premium assistance for 2015. Our 21 yr old daughter did not complete enough school to be considered a full time student, so we cannot claim her for our 2015 tax return. She did work, and earned about $9000.00. Will we be penalized because she should have had her own health care plan (MediCal). Should she enroll for 2016 for her own plan before I take her off ours?

Answer: Single dependents must file a federal income tax return if their earned income is more than $6,100. So your daughter must file a tax return for 2015. She needs to create a Covered California application for her own 1-person household. Her income makes her eligible for Medi-Cal in 2016. You will need to update your Covered California account by removing her from your household. There are no penalties for either your daughter or yourself. If you received more premium assistance in 2015 than you were entitled to, you will pay some of it back to the IRS when you file your tax return for 2015.


Recoup Medi-Cal Benefits?

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Question: In 2014 my girlfriend became pregnant with my child. At the time of her pregnancy in 2014, we were living separately and she was on Medi-Cal. During 2015, she gave birth to our child and we moved in together. All the healthcare expenses (prenatal, delivery, postnatal, vaccinations, well-child visits) for her and our child for 2015 have been covered up to this point by Medi-Cal. My AGI for 2015, looks like it will be around $30,000. At this AGI, our family does not qualify for Medi-Cal. If I claim my girlfriend and child as dependents on my 2015 tax return will I be subject to back payment of healthcare expenses for her and the child from 2015?

Answer: You can claim your wife and child as dependents for 2015. Doing so will not make you liable for asset recovery from the state. Your partner will no longer be eligible for Medi-Cal. You should apply for Covered California right now for a household of three for 2016. If your household income remains in the $30,000 range, you will receive a lot of premium assistance as well as enhanced benefits.


File Taxes with $0 Income?

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Question: When I re-enrolled last November for Covered California I estimated my income about $1500/month (based on my income for the past 10 years). In January 2015, I became unemployed. I forgot to report my income change and been receiving premium assistance and been paying my adjusted premium. Since I had no income in 2015 do I have to file for taxes? Is there a penalty I have to pay since I forgot to report my income change and been receiving premium assistance? Thanks!

Answer: For starters, because you enrolled through Covered California you have to file a tax return for 2015, even if you had no income. With no income in 2015, you were eligible for Medi-Cal, not Covered California. But, since you made no money, there is no taxable income from which the IRS can recover the premium assistance your were given. So you get to skate by this time - no penalty, no tax recovery. Your Covered California coverage will end at the end of 2015 and your Medi-Cal coverage will start January 1st, 2016.

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