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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.

Medi-Cal and Covered California Overlap for Pregnant Applicant?

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Question: Our family of four, husband Wife and two kids, with yearly income of $48000 qualify for premium assistance and cost sharing (Silver 87 Plan) according to Covered California’s shop and compare tool. However, when we applied, Covered California qualified kids for Medi-Cal. Pregnant wife also qualified for Medi-Cal. Now Covered California says the husband does not qualify for any premium assistance and cost of sharing plan because it will not consider Medi-Cal eligible members in the household size for covered California. Medi-Cal eligible members reduced the family size to one member for Covered California.Does Covered California not include Medi-Cal eligible members in the family size while determining eligibility? Does Medi-Cal not include Covered California eligible member in the family size while determining eligibility? Are Covered California and Medi-Cal programs mutually exclusive or inclusive or overlapping?

Answer: (1) Your 4-person household will receive premium assistance and cost-sharing (Silver 87) benefits based on your $48k annual income. The fact that your kids are eligible for Medi-Cal does not reduce the subsidy or cost-sharing (still calculated based on 4-person household, not a 2-person household). (2) Your wife’s pregnancy provides additional choices. When you apply through the Covered California enrollment portal you will be enrolled in Covered California coverage and your application will also be sent to Medi-Cal in your county. In your family’s case, your wife is eligible both the Medi-Cal Access Program and Covered California during her pregnancy and immediate postpartum. You cannot have the Medi-Cal Access Program and Covered California at the same time; you must make a choice. (3) If your wife chooses to enroll in Medi-Cal Access until after the baby is born, the husband’s Covered California eligibility will still be based in a 4-person household, but with only one person enrolling. He is still eligible for a subsidy and cost-sharing reductions, but the net Covered California premium for the husband alone would be higher than the net premium for both spouses in enrolling Covered California.

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My wife has a pre-existing condition she needs an operation to have gall bladder removed. I am 66 yrs of age and barely making enough thru Social Security and my employment to have health insurance so we have been on Medi-Cal, recently we received notification that we are on Covered California. What will we need to do to go forward to have my wife operated on?

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