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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.


Coverage During Appeal?

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Question: I would like to appeal a Covered California decision that my plan was terminated due to non-payment. I understand that I may be eligible for continuing enrollment while the appeal is pending. If this is the case, how would my eligibility be affected in the scenario that the appeal is decided in my favor vs if it goes against me. When would coverage end in either scenario? If I lose the appeal, would coverage under “continuing enrollment” simply end on the day the appeal is decided or would it terminate on an earlier or later day? I guess I am asking if I am safe using health care while an appeal is pending or if I am at risk of incurring liability if the appeal goes against me. Thanks!

Answer: I asked my colleague, Max Herr, to answer this question as I was uncertain. Here’s what he had to say: “The question, ‘When would coverage end if I lose the appeal?’ is simple: Almost certainly on Day 1 of the original cancellation date (the first day of the month for which the first unpaid premium was due) — It should have terminated then, and it remains terminated as of that date. If premiums were paid in the interim, they may or may not be refundable, possibly even if claims are not paid (they would almost certain NOT be refunded to the extent that they offset any claims paid). Now, on the other hand, if the appeal determines that coverage was improperly terminated by the insurance company (which is highly unlikely, but could happen), the insured will still be responsible to pay any unpaid premiums that have accrued throughout the time it takes to get adjudication — three months or longer in most cases. And there will be a short deadline to make that payment, probably 20 days or less.” I would add that it is not “safe” to make claims against a policy that had been cancelled, even during the appeal process. You will most likely be left holding the bag for 100% of those claims.

2 Comments

I will add that Covered CA plan subscribers are granted a 3 month grace period to pay outstanding premium. However, coverage is suspended during the 2nd and 3rd month of the grace period and the subscriber is responsible for paying for any health care services received during the suspension if premiums are not paid in full. I recently advised a client whose plan was terminated by the insurance company during the grace period. The policy was re-instated retroactively.

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