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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.

September 2016 Archives

Question: I have lived in CA with student visa (F1) and earned a small amount a year. I wanted to enroll Covered CA but my case was tranferred to Medi-Cal that I was not qualified because of my visa. How can I enroll Covered CA with a low income?

Answer: H-1B, F-1 and J-1 visa holders who are on work visas, student visas and exchange programs who have been in the country for less than five years are eligible to buy insurance through Covered California or directly from one of the insurance companies in the California individual market. Even if you work and pay taxes in the US, you are not considered a legal resident by the IRS, so you cannot cash in on government programs like Medi-Cal or Obamacare subsidies.


Question: My wife and I are covered for health insurance through my job but I am retiring at the end of 2016. I will be going straight into medicare but she is 61 and will need separate health insurance until she reaches 65. She does not work but will start receiving social security in May. For purposes of the premium subsidy, us only her income counted under household income or does have to include my retirement income count as well?

Answer: Yes. Your taxable retirement income is included with your spouse's social security income. When you open your Covered California online account, your wife should be the primary on the account, but include yourself as part of the household. Indicate that only she wants Covered California coverage, but include your total household income.


Insurance for Newborn?

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Question: I am 24 years old and I was put under my parent's healthnet HMO insurance as a dependent while I was pregnant. I had an early delivery and the baby is currently in NICU. I am aware that I am unable to add my newborn under the current insurance because I am listed as the dependent and not the main insurance holder. And I am also unable to enroll in a different healthnet insurance because I have no income. Is there a way I can separately get an insurance for my newborn?

Answer: Yes. You can get coverage for your newborn, if you apply within 60 days of his or her birth. Your baby is eligible for Medi-Cal. You can apply directly through your county health services office or through Covered California. Medi-Cal is pretty much free both in terms of $0 monthly premium and 100% coverage. The other option is to purchase a commercial health insurance plan directly from one of the insurance companies or through Covered California. In either case, your baby will not be eligible for premium assistance so you would be paying between $90 and $200 per month depending on the level of coverage.


Son Aging Off Medi-Cal?

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Question: Currently my husband and I are enrolled in a subsidized insurance through Covered California, but our three kids are qualified for Medi-Cal. Our oldest child is turning 18 in December. Will he be moved to our subsidized insurance then? If so, what do we need to do? If not, when will he be qualified for our subsidized insurance?

Answer: Your son will remain on Medi-Cal one more year. Eligibility for Medi-Cal ends at age 19 for a dependent child. When your son is within 60 days of his 19th birthday, notify Medi-Cal to terminate eligibility in the statewide system. This will trigger a qualifying event and your Covered California account will be updated by your county Medi-Cal staff. Once the update to the account has been made the you, your agent, or a CC call center representative can complete the plan enrollment within the Covered California account.


Taking No APTC?

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Question: If I take 0 APTC next year, do I still have to fill out the financial section when I re-apply and provide documents for Verification? My income will probably be different next year than it is now.

Answer: I suggest that you simply update your Covered California account with your higher income projected for next year. If that places you above the threshold for premium assistance, you will receive $0 in advance premium tax credits. If that creates a documentation problem for you, here's another way to handle it. Use whatever income that your last tax return indicates, but change your premium assistance payment to annual mode. That way you'll get $0 in advance premium tax credits during the year, but should you qualify for any assistance based on your actual income for next year, you will receive it as a tax credit when you file your return.

Question: If I leave Covered California and buy health insurance elsewhere, can that company ask about pre-existing conditions and charge me more based on my answers?

Answer: No. The Affordable Care Act regulates all health insurance plans whether they are administered by the exchange or not. Coverage is guaranteed regardless of health. Rates are determined only by age and zip code.

Subsidy Repayment?

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Question: A twenty seven year-old friend moved from California to Oregon, and failed to report the change of residence within the ninety day grace period. She works part time at a minimum wage job. Will she have to repay her California subsidy in order to move ahead in her new state?

Answer: No. She can buy coverage through the Oregon Health Insurance Exchange as soon as she is a resident. Since the subsidy is paid by the IRS, not the state of California or Oregon, her 2016 federal tax return will reconcile the total advanced tax credits (subsidy) received in both states. If more subsidy was paid than she was due, her federal taxes due will include any overpayment (or underpayment) of subsidies for the 2016 tax year. When her Covered California health insurance lapses after 90 days, the subsidy which the feds paid to the insurance carrier during the 90-day grace period is returned to the IRS except for the amount covering the first 30 days.

Question: I’m behind on my premium payments and trying to catch up, but meanwhile I got sick and so had to make more health care claims. Does my insurance have to pay them even though?

Answer: If you are receiving advanced premium tax credits, the insurer is required to pay your claims during the first 30 days of the grace period. After that, during the second and third month of the grace period, the insurer is allowed to hold your claims and only pay them if and when you get caught up in your premium payments.

How is Family Premium Computed?

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Question: I’m 59, my spouse is 55, and our kids are 24, 17, 15, and 13. What age premium will we be charged for health insurance in the Marketplace?

Answer: To compute a “family premium,” insurers will add together a separate premium for each adult age 21 and older. In addition, insurers can charge a separate premium for up to three children under age 21. In your example, your family premium will reflect three adult premiums and three child premiums.

Is Dental Coverage Included?

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Question: Is dental coverage included in Covered California?

Answer: Dental coverage for children through age 18 is imbedded in all Covered California health plans since January 2015. This is not the case for adults. Insurers don’t have to include adult dental coverage in their health plans, but several stand-alone dental plans are available for adults through Covered California.

Using a Doctor Not in Network?

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Question: What happens if I end up needing care from a doctor who isn’t in my health plan’s network?

Answer: Insurers are not required to cover any care received from a non-network provider, though all PPO plans sold in California today do, at least to some extent. If you do receive care out of network, it could be costly for you. Generally plans that provide an out-of-network option cover such care at a lower rate (e.g., 80% of in-network costs versus only 50% of non-network costs.) In addition, insurers are not required to apply your out-of-network costs to the annual out-of-pocket maximum. Non-network providers also are not contracted to limit their charges to an amount the insurer says is reasonable, so you might also owe “balance billing” expenses.

Cancelled for Partial Payment?

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Question: My income is about $17,000, so my portion of the monthly premium is about $80/month. The subsidy pays the rest, which is about 90 percent of the total premium. I missed 4 premium payments in a row. Can they cancel my coverage even though they got 90 percent of the payment on time from the IRS?

Answer: Yes. If you are receiving premium assistance through Covered California, you have a 90-day grace period to pay all premiums that are owed. If you don’t pay in full by the end of the grace period, the insurance company can terminate coverage and return funds it received from the federal government for all but the first 30 days of the grace period.

What are My Options at Age 23?

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Question: If I'm 23 and starting a full-time job, am I forced to use my new employer's Covered California plan, or can I stay on my parent's coverage until I turn 26?

Answer: Yes. You can stay on your parent's plan until you are 26 years old. When you are 26, you will have to enroll in your employer-based health plan.

Cancelling Covered California?

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Question: If I wish to leave Covered California all together, can I use the terminate plan button? I have read that it is just for changing from one plan to another in the CC system.

Answer: Using the "terminate plan button" on your Covered California is all you need to do to cancel your coverage at Covered California. But don't stop there, call your insurance company and cancel with them too. DO NOT just stop paying your premium or you will create a mess that takes a long time to fix.

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