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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 2016 Archives


Can I Lose Birth Control Coverage?

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Question: My Facebook friends are urging me to get an IUD before coverage for birth control disappears. Will I lose really lose that benefit?

Answer: In the days immediately after the election, there was panic about birth control. Women were Urging each Other to “Get IUDs Now, Before It’s Too Late,” and “a Trump presidency will threaten women’s reproductive rights.”

For the past six years under Covered California, women have had access to free birth control through their insurance plans because of a provision requiring coverage for preventive health benefits. Trump hasn’t addressed this issue, but fears have been stoked because he became more clearly opposed to abortion as the campaign went on. And Vice President-elect Mike Pence is a strong social conservative who opposes abortion in almost all circumstances.

Technically speaking, Trump might not even have to rely on Congress to get rid of these benefits. HHS could redefine what types of services must be included among the preventive care the law requires insurers to provide.


Free Women's Preventive Services?

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Question: What are the free preventive services for women with #CoveredCalifornia?

Answer: All Covered California plans offer preventive services for women without cost sharing. For example, these include counseling and screening services including prenatal and preconception care; breast and cervical cancer screening; genetic counseling and testing for women at high risk of breast cancer; Chlamydia and Gonorrhea screening and counseling for high risk women; at least one well woman visit a year; contraceptive counseling, services and supplies including prescriptions for FDA approved contraceptives; breastfeeding counseling and support services including breast pump rental; and intimate partner violence screening and counseling. So long as the preventive service is performed by an in-network provider, is not billed separately from the office visit, and is the main reason for the office visit, then the visit and the preventive service will be covered by the insurer without cost-sharing.


Question: Will #CoveredCalifornia Go Away? If so, how soon?

Answer: It now seems certain that Congress and the Trump administration will repeal and replace the ACA (Obamacare). How soon your Covered California health plan would go away is hard to know, but there are some clues. Early this year, when lawmakers sent President Obama an ACA-repeal bill, which they knew he wouldn’t sign, they included in the legislation a two-year period before the marketplaces and other parts of the law ceased. Right now, the open enrollment for 2017 marketplace health plans is underway. The plans that consumers can buy until Jan. 31 have pledged to participate through 2017.


Question: I received financial assistance from #CoveredCalifornia in 2016. In October of this year, I lost my job and my total income for this year ended up being just under 100% of the federal poverty level. Will I have to repay the premium tax credits that reduced my premiums all year?

Answer: No, there is a special rule to protect people in your circumstance. If Covered California found you were eligible for premium tax credits at the time you enrolled and if your income later fell below the poverty level, you are still eligible for the tax credits you received last year. You will not be required to repay the premium tax credit when you file your tax return. To benefit from this special rule, advanced premium tax credit must have been authorized and paid for one month or more during the year.


Question: I’m collecting a VA disability pension and benefits. Does #CoveredCalifornia count this in determining my eligibility for subsidies?

Answer: No. Veterans Administration disability pension benefits generally are not subject to federal income tax and so are not counted as income in determining eligibility for premium tax credits.


Question: Is there any reason #CoveredCalifornia wouldn’t automatically adjust and continue my premium tax credit at renewal time?

Answer: Yes. (1) It could happen if you failed to authorize Covered California to check online income data, including from your tax returns, for another 1 to 5 years. If you did not authorize this, your financial assistance will NOT be automatically continued for next year. If so you can reapply for financial assistance if you want the subsidy to continue for another year. (2) Covered California will check the most recently available federal income tax return. If the income you reported on your tax return was more than 500% of the federal poverty level ($59,400 for a single person, $121,500 for a family of 4), your financial assistance will not automatically be continued for 2017. To continue receiving APTC in 2017, you will have to reapply for financial assistance and provide information about your expected 2017 income (3), If you did not file a 2015 federal income tax return including Form 8962, your financial assistance will NOT be continued for 2017. You will need to file a 2015 tax return as soon as possible, including a completed IRS Form 8962.


Can I Switch to a Different Plan Now?

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Question: I signed up for a #CoveredCalifornia health plan at the beginning of Open Enrollment. Now I changed my mind. Can I switch to a different plan now?

Answer: Yes. You can switch to a different plan at any time during Open Enrollment, that is between now and january 31, 2017.


When Will Coverage Take Effect?

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Question: How long after I enroll in a #CoveredCalifornia plan will coverage take effect?

Answer: If you enrolled in a #CoveredCalifornia health insurance plan by December 17 and make your first premium payment by the due date specified by your plan, your new health coverage starts January 1. After that, if you enroll between the 1st and 15th day of the month and pay your premium by the due date, your coverage begins the first day of the next month. So if you enroll on January 10, your coverage begins February 1. If you enroll between the 16th and the last day of the month and pay your premium by the due date, your effective date of coverage will be the first day of the second following month. So if you enroll on January 16, your coverage starts on March 1.


Where Do I Send My Initial Payment?

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Question: I’ve picked the plan I want. Now do I send my premium to Covered California?

Answer: You will make your #CoveredCalifornia premium payments directly to the health insurance company. Once you’ve selected your plan, Covered California will direct you to your insurance company’s website to make the initial premium payment. If you missed that step, login to your Covered California account, select “Summary”, then select “Current Enrollment”, find “Initial Payment” and select “Pay”. The insurance company must receive and process your payment at least one day before coverage begins. Note that if you have qualified to receive an advanced premium tax credit, the government will pay the credit directly to your insurer and you will pay the remainder of the premium directly to the insurer. #CoveredCalifornia


Question: We have a teenage daughter who has a part-time job. Do we count her income as part of our household income when we apply for #CoveredCalifornia subsidies?

Answer: The answer depends on her income. Generally, kids who qualify as tax dependents aren’t required to file a federal income tax return or pay taxes on their income if they earned less than $6,350 in 2017. If your daughter earned less than that, you would not count her income as part of your household income.


Question: I’m covered as a dependent under my parent’s plan and I’m pregnant. Will my parent’s plan cover my prenatal care and delivery? Will my parent’s plan cover my baby after he’s born?

Answer: The rules are somewhat different depending on the plan your parents have. If your parents are covered under a small employer plan (less than 50 workers) , or if your parents are covered under an individual policy they bought themselves, then your parent’s plan is required to cover your prenatal care and delivery.

However, if your parents are covered under a group health plan offered by a large employer (50 or more workers), then your parent’s plan is only required to cover your prenatal care, but is not required to cover the delivery. Medicaid covers prenatal and delivery services in all states. You could see if you can qualify for Medicaid on your own.

Your parent’s plan, regardless of the source, generally won’t be required to cover your child as a dependent. You will be responsible for obtaining coverage for your baby. Depending on your income, your child may be eligible for coverage under the Medicaid/CHIP program in your state. Or, you can buy a family policy through the Marketplace and, depending on your income, you may be eligible for a premium tax credit to reduce your cost of that coverage.


Never Fiiled a Tax Return?

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Question: I never filed an income tax return before. Can I claim a premium tax credit this year?

Answer: Yes, in most cases you can qualify for a premium tax credit. However, there is a requirement to file a return for the tax year in which you receive a premium tax credit. If you got an advanced premium tax credit last year, you must file a federal income tax return for that year to be eligible to receive an advance premium tax credit next year.


Cost Sharing Repayment?

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Question: If I underestimate my income for 2017 and end up earning more than 250% of the federal poverty level next year, will I have to pay back the cost sharing subsidies?

Answer: Cost sharing reductions are available for those with incomes between $138% to 400% of the Federal Poverty Level (FPL). Cost sharing reduces the deductibles, copays, and the out-of-pocket maximum on your coverage. Unlike premium tax credits, which are reconciled each year based on the income you actually earned, cost sharing reductions are not reconciled.


Moved From Texas Without Insurance?

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Question: I moved from Texas to California in September. I was told that I could not buy from Covered California because I did not have health insurance in Texas. Can I apply now?

Answer: Yes. You can buy health insurance now during open enrollment, either through Covered California or direct from one of the insurance companies. You were previously denied by a new ACA rule regarding permanent out-of-state moves outside open enrollment periods. Starting July 11, 2016, if you move you will be eligible for a special enrollment period only if you had previously been enrolled in other coverage. The new rule is that you must have been enrolled in minimum essential coverage (such as a job-based plan, Marketplace plan, or Medicaid) for at least 1 day in the 60 days preceding the date of the permanent move in order to qualify for the permanent move special enrollment period.


Question: I have coverage with Blue Cross through Covered California. Is my plan required to cover contraceptives without cost?

Answer: Yes, your plan must cover the full range of FDA-approved contraceptive methods, but can impose some restrictions on the contraceptives offered at no cost to you. For example, the plan may require that you choose a provider within the network, and use generic rather than brand name contraceptives, unless the brand name is medically necessary. If the generic drug or device does not work for you, you can ask your doctor to request a waiver from the insurance plan to receive the brand name drug or device without cost sharing.


Enroll While Pregnant?

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Question: I’m pregnant and my baby is due in March. Can I enroll in a Covered California plan now and be eligible for premium assistance?

Answer: Yes. You may enroll during Open Enrollment (until January 31, 2017). You may also be eligible for a premium subsidy, depending on your family income and your eligibility for employer coverage. Once you give birth, you can add the baby to the plan. You will also be allowed to change plans at that time since the birth of a child is a qualifying event that allows you to enroll in or change your coverage, no matter when during the year the baby is born. Your special enrollment period will last for 60 days from the date of birth. Adding the baby will change the plan premium and also your subsidy, assuming you qualify for premium tax credits. Depending on your income, you might also qualify for Medi-Cal and there is not a limited open enrollment period for Medi-Cal.


Question: I’m 63 and enrolled in a retiree health plan from my former employer. Can I look for better coverage and subsidies in the Marketplace?

Answer: Yes. You can drop your retiree coverage and enroll in a subsidized Covered California plan as long as you do so during the Open Enrollment period (ends January 31, 2017). However, it looks like Obamacare subsidies will not be available for more than another year or two. You may want to hang on to your retiree health plan after all.


Child Support Included as Income?

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Question: I receive child support payments from my ex-spouse. Do I count that in determining eligibility for subsidies?

Answer: No. Child support payments are not included in your household income calculation.


Question: My friend and his wife are interested in Covered California, but he's a citizen and she is not legally in the US. They file joint taxes... the children are covered under medi-cal and she has emergency medi-cal only. Is there any way for them to take advantage of a subsidy through Covered California?

Answer: This is a 4-person household with the undocumented spouse declining coverage. The husband and children can be eligible for subsidized Covered California coverage and/or Medi-Cal depending on income.


Unmarried Household Eligibility?

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Question: We are an unmarried couple with two children. How do we count our household size and income when we apply for subsidies in Covered California? Can we buy one policy to cover the whole family?

Answer: It depends on how you file your taxes. Unmarried couples are never eligible to file a joint return, so no you cannot buy one policy for the entire family. If you and your partner file separate returns and you each claim one of your children, you each will be considered as a household of two. The income of each household would be evaluated separately to calculate eligibility for and the amount of premium tax credits and cost-sharing reductions. If one of you claim both children as dependents on your tax return, then you and your children will be considered a household of three. Your income will be the basis for determining subsidy eligibility for the 3 of you. Your partner will be a household of one and his/her eligibility for premium tax credits will be determined separately.


Question: My income varies because I am self-employed. Most years I make between $20,000 and $30,000, though two years ago I did especially well and earned $35,000. How will this affect my application for premium tax credits for the 2017?

Answer: Covered California will compare the amount of income you estimate for next year to the most recent information about your income that is available (at this time that will be your 2015 income tax return). Generally, if that amount is different from the amount you put on your application by more than 25% or $6,000 (whichever is greater), you might receive a “data match inconsistency” notice from Covered California and you’ll need to provide more documentation within 90 days. During that period, you can get premium tax credits based on the income you attested to in your application. However, if you have not resolved the data match inconsistency within 90 days, Covered California will adjust or end your advance premium tax credit based on the most recent income information it can find.


Question: I have a Covered California policy with premium tax credits because the employer coverage was unaffordable (more than 9.69% of income for employee-only). In September, I picked up a second part-time job. Now my employer’s insurance would be less than 9.69% of my total income. I can’t sign up for my employer plan until next June. What should I do? When I file my taxes will I be required to pay back my subsidy?

Answer: As long as Covered California determined you were not eligible for affordable job-based coverage when you initially applied, that determination will hold for the remainder of the year. The IRS refers to this as a “safe harbor,” and won’t require you to go back and re-compute the affordability of your job-based coverage at year end when you file your taxes.

As for 2017, you should report your income change to Covered California as soon as possible. They will determine your new eligibility for premium tax credits, based on your higher income, and adjust the level of subsidy going forward. In June, you can enroll in employer coverage and cancel Covered California coverage.


Question: Is the open enrollment period the same for Covered California and Medicare?

Answer: No. They are not the same, although there is some overlap in the enrollment periods. The Medicare open enrollment period runs from October 15 through December 7 each year. For Covered California, the open enrollment period will run from November 1, 2016 through January 31, 2017. If you are covered by Medicare, and you are interested in reviewing and comparing your Medicare coverage options, make sure the plans you are considering during the open enrollment period are Medicare plans, not Covered California plans. Medicare plans are not sold through the Covered California websites.


Question: I will be 65 soon and and can go on Medicare. My income is $120k and I will be required to pay higher premiums for Medicare Part B and Part D. Can I sign up for health insurance from a Marketplace plan now instead of enrolling in Medicare when I turn 65?

Answer: If you are not yet enrolled in Medicare, you can buy health insurance coverage through Covered California before you turn 65. Once you have a Covered California plan, you can choose to renew it after you turn 65. But once you become entitled to Medicare coverage, you cannot buy a new Marketplace plan. These facts might help your decision. At your stated income of $120,000, you will pay about $300/mo extra for Medicare Part B and Part D bringing your total cost for A,B, and D to about $430/mo. A Silver level Covered California plan which is roughly comparable in benefits would cost you at least $700/mo.


On SSDI with No Health Insurance

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Question: I am 54 and permanent disabled. I have been receiving Social Security disability insurance (SSDI) payments for the past 12 months. I do not have health insurance. I am required to wait another 12 months before I can go on Medicare. Am I eligible for Covered California coverage? Am I eligible for a subsidy or Medi-Cal?

Answer: Yes, you are eligible to purchase coverage through Covered California, and if your income is between 138% and 400% of poverty ($16,400 to $47,520 for an individual) you will qualify for premium tax credits. If your income is less than $16,400 for an individual, you are eligible for Medi-Cal.

Your eligibility for subsidies will end when your Medicare Part A and Part B coverage automatically begins after the two-year waiting period. At that point, you will have to pay the full price for your Covered California coverage or enroll in Medicare Part A, Part B and Part D.

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