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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 2017 Archives


Question: I’m 61 and receive Medicare as I’m permanently disabled. Currently I am paying $200 out of my $1000 social security income towards my Kaiser Senior Advantage, plus high co-pays. My income is very low (social security only) but I do have assets that I am spending down to augment my income. Can I qualify for Medicaid as well based on income only?

Answer: Medicare beneficiaries in California who have limited income and resources may get help paying for their premiums and out-of-pocket medical expenses from Medi-Cal. Medi-Cal also covers additional services beyond those provided under Medicare, including nursing facility care beyond the 100-day limit or skilled nursing facility care that Medicare covers, prescription drugs, eyeglasses, and hearing aids. Services covered by both programs are first paid by Medicare with Medicaid filling in the difference up to the state’s payment limit.

Income limit: The Medi-Cal income limit is calculated as 100% of the federal poverty level (FPL), which changes every year. The current limit is $11,880/yr per individual and $16,020/yr for a couple.

Assets: Individuals may own assets worth no more than $2,000; married couples may own $3,000 worth. But not all assets are included in the count. Exempt assets include:

  • A primary home
  • One vehicle
  • Household items
  • Personal belongings including clothing, heirlooms, and wedding and engagement rings.
  • Burial plots and any money in a designated burial plan fund
  • Life insurance policies and the balance of pension funds, IRAs, and certain annuities

Out-of-Network Consequences?

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Question: I went to a doctor who is not in my health plan’s network. What now?

Answer: PPO plans cover some of your out-of-network medical expense. HMO and EPO plans cover only emergency non-network expenses. Generally plans that provide an out-of-network option cover such care at a lower rate, for example a Silver Plan covers 80% of in-network costs after deductible versus only 50% of non-network costs after deductible. In addition, the out-of-network deductible is twice as much as the in-network deductible, $5,000 vs $2,500 for Silver plan. Finally, the annual out-of-pocket maximum for the Silver Plan in-network id $6,800, meaning you are covered 100% after your out-of-pocket expenses on covered items reaches $6,800 in a calendar year. The annual out-of-pocket maximum for the Silver Plan out-of-network is $9,800 and it’s separate from the in-network maximum.


Get Son Off Medi-Cal?

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Question: Me and my husband are on Covered California and our kids are on Medi-Cal. Our son is turning 19 in December. Will he be moved to our Covered California insurance then? If so, what do we need to do?

Answer: Notify Medi-Cal to terminate your son’s eligibility. 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 then you, your agent, or a Covered California call center representative can complete the plan enrollment within the Covered California account.


Question: I took out $20,000 from my IRA, I believe it raised our income to $47,000 which normally be around $27,000. I did not report this change as I am confused on what is Income, if I do not count on that money yearly nor will I have it ever again, how do I calculate or preview plans that are based solely on our ‘Income’ and not extras, as not to over pay.

Answer: Since you are collecting monthly premium assistance in the form of tax credits based on an estimated annual income of $27,000, your excess tax credits for actual 2017 income of $57,000 will have to be repaid when you file your taxes for 2017. Assuming you do not plan to make another IRA withdrawal, I suggest you do not change your stated income in your Covered California account, because your 2018 income will return to to about $27,000 and you’ll be back on track will a minimum of complications.


Question: When a married couple is separated but not divorced, maintaining two households instead of one and having 2x the housing expenses, is that a factor that can be taken into account in determining whether each of them is eligible for a subsidy for the purchase of insurance?

Answer: No. Your living expenses are not considered in determining your eligibility for premium assistance under ACA rules. Your tax filing status and adjusted gross income (AGI) are the only considerations. As a married couple living separately, your federal income tax filing status is key. If you file as "married filing jointly", you may be eligible for premium assistance depending on your joint income. You and your husband and any dependents would be considered one household even if you live apart. If you file as "married filing separately, neither you or your husband will be eligible for premium assistance.


Question: Hello,My wife and I are enrolled in Covered California healthcare blueshield ppo 87. We claimed my mother in-law as dependent on tax return. My question is can my mother in-law still apply for medical while my wife and i have this blueshield ppo 87 ? Household income is about $40K. Thank you.

Answer: I assume that your mother-in-law is included in the three-person household for which you received premium assistance and reduced out-of-pocket expenses through Covered California. She is not eligible for Medi-Cal unless you remove her as a dependent for federal income tax and change your Covered California account to a two-person household. It would be expensive for you to do that. You would lose the $4050 dependent tax deduction for 2017 and going forward. Also, some of the premium tax credits you received while your mother was listed as part of the household, will be reflected as added taxes for 2017. Additionally, as a two-person household your premium assistance would decrease by about $50/mo compared to a three-person household.


Add Dependents to SHOP

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Question: Can dependents be added to SHOP plans?

Answer: Most employer-sponsored health plans offered through the Covered California SHOP include spouse and dependent coverage, but the employer has the option to offer employee-only coverage. Dependents can be added at the plan's open enrollment period each year. A newborn can be added within 60 days of birth.


Moving to CA?

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Question: I am moving to CA from NY in mid October. (1) When should I apply for health insurance in CA? My family may qualify for Medi-Cal or other subsidized programs. (2) Would the effective date be the exact date of the move, for example, October 15? Or, would I be covered by my NY plan until October 30, then start my CA coverage on November 1?

Answer: You must be a California resident to apply, so apply as soon as you have a California address. Apply through Covered California to determine your eligibility for premium assistance or Medi-Cal. Typically, your NY health insurance coverage will expire at the end of the month and your CA coverage would start on the first of the next month.


Estimate S-Corp Income?

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Question: I have recently quit my job that provided health insurance to me and my family. My wife and I have a small business set up as an S-Corp where we draw a salary as employees of the company. There are additional business profits that reside in the business bank account and are not drawn as salary or as owner distribution. What do we consider when estimated our yearly income....only the salary and distributions that we take? Or the entire company net profit no matter where the funds reside? Thanks!

Answer: I assume your intention is to purchase individual health insurance through Covered California rather than group coverage through the SHOP. If so your family income is based on your Form 1040 adjusted gross income (AGI). S corporations and partnerships pass through the reporting of the company's entire profit to the shareholders or partners. You and your spouse are liable for taxes on the corporation's profit whether or not it was distributed. Those profits are included in your 1040 AGI.


Exceed Medi-Cal Income Limit?

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Question: My husband and I are on Medi-Cal. It is possible that December's income will put us over the yearly limit. Then what happens? Do we owe back money?

Answer: If your income exceeds the Medi-Cal limit for your household, you will no longer be eligible for Medi-Cal. However, you are not required to pay anything back. It is your obligation to notify Medi-Cal if you expect your earnings to continue to exceed the Medi-Cal limit. Once your Medi-Cal coverage is cancelled, you will be eligible for subsidized health insurance coverage through Covered California.


Buy Outside Of Covered California?

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Question: Am I able to buy health insurance outside of Covered California, or do I have to buy from one of the providers under CC? Additionally, will Covered California eventually become the only health insurance marketplace in California?

Answer: Yes. You can buy health directly from state licensed health insurance carriers (off-exchange) without going through Covered California. Covered California is the sole source of subsidized coverage based on income. Covered California is unlikely to become the only health insurance marketplace in California.


Question: I am under Asylum Processing for about 90 days now ,and I want a medical insurance, However right now I dont have SSN or a ID ,just passport from China, how do I get a medical insurance?

Answer: I recommend International Travel Insurance which you can purchase as a Chinese citizen. You can get coverage for a limited period of time while in the United States. You select the length of time, but 90-days is no problem. The plan covers pre-existing conditions only in the case of acute onset. You can pick your deductible and coverage limits depending on your budget. Cost of overage is very reasonable. Click here for a quote Under Patriot Travel Medical Insurance, select Patriot America


Spouse Not Covered by Employer

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Question: Both my spouse and I are insured through Covered California. My job is offering me 100% medical coverage but nothing for my spouse. Are they eligible to still go through CA for insurance?

Answer: If your spouse has access to coverage through your employer, he or she is no longer eligible for subsidized coverage through Covered California even though the employer makes no contribution toward the spouse's coverage. If your employer-sponsored coverage is not offered to the spouse and dependents, then he or she is still eligible for subsidized coverage.

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