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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.

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What is My Family Premium?

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Question: I’m 57, my spouse is 55, and our kids are 23, 17, 15, and 13. What age premium will we be charged for health insurance in the Marketplace?

Answer: Family premiums reflect the composition of family members and their ages. 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.

Question: What income is counted in determining my eligibility for premium tax credits?

Answer: Eligibility for premium tax credits is based on your Modified Adjusted Gross Income, or MAGI. When you file a federal income tax return, you must report your adjusted gross income (which includes wages and salaries, interest and dividends, unemployment benefits, and several other sources of income.) MAGI modifies your adjusted gross income by adding to it any non-taxable Social Security benefits you receive, any tax-exempt interest you earn, and any foreign income you earned that was excluded from your income for tax purposes. Note that eligibility for Medi-Cal is also based on MAGI, although some additional modifications may be made in determining eligibility for these programs.

Subsidies Cancelled, WTF?

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Question: I just read that Trump has cancelled Obamacare subsidies. WTF? Does that affect Covered California too?

Answer: Trump recently cancelled the funding for Obamacare subsidies called “Cost Savings Reductions” which lower the out-of-pocket expenses like deductibles and copays for the lowest income portion of the ACA market. The funding for CSRs had been on shaky ground from the beginning. Fortunately, Covered California anticipated the latest political maneuver to sabotage Obamacare. What that means to you is that your Silver Level coverage will continue unchanged for 2018. The rate increased considerably, but so did the subsidy, resulting in a net premium that’s not too much more than you paid this year. The 2018 Covered California rates for Silver Plans, the only plans that include the CSR benefits, include an average 12% increase to cover defunding the CSR. A new bipartisan bill to fund the CSRs has Trump’s support and looks promising, but it’s unlikely that it will become law quickly enough to reduce Silver Plan rates before Open Enrollment for 2018 closes.

Question: I forgot the login for my Covered California account. Help?

Answer: You can recover your username and reset your password at the Covered California Login page by clicking on “Forgot Username” or “Forgot Password”. After you correctly answer your security questions, you will be able to retrieve your username and create a new password. If you do not remember the answers to your security questions, it is best to leave them unanswered and call the Covered California Service Center at (800) 300-1506. A Service Center representative can help reset your password.

Question: My son is covered by Covered California as part of our household. Does his student health coverage count as essential coverage for Obamacare?

Answer: Yes. Student health plans count as “minimum essential coverage” under the Affordable Care Act. If your son chooses to enroll in a student health plan, the rest of the family is still eligible for advance tax credits through Covered California. Update your Covered California account to indicate that your son is a tax dependent and he is not seeking health coverage through Covered California.

Premium Assistance Repayment?

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Question: I am planning to apply for coverage during open enrollment, ending my current COBRA coverage. My question is this- If I am on Covered California or even MediCal for part of the year and then I get hired for a full time position (that exceeds the income threshold for Covered California) with employee benefits 6 months into the year, will I need to pay back the benefits I received during the first part of the year or pay a penalty? Thank you!

Answer: If you receive premium assistance through Covered California in 2018 based on your current income and subsequently earn more, you will repay some or all of the premium assistance you drew when you file your tax return for 2018. If you are covered by Medi-Cal, no repayment will be required.

Question: I was told today by a person from Covered California that if we purchase private insurance for our kids while they are eligible for Medi-Cal, we could lose our premium assistance. Is it true?

Answer: No. You will not lose your premium assistance if you follow these directions. Update your Covered California account to remove your children from coverage by answering "no" when asked if the child wants coverage. This will drop your kids from the Medi-Cal roles. If you don't do this, you could have problems in the future because your children's social security numbers will continue to appear in the Medi-Cal database.

Spouse Medicare Eligible?

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Question: My spouse turned 65 in September, can he stay on our current plan until December without incurring a penalty or losing our current subsidy?

Answer: No. Once he became Medicare eligible, he was no longer eligible for premium assistance under Covered California. He can be covered through Covered California without premium assistance but signing up for Medicare would be a much better deal.

Why a Minimum Income Limit?

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Question: My ex-wife lives with my son and he will claim her on his 2017 taxes. He is a student and works part time with an expected income of 15,500 gross for 2017. His mother does not work and has zero income. He applied under Covered California and was denied assistance or tax credits due to his income being too low. His mother was placed on Medi-Cal. Why would they deny him assistance or credits because his income for a family size of 2 is too low.

Answer: His income would have to be over $22,000 annually in order to qualify for Covered California coverage otherwise he is eligible for Medi-Cal. This rule exists because it is more expensive for the government and ultimately the taxpayers to provide highly-subsidized coverage on Covered California than to provide Medi-Cal coverage.

IRA Income Reporting?

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Question: I have incurred a large state tax in 2017. If I take an IRA distribution (over 59 1/2) equivalent to this. Will I have to include this as income for MAGI assuming that the deduction will offset the income?

Answer: You have to report IRA distributions as income and it will be included in your MAGI calculation. Whether your state tax deduction will offset the IRA income is a question for your accountant.

Question: If I am getting premium assistance and I was told my premium on my plan rises by 25% for 2018. Does that mean I’m going to have to pay 25% bottom line?

Answer: Probably not. Assuming your income and household status remain the same in 2018, as your premiums increases, so do your tax credits, so the premium assistance will counter at least some of the rate hike. At Open Enrollment, starting November 1st you can keep the same plan at the new rate or switch to a lower cost plan if you wish.

Question: A am 25 years-old single person with Covered California Silver 87 Plan. I recently lost my job. I have a new job starting in January. I plan to use my 90-day grace period and stop paying my subsidized Covered California health insurance for the rest of the year. If so will I have to repay my subsidy?

Answer: When your Covered California coverage lapses after 90 days for non-payment, the subsidy which the feds paid to your insurance carrier during the 90-day grace period is returned to the IRS except for the amount covering the first 30 days of the grace period. When you file your 2017 federal tax return, you reconcile the total subsidy received. If more subsidy was paid than you was due, your federal taxes due will include any overpayment (or underpayment) of subsidies.

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.

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.

Physician Balance Bill?

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Question: I have Anthem Blue Cross silver 94 PPO. I had to visit to ER in March and I verified the facility was in network. I received a balance bill from the Doctor demanding me to pay what anthem did not pay. Do I have to pay this bill?

Answer: You are not alone. A recent Consumers Union survey found that one-quarter of Californians who had hospital visits or surgery in the past two years were charged an out-of-network rate when they thought their provider was in-network.

Emergency physicians in California are barred from "surprise" balance billing. Health plans pay non-contracting physicians the plan's average contracted rate or 125% of the Medicare rate, whichever is greater. Your insurer, Anthem can tell you what portion of the doctor's bill you are required to pay under your plan of coverage.

A new California law goes into effect on July 1, 2017 that extends the "no surprises" balance billing restrictions to non-emergency medical services. The bill, passed by the California General Assembly after months of tough negotiations, also tightens requirements on health plans to offer adequate provider networks.

Question: Last year we had a Bronze HSA plan with Blue Shield. This year we have a Bronze HSA plan with Anthem. After several claims this year I have noticed that IDENTICAL procedures are being paid differently to providers by Anthem vs. Blue Shield (and not to our benefit). Why would plans which are considered the same metal (i.e., Bronze) pay differing amounts? I thought the only difference between insurers was the providers that accepted the plans? If that is not the case, how would it be possible to find out this information before selecting an insurer?

Answer: Each health insurance carrier negotiates payment rates with their own network providers. That's how Anthem and Blue Shield can pay the same provider different amounts for the same treatment. The contracted rates between carriers and providers are not available to the public, so a consumer cannot know in advance exactly what a carrier will pay the provider for any specific treatment of procedure.

Question: It is February now. We just found out a doctor that we have been seeing does not accept our plan this year. Can I change my plan to another carrier now?

Answer: If your insurance carrier listed your doctor within their provider network in error, then you are eligible for a Special Enrollment Period (SEP). That means you can choose another health insurance carrier that includes your doctor.

Question: We are married but filing separately. Do we apply Medi-Cal or Covered CA separately also? or must be together?

Answer: You must apply as a couple, but because you file taxes separately, you will not be eligible for premium assistance through Covered California. Your tax filing status will not matter if you are eligible for Medi-Cal coverage based on your income.

Question: My daughter is 18 and on my ex husband's health insurance policy at his work. I claim her as a dependent on my taxes. If he drops her from his policy after open enrollment closes, does that create a special enrollment for her under my Covered california policy?

Answer: Yes. She will be eligible for a Special Enrollment Period (SEP) for 60 days after her loss of coverage. Since she is part of your household, you can add her to your Covered California coverage at that time.

Payback All the Subsidy?

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Question: My 20 year old son is a dependent on my covered CA. His income put me over the Max amount of earnings to qualify. My tax credit was approx $1000 a month. Does that mean I have to pay back $12,000.00 dollars?

Answer: When you say "over the max amount of earnings", I assume you mean that your combined household income was over 400% of the Federal Poverty Level (FPL). If that is the case, then you will have to pay back all of the premium assistance (subsidy) you received in the previous year.

Terminating CC for Medicare?

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Question: My wife and I have Covered California coverage for 2017. I am listed as “primary subscriber” with Blue Shield. I will turn 65 in Feb 2017 and will be on Medicare, My wife however needs to remain on our CC plan for 2017. What is the best way to terminate my account with CC/Blue Shield since I will start Medicare but not change my wife’s continuation with Covered California, and then list her as primary subscriber after February?

Answer: Login to your Covered California online account and use the “report a change” feature. Under the “Personal Data” tab, go directly to the healthcare section and select “Yes” to receiving medicare benefits under the recipient’s name. The Covered California system will automatically terminate coverage for that subscriber without removing the required household details. The subsidy will automatically adjust for remaining subscribers.

Question: My 21 year old son was added to our #CoveredCalifornia account with a start date of 9/1/16. He made $12,000 during the last 4 months of 2016. We are having issues with him stating that he is going to claim himself. Which do you think would be the harder hit, taking the $12,000 overage on our income for the year or covering him for 4 months and not claiming him.

Answer: My original answer to this question was wrong. This is the corrected answer. Explain this to your son. If he claims himself, his taxable income will be $12,000 minus his standard deduction of $6,300 minus the personal exemption of $4,050 for a net taxable income of $1,650 resulting in a $165 tax liability. If you claim him as a dependent, he loses the exemption so his taxable income will be $12,000 minus his standard deduction of $6,300 for a net taxable income of $5,700 resulting in a $570 tax liability. So basically, your son will lose $405 if you claim him. However, the tax benefit to you, the parents, will probably be more than $405 because you are probably in a higher tax bracket. I am unable to compute the financial consequences in your 2016 Covered California account without more demographic info. Send another question with your email address, zipcode, ages of family members and income by member and I will be more specific. In 2017, you should no longer claim your son as a dependent. Thank you Ernest for providing this answer.

Question: I wanted to shop for new coverage for 2017, but didn’t get around to it yet. Meanwhile, Covered Cal;ifornia automatically renewed my current policy. Can I still make a change?

Answer: Yes. If you pick a new plan by January 15, coverage under the new plan will take effect on February 1. If you pick a new plan between January 16 and January 31, coverage under the new plan will take effect March 1. In order to avoid a gap in coverage, you will have to pay the premium for your current policy until your new coverage takes effect.

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.

Age 65 and Not Medicare Eligible?

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Question: I am 65 years old next month, but I have to pay a premium for Part A because I have not worked long enough to qualify. Can I sign up for a Covered California plan?

Answer: Yes, People age 65 or older who are not entitled to premium-free Medicare can purchase health insurance coverage in Covered California (except undocumented immigrants). If you sign up for a Covered California plan, you may be eligible for premium tax credits to make the coverage more affordable depending on your income.

Keep in mind that if you are able to continue working, you may be able to earn enough work history to qualify for premium-free Medicare in the future. So another option for you to consider would be to sign up for Part A and Part B coverage when you turn 65 (you will have to pay a premium for both Part A and for Part B), and when you become eligible for premium-free Part A through your work history, you will then only have to pay a premium for Part B.

Drop COBRA Now?

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Question: My COBRA coverage won’t expire for another 9 months. It’s very expensive. Can I drop it and enroll in Covered California now?

Answer: Yes. During Open Enrollment, you can sign up for a Covered California plan even if you already have COBRA. After Open Enrollment ends (January 31,2017), if you voluntarily drop your COBRA coverage or stop paying premiums, you will not be eligible for a special enrollment opportunity and will have to wait until the next Open Enrollment period. Only expiration of your COBRA coverage triggers a special enrollment opportunity.

Question: I’m getting a monthly subsidy that lowers the premium of my Covered California plan. What will happen to this subsidy if Obamacare is repealed?

Answer: It seems likely that Obamacare will be repealed soon, but it will take a year or two to build a system to replace it. Subsidies will probably continue to be funded through 2017 and perhaps beyond. The new administration has proposed some new ideas for a replacement plan, for example subsidies based on age rather than income.

Medi-Cal for Mother?

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Question: My mom lived with me since 2015 summer. She got her green card recently. She is now 74, she does not have any income.

  • Can she apply for Medi-Cal now? Yes
  • Can the medical benefits (through Medi-Cal) kick in for the remainder of 2016? Yes.
  • What should she show as her household income? $0
  • Does she have to file a separate tax return in 2016 (or) can I still include her as dependent in 2016? No. You can still claim her.
  • After receiving Medi-Cal benefits in 2017, does she have to file a separate tax return in 2017? No

  • Question: I earn less than 30,000 a year. I have 2 daughters and me. I'm insured through my employer. I am paying $400 a month. Do I qualify for a subsidy?

    Answer: If you pay $400/mo for health insurance that does not include your daughters, it is officially "unaffordable" because it represents over 16% of your income. The law says you can cancel your unaffordable (greater than 9.6% of income) employer-based insurance. You are eligible to buy subsidized coverage at Covered California. Your daughters are eligible for Medi-Cal. Your cost for very good insurance will be about $100 per month.

    Question: How do I find out how much my prescriptions are going to cost?

    Answer: Each health insurance company has a drug formulary posted on their website. No matter which health plan you choose, the drugs will be labeled as Tier 1 (generic drugs), Tier 2 (preferred drugs), Tier 3 (non-preferred drugs) or Tier 4 (specialty drugs). Your cost for your prescriptions will be lowest for Tier 1, and highest for Tier 4. Each carrier must provide current and prospective members with an estimate of the out-of-pocket cost for specific drugs. In 2017, California insurance carriers cannot charge more than $250 per month for one 30-day supply for Silver 70, Gold 80 and Platinum 90 plan members and no more than $500 per 30-day supply for Bronze 60 plan members. These costs apply to Tier 4 (specialty drugs). Drugs in lower tiers have lower costs.

    Question: Is covered California just for people who qualify for subsidies? If so, how do higher income people apply?

    Answer: If you are not interested in financial help, you can use the Covered California online application at CoveredCa.com. If you do not want financial assistance for a Covered California health insurance plan or coverage through Medi-Cal, you can indicate that you are not interested in premium assistance when asked. From that point, you will complete the application and select a plan without entering income information.

    Undocumented Family Member?

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    Question: My husband does not have a green card yet, but he pays taxes. We both work but his income is more than mine. We have 2 kids. When I apply at California Covered what do I put in for income, just mine of both?

    Answer: Families that include undocumented immigrants can apply. On your application, include your husband in the household and include his income. Your Covered California eligibility will be based on a 4-person household. Indicate on the application that your husband does not want coverage.

    Continuity of Care?

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    Question: I can save $170 per month by changing insurance companies this year. I just had back surgery and need follow up care, but my doctor is not in the new plan. It’s almost worth paying cash for treatment since I’m saving over $2,000 for the year. Am I overlooking anything?

    Answer: If your doctor does not take your new health insurance, but you are getting treatment for a serious condition, call your new health insurance company to let it know about your treatment. Depending on what illness or condition you are receiving treatment for, your new health insurance company may be able to work with your current doctor while you finish your existing treatment. Be sure to tell your current doctor that you have new health insurance.

    Premium Assistance Options?

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    Question: My income may go up during the year. I don’t want to have to pay a penalty for taking too much subsidy. How do they handle that?

    Answer: If you are paid too much premium assistance during the year, the IRS will recover some or all of it through your tax return. The balance due is added to your taxes due for the year.

    You can avoid having to repay excess premium assistance in several ways. (1) If your income increases during the year, update your Covered California account to reflect the income change and your subsidy will be reduced going forward. (2) You can elect to take less premium assistance on a monthly basis or (3) you can take all of your premium assistance in a lump sum at the end of the year.

    Question: I was recently forced into early retirement and am losing my employer-provided health benefits. I made far too much money in 2016 to be eligible for a Covered CA subsidy, but I will certainly qualify in 2017, since my income in retirement has dropped considerably. Can I take COBRA for the remainder of 2016 (1.5 months), then enroll in covered CA starting on Jan 1, 2017 with the subsidy?

    Answer: Yes. If you enroll in COBRA now, you can change to Covered California during open enrollment for a January 1, 2017 effective date of coverage. Also, your loss of coverage because of job loss makes you eligible for a special enrollment period that lasts 60 days from the date you lose coverage, but your Covered California coverage would not start until January 1st anyway. Something you should know about your COBRA rights: you have a 60-day period during which you can enroll in COBRA. You don't have to enroll now. What that means to you is you may be able to avoid paying for COBRA for a month and a half if you have no medical expenses during that period. If you have unscheduled medical expenses in that period of limbo, you can sign up for COBRA with a retroactive effective date back to the date of your loss of employer-based coverage.

    Primary Care Provider?

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    Question: Why am I being asked to select a Primary Care Physician for a PPO plan? I thought the whole idea of a PPO is to be able to see any provider in the network.

    Answer: Covered California believes that being matched with a Primary Care Provider (PCP) improves your health care. Having a PCP means you will have someone you can turn to for health care advice — whether it’s preventive care, treating common illnesses and injuries, or recommending a specialist when you need one.

    When you renew your plan, your health insurance company will match you with a PCP, in part and when possible, based on the physician you have been seeing. If you have not been seeing a specific physician or are renewing with a new health insurance company, that company will match you with a physician as near to your home as possible. You can change this match AT ANY TIME by contacting your health insurance company.

    Having a PCP does not change your PPO/EPO, but is an added feature. You may still access any provider, inside or outside the network for PPO’s and inside the network for EPO’s, and do NOT need a referral to access specialists.

    Tax Dependent Apply Separately?

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    Question: I believe I would be eligible for Medi-Cal and so I plan to apply through Covered California. When applying, can I/do I apply for myself separately or do I need to apply along with the rest of my family? I currently live with my parents, who report me as a dependent. I am a 22 years old recent graduate, I am currently unemployed but looking for work. I am not covered under my parent's health plans because of the cost.

    Answer: You are eligible for Medi-Cal. Apply through Covered California for yourself alone. You will have to promise to file a tax return in 2017. When you do file your tax return for 2017, you need to check a box on your own tax return to report that you can be claimed as a dependent on somebody else's tax return. Your parents can continue to claim you as a dependent until you earn more than half of your total support for the year or reach age 24.

    Medi-Cal Asset Recovery?

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    Question: I am over 55 and have my own health insurance, but my son, who is 9 years old, receives Medi-Cal. Can the state take from my estate after I die in order to reimburse themselves for my son’s premiums?

    Answer: No. California only seeks to recover assets from the estates of those who have used Medi-Cal to pay for nursing home expenses.

    Unemployed Adult Living w/ Parents?

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    Question: I am 25-years-old, have no health insurance, am unemployed, and currently live with my parents. I have no income and so I don't personally file income tax, but my parents have been kind enough to cover my limited expenses. I am a student enrolled half-time at a nearby community college and I am currently in the process of preparing all the things required to enroll into a nursing program for an ADN. One requirement is for proof of health insurance and so I will need to apply for a plan. I am not enrolled under one of my parent's plans due to them being cost prohibitive. My question then is what are my options? What course of action may prove best for me?

    Answer: You are eligible for Medi-Cal. You can sign up now through Covered california and be covered immediately. Medi-Cal enrollment will satisfy your nursing program requirement.

    Proof of $0 Income?

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    Question: Hello, I work for my mother I'm her caregiver, she pays me with a VA Benefit Aid and Assist, which is only for her care this income is not tax deductible, therefore I don't file income tax, how do I provide proof of my income for subside? Thank you.

    Answer: If you have $0 taxable income, you are not eligible for a subsidy. You are eligible for Medi-Cal. You can provide proof-of-income with a letter explaining your income details.

    Consumers After Obamacare?

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    Question: I currently get a subsidy for my insurance on Covered California. If the Affordable Care Act is repealed, will I be able to change my plan to a lower-cost plan?

    Answer: While it now seems certain that the Affordable Care Act (Obamacare) will be replaced, nobody knows what will replace it. We can make some educated guesses though. President Elect Trump had indicated that he wants to keep the "guaranteed issue" feature, but those with preexisting conditions could pay a higher premium. Look for subsidies as well as penalties to go away. The health insurance companies will be less restricted in what they can offer. Look for cheaper plans that don't cover as much. So you will probably not be able to buy a lower-cost plan, but without a subsidy.

    Question: Is dental coverage included in Covered California plans?

    Answer: Children’s (through age 18) dental coverage is included as part of all health insurance plans sold through Covered California. This is known as “embedded children’s dental coverage.” Embedded children’s dental coverage is part of all health insurance plans sold through Covered California, so no additional enrollment is needed to receive children’s dental benefits if you already have a health insurance plan through Covered California. The dental benefits for children are part of the coverage you have purchased.

    Optional adult dental benefits are also available through family dental plans. All plans include free preventive and diagnostic care, like cleanings, X-rays and exams. Family dental plans are offered during the renewal period, but you must purchase a health plan through Covered California in order to be eligible.

    Question: Do people holding temporary visas like H-1 and student visas have to buy health insurance or be penalized?

    Answer: All “lawfully present” individuals in the United States must have health insurance or pay a penalty unless exempt. Lawfully present includes temporary US residents holding worker visas and student visas. The IRS grants exemptions from penalty if the income is below the minimum tax filing threshold also if minimum essential coverage is unaffordable.

    Question: If the consumer does not have an online account and wants access to their application information, what is your first step

    Answer: (1) Go to the Covered California Login Page and Apply for Coverage. (Looks like this: CC1.pdf) (2) At the Login page, create an account (Looks like this: CC2.pdf)

    Question: My husband makes less than $20,000 a year and he's currently on my insurance plan through my employer but it has gotten too expensive and we cannot afford it. I wanted to see if he can apply for covered California on his income alone. We file our taxes separately & file single. Does he still have to report my income to apply? I make over $50,000 a year and I'm sure he won't qualify for tax subsidy if he reports my income.

    Answer: Your spouse has access to your employer's health plan. That makes him ineligible for premium assistance (subsidy) through Covered California. So he can only buy private insurance coverage at full price, if not from your employer. His income (or your income) has no affect on this case. Your tax filing status is dicey (should be either married filing joint return or married filing separate return but not single taxpayer), but has no affect on this case either.

    Political Asylum Pending Status?

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    Question: I am here on a political asylum and my status to be approved for political asylum is still pending, however, I do have a work permit and a Social Security number. By law, do I have to purchase health insurance under my current status?

    Answer: The rule on pending asylees is as follows, "Applicants for asylum are eligible for Marketplace coverage only if they've been granted employment authorization or are under the age of 14 and have had an application pending for at least 180 days." That includes your situation, but your question was "do I have to purchase health insurance?". Yes. You have to purchase minimum acceptable coverage or pay a penalty. That's because you have the right to work in this country. As a taxpayer, you are eligible for subsidized health insurance coverage. With the eligibility for taxpayer benefits comes responsibility to insure yourself so as not to be a burden on other taxpayers.

    Question: I work part time and share rent with my parents. I'm 29. I earn an average of $750 net per month. Aren't there any other more affordable plans for part-time workers? I want to abide by the law. So, now what are my options?

    Answer: Your income makes you eligible for Medi-Cal. Apply at CoveredCa.com. Your coverage will start immediately and it should be nearly free both in terms of monthly cost of coverage and out-of-pocket expenses for medical care.

    Question: My income will vary next year. Let's say i think i will make $40,000 next year and my covered calif. premium is $265 a month. But after the year ends i find out i only made $35,000 which would mean my premium would of been $199 a month. Will i get a refund then since i overpaid on my premiums compared to what my actual income came out to be

    Answer: You will get every penny of subsidy due you based on your income. Income fluctuations from month to month get ironed out at the end of the year when you file your tax return. The IRS computes your total premium assistance on an annual basis at that time based on your adjusted gross income. You add up all the premium assistance your received during the year (Form 1095A) then match it against the IRS computation. If you did not use all the premium assistance you were due for the year, you will get the difference as an additional tax credit against your federal taxes due. Conversely, if you received too much premium assistance, given your final annual adjusted gross income, you will pay the difference as added tax to your federal income tax.

    Do Student Health Plans Count?

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    Question: Do student health plans count as Obamacare coverage? What happens to the parents Covered California household if one or more dependents are on student health plans?

    Answer: Yes. Student health plans count as “minimum essential coverage” under the Affordable Care Act. Students can opt out of their student health plans and purchase coverage through Covered California. A student with no income would be eligible to receive low- or no-cost coverage through Medi-Cal. Also, if students are a tax dependent of their parent(s) or under the age of 26, their eligibility for student health coverage does not make them ineligible to be covered on their parent’s family health plan.

    If students choose to stay or accept their student health plan, their parents would still be eligible for tax credits through Covered California, if otherwise eligible. However, parents must correctly state on their application that although their child (the student) is a tax dependent, they are not seeking health coverage through their (the parents’) Covered California health plan.

    Exemptions for Students?

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    Question: Does a student, earning no income, need to purchase health insurance or be penalized?

    Answer: Most students will have to purchase health insurance or they will be subject to a tax penalty. If you are not claimed as a dependent by your parents and you do not file taxes because you are below the tax filing threshold, you are can qualify for an exemption from the tax penalty. You can apply for an exemption at healthcare.cov

    Question: My Daughter recently got hired as a elementary teacher and enrolled in a PPO plan through Blue Cross. She is 23 years old. When she met with the advisor they told her she had to enroll in a plan, she enrolled in the same insurance my husband and I have. Her first paycheck they took out 798.00. She is currently on our plan still as I have never dropped her. Since she is only 23 and she is single with no dependents can she just drop her insurance through her work and stay on ours??if so since she is still on our can she drop hers anytime as long as she shows proof that she is still insured through us or does she have to wait till open enrollment to drop hers. Which isn't until next July ?

    Answer: Your daughter can be included in your household health coverage through Covered California until age 26, even though she is employed. However, your household is not eligible for premium assistance or cost sharing enhancements from the time she was offered health insurance at work. If she is still included in your household coverage with Covered California and your household is drawing a subsidy, you will have to pay some of that back for this tax year. I would advise you to drop her from your CC coverage now. It almost always works out better for an individual to take the employer-based coverage, because by law the employer has to pay at least 50% of employee's cost of coverage. If her employer deducted $798 for health insurance, it must cover several months. That's certainly way more than her monthly cost for health insurance.

    Question: I am leaving my current job in a few weeks to relocate to southern california to help my family out and my health coverage will discontinue as of December 2016. I will be doing a 13 week temp job and then am unsure of my employment thereafter. I am wondering if I can sign up for Covered California now so that i will have coverage through my temp job and thereafter?

    Answer: Starting on November 1st, you can apply for Covered California coverage to be effective January 1, 2017. You will need a California address. Your initial premium assistance will be based on the monthly income from your temp job. When your income changes again during the year, you can update your Covered California account at that time.

    Question: I qualified for Silver 94 for 2016. My income and household size will stay the same for 2017, but CC only give me the option for Silver 87. Why is that?

    Answer: Households with income 139% to 150% of the Federal Poverty Level (FPL) are eligible for enhanced Silver 94 Plans. Your income was in that range in 2016, but apparently it is now between 151% and 200% FPl making you eligible for enhanced Silver 87 plans. Have a look at the income section of your Covered California account. You will probably find that your income has been increased. Covered California can and does change income figures when they receive data from the IRS that does not match your income estimate.

    Marital Separation Eligibility?

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    Question: I just separated from my husband, living on my own. I make $25,000/year income myself. We filed taxes together last year. Will I have a problem enrolling in a plan for 2017? I don't have an individual income tax return to show. I am wondering how that works.

    Answer: You can be eligible for Covered California coverage for 2017 as a 1-person household, if you get divorced and file a single taxpayer return for the 2017 tax year. Married filing separately will not work.

    Question: I recently got married, my husband has been receiving Covered California benefits and I have been on MediCal. I just signed a contract with a school district today that offers health coverage for both of us. I plan to sign up for benefits for myself, but is my husband required to accept my employer health coverage as well? Will we be penalized during tax season for the 3/4 of a year that we were receiving assistance before getting benefits?

    Answer: While your husband is not required to accept your employer-based health coverage, he will no longer be eligible for premium assistance through Covered California. He will not be penalized for receiving subsidized coverage in 2016. However, if you are filing a joint tax return for 2016, your combined income may result in a subsidy "overpayment" for him which you will have to repay as part of your 2016 federal income tax.

    Question: How do I get a new password for my CoveredCA account?

    Answer: You can reset your password by clicking “Account Sign In” and then clicking the “Forgot Your Password?” link. Enter your user name. After you correctly answer your security questions, you will be able to enter a new password. If you do not remember the answers to your security questions, it is best to leave them unanswered and call the Covered California Service Center at (800) 300-1506. A Service Center representative can help reset your password.

    Cancel VA for Covered California?

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    Question: I been on VA coverage for years. It sucks, but the price is right, especially the prescription drug prices. With my income, I could buy an enhanced silver plan for under $100/mo. Can I switch?

    Answer: Yes. You can cancel your VA coverage and enroll in Covered California coverage. The first thing to consider is the cost tradeoffs. Va coverage has $0 monthly premium and almost $0 out-of-pocket costs except for prescription drugs which by law a considerably lower than commercially available plans.

    Your fair share premium, lets say $90 for a Covered Ca policy would be due monthly, but on top of that you will have out-of-pocket expenses when you use your benefits. An enhanced Silver Plan on Covered California will cover 70% to 94% of your medical expenses depending on your income. Let’s say you have a $10,000 medical expense, at best with 94% coverage, you would be on the hook for $600, at worst with 70% coverage, you would have to pay $3,000

    If you choose to cancel your VA coverage and enroll in a plan through Covered California, you can reapply for enrollment in VA health care at any time, but you should keep in mind that returning to the VA for health care enrollment will be based on eligibility factors at the time of their application, which may result in a denial of enrollment.

    Question: Some of our family are undocumented. Can they apply for Covered California health care?

    Answer: Immigrants who are not “lawfully present” are not eligible to purchase a health plan through Covered California; however, they may be eligible for coverage through Medi-Cal.

    Individuals who are not lawfully present may apply for coverage through Covered California for their lawfully present family members (such as a dependent child), who may be eligible for coverage through a Covered California plan or through Medi-Cal.

    Additionally, Covered California encourages any U.S. citizen or person who is lawfully present to apply for health care coverage through Covered California even if they have family members in their household who are undocumented or not lawfully present. Families with mixed immigration status can still apply for health coverage through Covered California.

    How to Renew Medi-Cal?

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    Question: My son is on Medi-Cal. What do I have to do to make sure he is renewed for 2017?

    Answer: Medi-Cal coverage is renewed throughout the year on the anniversary of the person’s enrollment in Medi-Cal. This means that a Medi-Cal renewal may not coincide with a Covered California open enrollment. Your son will receive a Medi-Cal renewal form from his local county human services agency. Complete this form and mail or fax it, along with any needed information the county requests, to your local county human services agency. You can also renew by visiting your county human services agency in person or by calling the phone number on the renewal notice.

    Question: I got a renewal notice from Covered California last week. It seemed to say that I don’t have to do anything and I will be renewed. Is that correct? What if I want to change plans?

    Answer: Yes. If you take no action to actively renew or change plans, you will automatically be renewed, 30 days after the date on your renewal notice, into the same plan you had in 2016. During open enrollment, you have two options to renew your health plan through Covered California: (1) If you want to keep your same health plan and coverage, Covered California will automatically check your information with federal government data sources and renew your coverage with the same health plan. You will be automatically renewed in the same health plan, if it is still available, with the appropriate tax credits, as long as you have filed your taxes the previous year. (2) To make changes to your coverage or switch health plans, either log on to your Covered California online account or contact your Certified Insurance Agent or call Covered California at (800) 300-1506 to make the change. If you decide to shop for a new plan, be sure to log into your account prior to using the tool, so your selection can be saved. If you add a plan to your shopping cart before you are signed in, your selection will not be saved.

    Question: Can you give me a quick outline of the benefit changes in Covered California plans in 2017?

    Answer: In 2017, Covered California health plans have improved benefit designs by reducing the number of services that are subject to a deductible. People in Silver, Gold and Platinum plans will pay a flat copay for emergency room visits without having to satisfy a deductible. Urgent care costs in every plan will be same as the primary care visit. People in Silver 70 plans will save as much as $55 on an urgent care visit and $10 on a primary care visit. Even people in the most affordable Bronze plans can now see their doctor or a specialist three times before the visits are subject to the deductible.

    Question: I will be eligible for Medicare starting in January. Can I stay in Covered California and keep gettin my subsidy instead or as a supplement to Medicare?

    Answer: If you are eligible for Medicare, you cannot purchase a Covered California health plan and get premium assistance. However, if your income is low you may still be eligible for Medi-Cal. The Covered California application automatically checks to see if consumers qualify for Medi-Cal. If you qualify for both Medicare and Medi-Cal, Medi-Cal will help pay for Medicare premiums and cost-sharing requirements. Medi-Cal may cover additional benefits, such as dental services, nursing home care, and personal care services. Medi-Cal may also provide extra financial assistance to help with the cost of Medicare Part D prescription drug coverage.

    Question: I received notification from Anthem Bluecross that an 36% increase is coming for 2017 1/1/17, I don't understand why such an increase, could you possible know why?

    Answer: There are two primary reasons. (1) Since 2014, the federal government has reimbursed health insurers who enroll higher-cost consumers in their plans through a reinsurance program. In 2017, those reimbursement payments will end. (2) Insurers now have a better understanding of the risk pool. In previous years many insurers set premiums too low to cover their actual costs. Even so, 2017 premium increases in California are lower than in most other states.

    Question: I'm applying for myself and my husband. I currently have a job and indicated income for myself on the application, however my husband is temporarily unemployed. Even though I didn't claim any income under his name, after I submitted my application I was asked to submit proof of income for him.From the look of it, my application won't be considered "complete" until all documents have been submitted, so I'm really not sure what to do.

    Answer: Generally you have 90 days to submit the proof of income. My guess is that the eligibility screen is locked up due to the reason code chosen during the Special Enrollment Period, not due to the need to show proof of income. I strongly recommend that you find a Certified Insurance Agent to help you with the application. It doesn't cost you anything and will save you considerable grief.

    Question: I lost my job in Nov 2015. I projected our 2016 income to be $33,000 which includes my husband's annual social security of $13,000. My unemployment ran out in July in which I collected a total of $10,800 making our gross 2016 income of $24,000. I have yet to get another job and have not had an interview. With tax exemptions our adjusted gross income will be below 138% of FPL. We have Silver PPO. How will this affect the ACA subsidies I've received to date and premiums I paid?

    Answer: In 2017, you will be eligible for Medi-Cal. You will not have to pay back any of the advanced premium tax credits you received in 2016.

    Question: I currently have insurance through Covered California (signed up Dec 2015). I have KP Silver 94 HMO plan. I'm trying to predict if I'm going to be dropped into MediCal based on my tax return for year 2015 which I'm close to completing and will be turning in soon, prior to extension deadline of Oct 17. It looks like my AGI will be around $17,480. Will I still qualify for Covered California...especially in consideration of any new changes to income qualifications during the upcoming enrollment period this fall 2016?... ...or will I be dropped into Medical?

    Answer: In 2017, the annual income cut-off for Medi-Cal eligibility for a one-person household is $16,394.40, a two-person household is $22,170.60, a three-person household is $27,820.80, and a four-person household is $33,534.00.

    Question: What if I don’t have health insurance?

    Answer: You may have to pay a tax penalty if you are deemed able to afford health insurance. The “shared responsibility payment” is a new tax penalty that Americans have to pay if they can afford health insurance but choose not to buy it. It’s called a shared responsibility payment because everyone in the United States is now required to be part of our health insurance system - buying health coverage for themselves and their families rather than relying on others to pay for their care. Those who don’t buy health insurance in 2017 may be subject to the penalty, which is $700 per adult and $350 per child, to a maximum of $2,085. or 2.5 percent of their income, whichever is greater.

    Question: My friend has Anthem Blue Cross through Medi-Cal. How does that work?

    Answer: Medi-Cal offers 22 managed care health plans, some of which are also offered by Covered California. Your choices depend on the county in which you live. Most counties offer commercial plans, including Anthem Blue Cross, Kaiser, Health Net, and Molina, as well as local not for profit health plans like L.A. Care. In some counties, one public plan is available and all Medi-Cal members are enrolled in that plan. An example is Cal Optima health plan in Orange County. Every county’s Medi-Cal plans provide the same high quality care to Californians at low or no cost, no matter where you live. The directory of Medi-Cal health plans will give you more information about your specific county.

    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.


    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.

    Reside in Two States?

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    Question: I live in different states during the year. My summer home is in Michigan; my winter home is in California. Where do I sign up for health coverage? And if I sign up for a plan in one state, how do I find in-network health providers in the other state?

    Answer: You don’t have a choice. You must buy coverage in the state where you officially reside. Your official state of residence is where you spend most of the year, where you pay taxes, where you register your cars, or are registered to vote. For instance, if you are buying coverage in California, but spend a significant amount of time in Michigan, you should buy a PPO plan from Anthem Blue Cross or Blue Shield of California, so that you can find participating in-network providers from Blue Cross Blue Shield of Michigan when you are there.

    Question: We buy health coverage from Covered California but our son will attend college in Arizona. We want to cover him on our policy. Can we do that?

    Answer: Yes, you can. One key consideration, though, will be whether he can access in-network services while he is away at school. In California, only Anthem Blue Cross or Blue Shield of California PPO Plans will give in-network access out-of-state. Both of these carriers offer “Blue Card” benefits outside of California in any state with a Blue Cross Blue Shield Association carrier (36 states including Arizona). To access care, your son would select any BCBS of Arizona provide and his health plan benefits would be the same as if he were in California. All PPO plans also have out-of-network benefits available when in-network providers are not accessible, but the members’ out-of-pocket expenses will be much higher out-of-network.

    What is SLCSP on Form 1095-A?

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    Question: I have an anthem bronze ppo plan for which I am paying 100 percent of the monthly premium (no subsidy). Reading about the 1095a statement, I NOTICED a column called slcsp. WHAT IS THAT, AND DOES IT APPLY TO SOMEONE IN MY SITUATION? I DON'T QUALIFY FOR ENHANCED SILVER BENEFITS. A WEBSITE I looked at said if the column reads 0 IT IS INCORRECT. I ASSUME IT WOULD READ 0 SINCE I did not get any enhanced silver plan benefits.

    Answer: The second-lowest cost silver plan (SLCSP) that applies to you is usually found on your Form 1095-A. If you receive premium assistance during the year, you need to know the SLCSP to figure out your final premium tax credit for the year. If you did not receive any premium assistance during the year, the advance premium tax credit field should be $0. The The SLCSP field may be zero too, since it doesn't matter.

    Question: I am receiving a subsidy in 2016 that reduces my monthly health insurance premium. I want it to continue in 2017. Do I have to do anything?

    Answer: You should return to Covered California to update your application for financial assistance. You can do this on your own, either by logging in to your account on the web site or by calling your agent to help you do it. If you don’t have an agent, you can call the Covered California Call Center at 800-300-1506.

    If you don’t update your application by December 15, Covered California will automatically adjust the amount of your 2016 premium tax credit for 2017. The automatic adjustment will be based on a rough inflation adjustment to your most recently reported income and on changes in the cost of the benchmark Silver Plan in 2017.

    Updating your application is a good idea because the automatic adjustments made by the Covered California may not fully reflect your situation. It is important to report any changes in your household income and your family status so your eligibility determination will be up to date and so the amount of financial assistance you receive in 2017 will be as accurate as possible.

    Question: I filed my 2015 federal income tax return but didn’t realize I needed to include Form 8962. Can I still receive premium subsidies in 2017?

    Answer: If you received advance premium tax credits in 2015, you must reconcile your tax credit amount 2016 year in order to continue receiving advance tax credits next year. Remember, the subsidy you received in 2015 was based on your estimated income for that year. The law requires you to file a tax return at year end and reconcile your estimated income with your actual income. If you had under-estimated your 2015 income, you might have repay some of the 2015 tax credits that you received. If you had over-estimated your 2015 income, you could claim additional tax credit when you filed your return. Either way, the IRS requires this annual reconciliation. People who fail to reconcile the premium assistance they received last year will not be allowed to continue receiving advanced premium tax credits next year.

    To continue receiving APTC in 2017, if you haven’t yet filed a 2015 return with a completed Form 8962, you should do so as soon as possible. To do this, you will also need Form 1095-A, which should have been sent to you by Covered California in January with information about your 2015 APTC. If you don’t have form 1095-A, you should call the Covered California Call Center at 800-300-1506 to obtain a copy. As soon as you file your 2015 tax return and completed Form 8962, contact Covered California to update your account to reflect this change.

    Social Security Income and MAGI?

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    Question: Are annual social security benefits counted towards MAGI, including the untaxed portion (as far as CC is concerned)? Sometimes, depending on income only a portion of my wife's SS is considered taxable.

    Answer: MAGI (modified adjusted gross income) includes your adjusted gross income, tax-exempt interest income and non-taxable Social Security benefits. Some people who get Social Security benefits must pay federal income taxes on up to 85% of their Social Security benefits. If your income is less than $25,000 for individual tax filers or less than $32,000 for joint income tax filers, you pay no tax on your Social Security benefits. If you are married and file a separate return, you probably will have to pay taxes on your benefits.

    Question: My projected income was over 400 percent of the fpl. However, it will wind up being lower. When I initially signed up last year, I think I chose to get a subsidy in one lump sum. Obviously, I have not gotten anything, because my projected income is high 83k.Is there a way to look at the website and see what I chose. I WOULD RATHER NOT CALL THEM, FOR FEAR THEY WOULD ASK ME ABOUT INCOME CHANGE. Do I need to worry about what I chose, since my projected income disqualifies me for aptc. Would I have been given a subsidy option with my income that High? I can't remember exactly what I did when signing up. Plus, I did call to report an income change, and the person on the phone asked me to break Down my income from various sources by month, so I am not sure if something might have been changed. My projected income was still higher than the 400 percent. Should I just not call them and leave it for reconciliation at tax time next year.

    Answer: If you opted for premium assistance in one lump sum, you are in good shape. If you qualify for a subsidy, you'll get it when you file your taxes. if you were not due any premium assistance, there's nothing to repay. Logon to your Covered California online account, from the homepage select "Summary" and then select "Change Premium Assistance Amount" and the next page you see will explain which payment option you have - monthly or lump-sum. If it's not what you want, you can change it.

    Question: I will be applying to Medi-Cal in September of 2016. I do not know if I should provide ONLY my information in the application or my parents information AND my information in the application. I was claimed as a dependent when they filed taxes on Feb. 2016 and when they file taxes on Feb. 2017 I will NOT be claimed as a dependent. In other words, I will be independent.

    Answer: Apply through Covered California even though you know you are eligible for Medi-Cal. The online application process at CC is much easier than applying at Medi-Cal. Since your parents will not be claiming you as dependent for the 2016 tax year, apply as an individual. You will not provide any information regarding your parents or their income.

    Question: If I wish to cancel my covered ca. Plan at the end of the year, can I do it easily on the website or do I have to call them. Is it as easy as clicking a cancel membership button and indicating the desired date of cancellation?

    Answer: To cancel coverage online, logon to your Covered California account and find the link that reads "Terminate Plan". If you are uncertain, contact the Covered California service center for assistance at 800-300-1506.

    Question: My Anthem Blue Cross PPO plan through Covered California won’t be offered again in 2017. Now what do I do? * Answer*: During Open Enrollment, you can shop for a different plan either with Anthem or any other insurance company available through Covered California. Or you can do nothing and Anthem will automatically enroll you in another plan it offers that is similar to what you had this year. You will receive a notice from AQnthem that describes that alternative plan and how it differs from your current plan.

    Question: I’m leaving my job and will be eligible for COBRA. Can I shop for coverage and subsidies on the Marketplace instead?

    Answer: Yes. Leaving your job and losing eligibility for employer-based health coverage will trigger a special enrollment period (SEP) that lasts for 60 days. You can apply for Covered California health plans and (depending on your income) for premium tax credits (subsidy)and cost sharing reductions during that period. However, if you enroll in COBRA coverage through your former employer beyond the 60-day SEP opportunity, you will need to wait for the next Open Enrollment period to voluntarily cancel COBRA and enroll in a Covered California plan.

    What are Catastrophic Plans?

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    Question: I just lost my job and I’m buying Covered California. I notice “Catastrophic Plans” that look even cheaper. What are those and can I buy one if I want?

    Answer: Catastrophic plans have the highest cost sharing - deductible and coinsurance. Not everybody is allowed to buy catastrophic plans. They are only for adults up to age 30, and for older people who can’t find any other Covered California policy that costs less than 8.13 percent of their income. In 2016, Catastrophic plans have an annual deductible of $6,850 ($13,700 in family plans). You will have to pay the entire cost of covered services (other than preventive care) until you’ve spent $6,850 out of pocket; after that your plan will pay 100 percent of covered services for the rest of the year.

    Question: I don’t have a green card yet. Can I buy a California Cover health plan?

    Answer: If you are not a U.S. citizen, a U.S. national, or an alien lawfully present in the U.S., you are not eligible to buy a plan through Covered California. However, you can shop for health insurance and buy insurance directly from one of the health insurance companies offering off-exchange plans. Insurers outside of the Covered California are prohibited from turning you down based on your health status or your immigration status and must follow generally the same rules as plans in Covered California.

    Question: I am moving to California next month. Will I qualify for a Special Enrollment Period of 60-days after I move?

    Answer: The feds just passed a new rule affecting permanent moves. Starting July 11, 2016, if you move to another state, you will be eligible for a special enrollment period only if you had previously had been enrolled in other coverage. The new rule is that you 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.

    Should I Buy in CA or NV?

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    Question: I live in California, but drive across the border every day to work in Nevada. What state should buy coverage?

    Answer: Generally, you should buy coverage in California, the state where you live.

    Question: I just moved from Arizona to California. I am staying with a friend until I find a job and can get settled, but I need health insurance right away. How can I establish residency in CA?

    Answer: The fact that you don’t have a permanent home should not affect your eligibility in California as long as you are currently residing here and intend to remain here. Covered California will accept an applicant’s statement regarding their state of residence without other verification. In situations where other information available to Covered California suggests that the applicant may live in a different state, it may ask for verification. This could happen in your case if records available to Covered California show your prior address in Arizona. You will need to provide a statement or other documentation showing that you have moved and now intend to reside in California. Also note that, starting July 11, 2016, to qualify for a special enrollment due to a permanent move, you must also have had been enrolled for at least one day, during the 60 days leading up to your move, under other minimum essential coverage, such as under a job-based health plan, another Marketplace plan, or Medicaid.

    When Does My Coverage Renew?

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    Question: I signed up for a Covered California health plan in April after I lost my job. Does my coverage get renewed in January or at the anniversary date next April?

    Answer: All Covered California health plans provide coverage based on a calendar year. Coverage under your current plan continues through December. Open Enrollment (November 1, 2016 through January 31, 2017) is the time to renew coverage. You can return to the Covered California website or call Covered California to renew coverage yourself so that it continues in 2016. If you don’t act to renew your coverage by December 15, 2016, they will automatically renew coverage for you. If your coverage is automatically renewed, but you would still like to change plans, you can still do so until the last day of Open Enrollment, January 31, 2017.

    Question: How do I prove that I had coverage?

    Answer: You should receive a form 1095-B from your health plan or insurance company indicating the months in 2016 when you were covered under the plan. If you were enrolled in family coverage, Form 1095-B will indicate the names of all family members who were covered with you under the plan. A copy of this form will also be reported to the Internal Revenue Service.When you file your tax return for this calendar year, you will have to enter information about your coverage on the return.

    Question: Do I need to be on the same plan as my spouse?

    Answer: No. There is no requirement in the Affordable Care Act that spouses be on the same plan. But if you want to qualify for a premium tax credit, or subsidy, to lower the cost of your insurance, be aware that subsidies are based on your total household income level. So even though your spouse will not be covered by the subsidized insurance plan, his or her income will be included when determining the level of subsidy you are eligible for.

    Question: I can barely pay my Anthem Blue Cross monthly bill now and that’s with a subsidy. I need the health insurance since I have diabetes.

    Answer: If your current plan becomes unaffordable after the 2017 rate increase, you have a couple of options available to you without losing your health insurance, but both options involve trade-offs.

    1. If you have a Silver or higher tier plan, you can downgrade, for example from Silver to Bronze. If you stay with the same insurance carrier, Anthem Blue Cross in your case, you will stay in the same provider network of doctors and hospitals. The trade-off is higher out of pocket medical expenses because of higher deductibles and copays.
    2. Shop a cheaper Silver Plan with one of Anthem Blue Cross’s competitors. For example, you may find that you can change to an 2017 Oscar Health Silver EPO plan at the same rate as you had for Anthem Blue Cross Silver PPO plan in 2016. However, you will have to check carefully to make sure your doctors and other providers are in the Oscar health network. The trade-offs in this example are loss of out-of-network coverage in switching from PPO to EPO plans as well as the network considerations.

    If you do not already have a Certified Health Insurance Agent now is the time to get one. Your agent can help clarify your options, guide you through the application process, and if subsidies are involved, make sure you get the best outcome possible.

    Question: Will I be able to keep the same plan in 2017 that I have this year?

    Answer: Probably. It depends on where you live. United HealthCare, after just one year of limited participation in Covered California, is pulling out in 2017. Other plans, including Oscar, Molina and Kaiser Permanente, are expanding into some regions. But even if you can keep your plan, a rate hike could put it out of your financial reach. To find a better price, more Covered California enrollees will have to switch plans, which means they could lose their current doctors. According to Covered California, about 80% of consumers will be able to pay less than they do now or cap their rate increases at 5% if they shop around and buy the lowest-cost plan at their current benefit level. Now more than ever, California health care consumers will benefit from the assistance of a Certified Insurance Agent to help them find a plan they can afford that includes access to their doctors and other health care providers.

    Question: If I am getting premium assistance and the premium on my plan rises by 20% next year, does that mean I’m going to have to pay 20% more out of my pocket than I did this year?

    Answer: Not necessarily. As premiums rise, so do tax credits, which means that, all things being equal, the premium assistance will absorb at least some of the rate hike. But you won’t be able to research your specific situation until early October. Because the Covered California online shopping tool won’t be updated for 2017 rates until then. If you already have a Covered California plan, you will receive a notice from Covered California in October explaining how much your current plan’s premium will change and what your tax credits — if any — will be for next year. You can keep the same plan at the new rate or switch plans during open enrollment.

    Medicare Mandatory at 65?

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    Question: I am currently insured with Blue Shield thru Covered California. I will be 65 in December. Must I choose Medicare and give up my current plan? I am retired and receiving social security benefits.

    Answer: If you do not sign up for Medicare when it is offered (age 65 birthday month), you will no longer be eligible for a subsidy through Covered California. Unless you have money to burn, sign up for Medicare.

    Question: I recently quit my job. I enrolled in a Covered California plan with premium assistance. My old company offered me COBRA coverage but it’s much more expensive. Does an offer of COBRA coverage someone from receiving a premium tax credit?

    Answer: An offer of COBRA coverage does not prevent you from being eligible for premium tax credits. You could not receive premium tax credits if the you had actually enrolled in COBRA, then dropped it in favor of Covered California coverage. If a former employee actually enrolls in the COBRA plan, it is considered minimum essential coverage and becomes a barrier to receiving premium tax credits. People who are enrolled in COBRA coverage generally must wait until the marketplace open enrollment period to drop that coverage and enroll in a Covered California health plan with premium tax credits.

    Question: I was offered health insurance by my employer, but missed the open enrollment period. Can I still keep my Covered California coverage with a subsidy?

    Answer: Probably not. If the coverage offered by the employer was “affordable” and met minimum value, that employer offer still counts as an offer of minimum essential coverage that prevents a person from being eligible for premium tax credits. A person in this position may enroll in marketplace coverage, but will be ineligible for financial help.

    Self-Employed Subsidy?

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    Question: Can someone who is self-employed qualify for subsidized coverage?

    Answer: Yes. A person who is self-employed can enroll in coverage through Covered California and potentially qualify for premium tax credits.

    Question: My company gives employees a certain amount each month for coverage instead of providing health insurance. Ami I still eligible for a subsidy?

    Answer: Yes. Some employers offer a cash “stipend” instead of offering health insurance. This cash stipend is taxable income, similar to a bonus or a pay raise, and cannot be conditioned on the purchase of health insurance. If the employee uses the stipend to purchase a marketplace plan, the payments will be made on an after-tax basis and will not be made through payroll deductions. This type of employer assistance does not disqualify a person from receiving premium tax credits. Employers cannot reimburse employees for the cost of their marketplace premiums using pre-tax dollars.

    Question: I have just started a new job and was looking forward to having a company health plan, but what they are offering me is not a good deal. I can’t afford it. Can I stay with my Covered California plan?

    Answer: Employee-only coverage is considered to be affordable if it costs less than 9.66 percent of household income in 2016. If employee-only coverage is affordable, then any offer of coverage for dependents is automatically considered affordable as well. This means that coverage offered by an employer to dependents may cost more than 9.66 percent of income and still be deemed affordable as long as the employee-only coverage costs less than 9.66 percent of income. In such cases, the dependents are not eligible for a premium tax credit because they are considered to have affordable employer-sponsored coverage.

    Question: My wife and I currently both have the Blue Cross Enhanced Silver 87 plan that we pay $129 a month for based on 2016 projected earnings of $30,130. What is the penalty for us if our earnings would be say $33,000 for 2016? If we exceed by $100 is the penalty the same as if we exceed by $1000?

    Answer: First of all, there is no "penalty" for unexpected fluctuations in annual income. If you received more premium assistance than you were entitled to based on your income, the IRS will make the adjustment retroactively on your tax return for that year. The premium assistance due for an income of $33,000 versus $30,130 would be about $400 less for the year. You would pay that back through an additional $400 in federal income tax.

    Question: I am eligible for a subsidy but would rather not take it. The amount would be small and not worth the time, trouble and stress getting paperwork together. Can I choose not to take it, and, if so, how do I do that?

    Answer: To avoid receiving premium assistance on a monthly basis ask Covered California to change your payment type to a "lump sum" at the end of the year. That way, you'll get any subsidy you may be due when you file your tax return and if you are not due any subsidy, you will not have to pay anything back.

    How to Cancel COBRA?

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    Question: I want to cancel my COBRA and enroll in a Covered California plan. How much lag time should I expect from time of application to activation of the new coverage?

    Answer: Applicants who are eligible for a Special Enrollment Period (SEP) due to loss of coverage can apply right down to the last day within a 60 day window of loss of coverage and the new Covered California coverage is effective the first of the following month. However, in your case you do not qualify for a SEP until the expiration of your COBRA coverage. You can voluntarily cancel your COBRA during the annual Open Enrollment Period (Nov-Dec). During open enrollment, applications received on or before 12/15/2016 will be effective 1/1/2017.


    Answer: It sounds like you may have accidentally clicked 5 instead of 4 household members at the beginning of app. If that's the case, you should go back to the beginning and fix that. The next place to check is the household relationship page and make sure that the parent/child, husband/wife section is accurate. Are you aware that a Certified Insurance Agent can help you with this at no cost to you. In addition to getting you over the land mines in the application, a knowledgeable agent can be a big help in selecting the right plan and making sure your doctor in in the network for the plan you select. (BTW check your keyboard. Your caps lock key appears to be stuck :)

    Question: I read that California now limits what Medi-Cal can recover from beneficiaries estates?

    Answer: Like the majority of Californians, I have long opposed California’s right to the seizure of assets, after death, of people who had received health insurance coverage through the state’s Medi-Cal program. While seldom enforced, it was a cloud over California’s 11 million Medi-Cal beneficiaries. Now, California’s $122 billion general fund budget includes money to dramatically limit the practice to recover money only for nursing home care.

    Question: I heard the my Blue Shield grandfathered health plan is being cancelled. How will that work?

    Answer: Starting this week, Blue Shield will begin sending notices to 2,062 grandfathered plan subscribers to inform them that their current Blue Shield of California health plan will no longer be available after December 31, 2016. The plans affected include Active Start, Vital Shield, and Shield Spectrum Plans. Blue Shield will automatically enroll these subscribers into an ACA-compliant plan on January 1, 2017. It is important that subscribers check to see if their current doctors are in the PPO network for the new plan. Subscribers who find that the new plan is unacceptable can select a different plan during the open enrollment period. Those who fail to do so, will have a Special Enrollment Period that extends from January 1, 2017 to March 31, 2017 to select another ACA compliant plan for 2017.

    Question: My husband and I are now legally separated - he does not have insurance but I do under my employer who does not provide for family ins. Does my husband still have to include my salary to get his own insurance now that we are legally separated?

    Answer: If you are legally separated under a final decree of legal separation you are considered single by the IRS and California state law. Therefore, your husband can apply for Covered California based on his income alone. You must both file your 2016 tax return as either single or head of household - not married filing jointly.

    Question: I did not know that I was signing my husband up for the HSA PPO, I thought I was signing up for a regular Bronze PPO with covered ca. It's June, and I haven't opened a special HSA account at the bank, but he hasn't used his insurance yet either. What am I supposed to be doing?

    Answer: It is not required that you open an HSA account just because you have purchased an HSA compatible health plan. But if you want to enjoy savings and tax benefits you should open an account now. Most banks offer HSA accounts. It's no more trouble than opening a checking or savings account. If you can open your account by July 1st, you will accrue 6 months of eligibility for the 2016 tax year. The annual contribution limit for an individual is $3,350 and for a family: $6,750. You can add another $1,000 annually as a "catch-up" benefit if you are over 55 yours old. Again, for 2016 your maximum contribution is one half of the annual limit. You can make contributions monthly or wait until the end of the year. Actually you have until April 15, 2017 to make your 2016 contribution. If you are interested in learning more about HSAs, google "health savings accounts".

    What is the Grace Period?

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    Question: I thought Obamacare made the grace period 90 days? I have been fighting with Blue Shield after they cancelled my coverage for non-payment. I was well within 90-days. Is that legal?

    Answer: The ACA law requires a 90-day grace period for on-exchange members receiving subsidies for their health plan. For off-exchange members not receiving subsidies, the grace period is 30 days. If you are on a 90-day grace period and do not pay 100% of your total premium due, the grace period does not start over. Example: Let's say you owe $600.00 for March and April. In April, you pay one month's premium for the month of March. In this scenario, you are still in the 90-day grace period with 30 days left until you are cancelled. The 90-day grace period will start over once you have paid 100% of the amount due.

    Question: I made more money than I estimated, so I will have to pay back some of the subsidy I received. My question is about the cost-sharing benefits I received with my Silver 87 plan. Will they charge me for that too.?

    Answer: Covered California enrollees at the lower end of the income spectrum receive cost-sharing reductions (CSR) in addition to premium assistance. CSR benefits include lower deductibles for medical and prescriptions drugs and lower out-of-pocket maximums. Currently the IRS can recover premium assistance overpayments, but not CSR payments. That may be changing. We recently noticed that some Covered California accounts are beginning to show a CSR monthly dollar amount - see CSR Amount Sample.pdf. Once a dollar amount is established, can recoverability be far behind?

    Question: When I purchased my health insurance through Covered California I did not apply for financial assistance. However I think I do qualify, how can I find out and how do I apply for past months.

    Answer: You can find out if you qualify for premium assistance by using Covered California's Shop and Compare Calculator. If you discover that you are eligible for a subsidy, you may qualify for a Special Enrollment Period which would allow you to apply for assistance right now. You cannot recover assistance for past months when you did not request it. This is not a change you can make online. You will have to call Covered California at 800-300-1506.

    Question: I purchased a 2016 Anthem Silver 70 PPO plan offered by Covered California in large part because the brochures describing the plan said: "Our preferred provider organization (PPO and Tiered PPO) plans also include extra coverage for non-emergency care when they visit participating BlueCard providers in the U.S. or travel abroad. They can see any provider they wish, but they'll pay less out of pocket when they use BlueCard providers and hospitals." When I called Anthem about getting non-emergency services outside CA from a BlueCard provider, they told me I have no coverage outside CA (whether in-network or out-of-network) unless it is an emergency or for urgent care. I thought that changed with the 2016 policies? Am I missing something?

    Answer: You got the wrong answer from Anthem Blue Cross. It happens. Here's how to use your BluCard. Let's say you are in New York City for a meeting. You have medical symptoms - not an emergency, but you want to see a doctor. Do a Google search for "Blue Cross Blue Shield New York City". Google will provide a link to the Empire Blue Cross Blue Shield website. You can use their online "Find a Doctor" feature or call them for names of in-network doctors nearby. As long as you use an in-network Empire Blue Cross Blue Shield provider, you'll be covered as if you were in California.

    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.

    HSA Eligibility?

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    Question: I have an HSA and a high deductible plan, but found out that if you have any co-pays, you're not eligible to use them. I have copays for the first three office visits, but am not covered for anything else until the deductible is met. I cannot find an HSA compatible plan in California anymore. Am I not eligible for an HSA because of these three copays?

    Answer: The high deductible plan you currently have is not HSA compatible. You will have to switch plans at the next open enrollment period in order to make contributions to your HSA starting in 2017. Here are 3 HSA compatible plan options: Anthem Bronze HSA PPO, Blue Shield Bronze 60 HSA PPO, and Kaiser Bronze 60 HSA HMO.

    (email: jaynedoe13@yahoo.com)

    Question: When I contact a doctor to see if they take our insurance and tell them we have Blue Shield PPO, they say yes. Once I give them my subscriber number they say, "Oh, we don't take Covered California plans." Since my understanding is that all plans on exchange mirror those off exchange, I have asked the insurance company why certain doctors refuse. They said they can't force doctors to take the plan. But, if the exchange plan pays exactly the same as the off exchange one, why would there be so many refusals (and trust me, there are a lot!). It has begun to feel like a plan purchased on exchange (without subsidy at this point) is like a welfare plan that no one wants to touch. Any ideas? Since we cannot switch to another plan at this point (no special circumstance) it has become quite irritating to be shoved off like we have the plague! Thanks!

    Answer: When your doctor says they take Blue Shield PPO, that means they are included in the Blue Shield PPO networks for employer-based health plans for the most part. They get higher reimbursement rates from those plans. Covered California fosters competition between authorized carriers to yield the lowest premium rates possible in the current marketplace. In order to compete, the carriers lean on their providers (doctors and hospitals) to accept ever lower reimbursement rates. Many providers refuse to participate in Covered California carrier networks resulting in "narrow networks" with fewer provider choices. Because 90% of patients are covered either by employer-based health plans or Medicare, doctors can opt of out Covered California with minimal downside to their practice.

    Question: I currently have individual health insurance with Covered California and receive a financial subsidy. I will be turning 65 in July 2016. I also have only 31 work credits with Social Security towards premium-free Medicare Part A. Accordingly, as I will not have the requisite 40 credits when I turn 65 this July for premium-free Medicare Part A, can I keep my existent Covered California plan and its financial subsidy?

    Answer: No. The law makes no distinction between premium-free and premium-required Part A enrollment, so all persons age 65 and older are supposed to enroll in Medicare. Those with less than the requisite 40 credits for fully insured status must pay the premium for Part A. In 2016, the Part A premium is $411. Part B premiums are a minimum of $122 per month. If you don't sign up for Part B when you're first eligible, you'll have to pay a late enrollment penalty for as long as you have Part B. Your monthly premium for Part B may go up 10% for each full 12-month period that you could have had Part B, but didn't sign up for it.

    Question: I was on Covered California with a subsidy. When I reported to Covered California that I am now pregnant, I was switched to Medi-Cal. I don’t want Medi-Cal because my doctor doesn’t take it. Can I get back on Covered California?

    Answer: Your problem is shared by thousands of other California women who reported their pregnancies to Covered California. It was triggered by a recent policy change in Medi-Cal eligibility. Covered California acknowledged the problem, blaming its computer system. That computer glitch will be fixed, but not until September. The computer system was immediately transitioning some low-income pregnant women into Medicaid. Usually, consumers are placed in either Covered California or Medi-Cal based on their income, with no choice in the matter, even though they can enroll in Medi-Cal via the Covered California website. But the rules are different for some pregnant women whose household income falls between 138 percent and 213 percent of the federal poverty level, or roughly $22,100 to $34,100 for a family of two. Under an October policy change, women who are pregnant at the time they apply for health coverage and fall into this income bracket will automatically be placed into Medi-Cal. Women in the income range who already have Covered California plans before they become pregnant are now supposed to be given the choice to remain in their subsidized plans — which have out-of-pocket costs such as co-pays and deductibles — or move to Medi-Cal, which is free. The idea is to allow them to keep their existing Covered California providers if they want. But the Covered California computer system wasn’t programmed to give them the choice, and some pregnant women were moved immediately into Medi-Cal. Covered California has trained its customer service reps to explain to pregnant consumers that reporting a pregnancy could trigger a switch to Medi-Cal. You can get your Covered California plan back, retroactive to the date you reported your pregnancy by calling Covered California’s customer service center at 800-300-1506.

    Question: Im on Cov Ca now but my employer just offered all of us employees new coverage. They are going to pay for most of it but its not as good as the coverage from Cov Ca that I have now and it will actually cost me a little more because I have a large subsidy. I was told that if my employer offered me coverage I couldn;t have Cov Ca and that if I kept it it was possible that I might have to pay back some or all of the subsidy that the state gives my family. I'm confused...should I cancel the Cov Ca and get on my company plan? I don't want to have to pay the IRS anything next year.

    Answer: Yes. You should cancel your Covered California coverage and sign up for your employer-based coverage. Once you have access to employer-based coverage, you are no longer eligible for a subsidy so you would have to pay back any premium assistance you received after that point.

    Question: I had covered California with kaiser for 2014 i cancelled it in Dec of 2014 since beginning jan1 2015 my employer was going to be covering me also through Kaiser. I received a letter from the IRS saying they could not finish my return due to being given an advance tax premium through the exchange. I didn't have covered California at all in 2015 and i received my 1095c from my employer showing me covered for the entire year how do i fix this?

    Question: Apparently. the IRS has received an erroneous 1095 from Covered California indicating that you received premium assistance in 2015. You need to respond to the IRS and tell them this. You also must contact Covered California and point out the error.

    Question: Can a school district force its classified employees to take out health insurance? If so, can the employee get help from the State of California to pay the premiums? My instructional aide was told that she MUST sign up for health insurance through our district. She is having a hard time living on what is left of her paycheck after all the required deductions. She is a single mother with one child. She works 6 hours per day for 180 days per year. I believe she earns about $13 per hour.

    Answer: This employee is eligible for Medi-Cal. Once she has Medi-Cal, she can opt out of her employer-based coverage. The school district must release her from their group coverage since she will have "minimum acceptable coverage" through another source.

    Marriage Causes Payback?

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    Question: I just got married in december 28 2015, my husband has his own insurance thru his employer, in 2016 i am covered by my husband, why am i being charged in our joint tax filing in 2015?

    Answer: You changed your tax status from single to married filing jointly for the 2015 tax year. As a 1-person household, you were eligible for premium assistance based on your income alone. Now your assistance is calculated on a 2-person household (even though your husband has employer-based coverage) and your joint income. You are paying extra tax to recover some or all of the premium assistance for which you are no longer eligible.

    Payback Entire Subsidy?

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    Question: I haven't filed my taxes yet because when I attempted to do so, I was told that I had underestimated my annual income, which meant that I owe an additional $750. It turns out that I was deemed eligible for Medi-Cal for the entire year of 2015. My caseworker and her supervisor found the mistake. Am I still going to be held accountable for paying back the IRS?

    Answer: If your actual 2015 income qualified you for Medi-Cal, you may have to repay a maximum of $300 for any premium assistance you received through Covered California.

    Can I Opt Out of the Subsidy?

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    Question: Can I opt out of the subsidy even if I qualify now or later? If I did, would I still have to prove income, report changes, etc. Does covered california provide such an option?

    Answer: There are a number of ways to apply through Covered California and opt out of premium assistance. (1) The very first question on the Covered California online application is: "Do you want to see if you qualify for free or low-cost Medi-Cal or tax credits with Covered CA?". If you respond "No" to this question, your income will not be considered and you will be ineligible for premium assistance. (2) If you respond "Yes" to this question, you can receive premium assistance if your income drops below the 400% FPL threshold. Most people should take this option, because they retain the option to receive premium assistance should your income drop. If you don't want to deal with having to repay premium assistance, report income changes, provide proof of income etc., here's what I recommend. When applying you can select and Annual Premium Assistance as opposed to the default, "Monthly Premium Assistance". The annual premium assistance option will credit any premium assistance due for the year on your tax return. That way you are not leaving any potential benefits on the table while minimizing income fluctuation reporting hassles.

    Unexpected Tax Consequences?

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    Question: We are husband and wife with $66,776 AGI. We are covered by Chinese Community health Insurance with monthly premiums of $1,629.79 and have a monthly advance payment premium tax credit totaling to $14,800. Now, this is what we owe the IRS. How are we being helped if at the end of the year we owe the IRS this much. Please help.

    Answer: ​With an AGI of $66,776 for a 2-person household, you are not eligible for any premium assistance. That is why you have to repay all the the advance premium tax credits you received for the year. Apparently you claimed a lower income on your Covered California application in the first place. To correct this, you must notify Covered California of your actual income.

    Back Payment to Medi-Cal?

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    Question: I am single with no dependents. I have been covered by Medi-Cal since March 2015. I had a surgery in October 2015. My AGI for 2015 would be around $19,000. Will I be subject to back payment of healthcare expenses? If so, how much?

    Answer: There is no penalty or repayment required for your previous Medi-Cal benefits. At $19,000 single-person household income, you are no longer eligible for Medi-Cal. You need to notify Medi-Cal of your higher income. They must release you before you can be eligible for Covered California coverage. You will be eligible for premium assistance and cost sharing reductions under Covered California​.

    Question: We have a family coverage that's through my employer. It's a PPO. Can we still have a covered CA insurance just for our son? There are certain therapy he needs that's not covered by my insurance.

    Answer: Your son cannot have a second health insurance plan, either Covered California or off-exchange, if he is already covered by your employer-based insurance plan. There is no option to make a change in his coverage at this time. Even if you were willing to pay full-price for health plan for your son, you would have to first voluntarily cancel his coverage under your group plan, but that would make him ineligible for a Special Enrollment in 2016. You will have to wait until Jan 1, 2017 to make that change.

    Question: Where can I find the 1095 form for my son who was covered under medi cal 2015?

    Answer: Each person who is or was enrolled in Medi-Cal will get his or her own Form 1095-B. Therefore, a household with more than one person covered by Medi-Cal may get a Form 1095-B for each person that had coverage. The 1095-B form will be mailed to you by March 31, 2016.

    Change Coverage Now?

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    Question: I chose Molina when I enrolled not knowing that Kaiser was available to me. I want to know how I can change from Molina to Kaiser. Is there a number I can call?

    Answer: You can only change plans during open enrollment. Your next opportunity to change you health insurance plan will begin in November 2016.

    Can My Son Go on Medi-Cal?

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    Question: I'm 52. My wife is 49. We make 60 thousand a year. My son is 19 and he live in our basement but is never home. He files his own taxes and claims himself. He works full time but would be on medical if our income was not added to covered cal. Does he have to pay for insurance or can he file medical by himself.

    Answer: ​Yes. He can apply for Medi-Cal by himself. Be aware that once you drop him from your Covered California account you become a 2-person household and your subsidy will be less than it was as a 3-person household given the income is the same.

    Question: I'm in an odd situation where I stopped working around August of last year to return to school, BUT I do try to get some work in during breaks. Since then it's been a non-stop cycle of "submit proof of income">submit last pay stub>"welcome back". What triggers these requests?

    Answer: Submitting your last pay stub doesn't really satisfy Covered California (even though they list it as an acceptable form of proof of income). They'll keep requesting proof of income until they get an easily verifiable form of proof such as your last tax return, W2 income, unemployment insurance, or disability income. Self employed income and "other" income such as rental, stocks, 401k etc almost always trigger the proof request. In addition, Covered California has access to IRS records, so if your income estimate for 2015 was more that 10% higher or lower than your 2015 tax return AGI (line 37 of 1040), you will be required to provide proof of current income again.

    Question: I provide more than 50% support for my friend/roomate, which means I can now claim her as a dependent on my taxes. We dont want her to loose her insurance, she cant afford her own. If I claim her as a dependent on my taxes would she then have to include me on the household number and my income information for her Covered CA health insurance application?

    Answer: Your friend can file a tax return, but not take a personal exemption (Line 6A for IRS Form 1040). That way you can claim a dependent exemption for her on your tax form without affecting her eligibility. She must complete her Covered California enrollment application as a single person household using her income only.

    Question: What is the penalty for not having any health insurance?

    Answer: In 2016, the penalty is $695 per adult and $347 per child up to a family cap of $2,500 or 2.5% of household income, whichever is greater. In 2015, it was $325 for adults, with a $975 maximum or 2% of household income. Kaiser Family Foundation predicts that in 2016, average penalties will increase, on average, from $1,177 to $1,450 per household. According to Peter Lee of Covered California, “The bigger penalty could be showing up in the emergency room and walking out with a bill in the tens of thousands of dollars,”.

    Question: I started Covered CA enrollment on 1/27/16, but got hung up on credit freeze, or submitting Documentation. Will finish ASAP, but need a few more days to finish. Can I get a few more days to finish?

    Answer: You have until midnight Sunday January 31st to finish your Covered California application yourself. But even if you get stuck and can't get it done by then, We'll get it done for you in overtime. That's right, you can have until midnight Saturday February 6th to finish it provided you use a Certified Insurance Agent or a Covered California Representative to complete it for you.

    Question: Can I apply by myself for Covered CA even if my parents claimed me as a Dependent? I am 21 and do not live at home with my parents, yet I did not make enough to be independent.

    Answer: Yes. Apply as a 1-person household and use your own income projection for 2016. You will have to file a tax return for the 2016 tax year, but you must waive the personal exemption. That way your parents can continue to claim your dependent exemption on their return.

    Question: Our medical insurance has been through my husband's work, and he is retiring April 1 (with no retirement benefits). He is over 65, but I am 59, giving me 6 years before Medicare. I've run the numbers, and we won't be eligible for subsidies. It seems I should purchase insurance on the open market through an insurance company's individual plan. Am I missing something; should I consider going through Covered California? I thought the only reason was to get financial help with the monthly premiums, and can't see a reason otherwise. If I should go through Covered California anyway, please explain why.

    Question: If you are not within the income range for a subsidy, there is no compelling reason to apply for coverage through Covered California. Some might argue that you may as well apply through CC now just in case you are eligible for a subsidy later. That way you could simply adjust your income in your online CC account and become eligible for subsidies immediately. However you could complete your CC application at that point where you income drops. It would take just a few more minutes to do it then. Purchasing an off-exchange plan directly from the insurer also offers some plan designs not available on Covered California. Finally, you don't have to disclose your personal IRS history to the insurer in a direct purchase as you would with Covered California.

    How Can I Get My Form 1095-A?

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    Question: How can I get my 1095-A form to do my taxes.

    Answer: During the month of January 2016, Covered California mails out the IRS Form 1095-A to all who received premium assistance in 2015. Covered California also makes the 1095-A forms available for download from the insured’s online account. If you know how to log on to your California account, do so. Then, from the home page, click on the Summary box. Then from the left margin menu, select Documents and Correspondence. If your 1095-A is available now, you’ll see it listed as CalNOD62AIRSForm1095A. Click on view and print or save the form. If you’ve given it time, (let’s say it’s February 15th and you have not received it) and you have no idea how to log on to your CC online account, and you don’t have a certified agent to help you, you’re going to have to call CC at 800-300-1506 and click on I’m feeling lucky.

    Question: My 28 year-old daughter lives with me. She is unemployed, no unemployment benefits, currently zero income. I have employer-based insurance for myself, and my income is over the thresholds for ACA subsidies. If my daughter earns nothing for the whole of 2016 (or less than $4,000) she is my "dependent relative". My question is, does that necessarily make us both part of one household, and therefore disqualify her for Medi-Cal because of my income? What happens if I choose to NOT claim her, even though I could?

    Answer: Your daughter should apply for Medi-Cal directly through your county office. Medi-Cal is only interested in your daughter's income and assets. That way you can continue to claim her as a "dependent relative" on your tax return.

    Question: My employer offered me, my spouse and my children a employer sponsored minimum essential coverage effective 01/01/2016. If my spouse and my children decline the employer sponsored minimum essential coverage offer, are my spouse and my children eligible for Covered California subsidy when my household income is greater than 266% of Federal Poverty Level?

    Answer: No. The fact that your spouse and children have been offered employer-sponsored health insurance makes them ineligible for premium assistance in Covered California even if household income is between 128% and 400% FPL.

    Question: My mom, a new green card holder, has an income less than $4000 from my home country. I have sponsored her green card, and signed the affidavit of support (I-846). I am not claiming her as a tax dependent. I've read that for certain federal and states benefits (including non-emergency medi-cal--see source below) my income would be counted as her income to assess her eligibility under "immigrant deeming rules". I have a high enough income that if added to hers, makes her ineligible for medical or discounts on CoveredCA market place. The medi-cal staff did not seem to know much about this and they say they are trained to count the IRS household income to assess eligibility, which means my income does not matter. Which one is correct? Is she eligible for medi-cal? If she is not eligible under medi-cal, does CoveredCA also deem my income as hers? The staff seem to be clueless. My research on this seems to go nowhere. I appreciate your help.

    Answer: You can apply for health insurance for you mom through Covered California. Since you do not claim your mother as a dependent, her income alone is considered for eligibility. Since her taxable income is far less than the Covered California minimum, she will be deemed eligible for Medi-Cal. She can "buy into" Medicare once she has been in the US for 5 years.

    File Your Own 1095-A?

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    Question: Our 1095-A for 2015 is nearly completely wrong. I went to Medicare in may but my wife was and still is on the same Covered California Kaiser policy, Because of this I expected some problems, but the form only has her coverage for the first 4 months, nothing for my coverage in that period, and does not show her continued coverage for the last 8 months. I believe it is because it took a great deal of effort to get them to continue her coverage. They had me listed as primary and first dropped her coverage and then reinstated it, I assume with her as primary. I think this is the problem now, but it shows wildly wrong numbers and will cost me dearly if I cannot get it corrected. How do I do that when they have no way for me to communicate with them? They give no email addresses, the message board will not accept replies, and the chat people don’t have any idea what to do, other then assure me she has coverage. I don’t have any confidence that they will get me a corrected form so that I can file.

    Answer: If you cannot get an accurate 1095-A before the tax deadline, you can file your own 1095-A. Here is what to do:

    Download a blank 1905-A form at https://www.irs.gov/pub/irs-pdf/f1095a.pdf Now collect the following pieces of information for PART III - Household Information:

    • The months you, your spouse, and dependents had coverage.
    • Your total premiums paid for you, your spouse, and dependents.
    • The cost of the Second Lowest Cost Silver Plan in your Marketplace at https://www.coveredca.com/shopandcompare/2015/
    • The total amount of Advanced Premium Tax Credit that was paid on your behalf. (Your insurer will have this information too) NOTE: You can compare what you actually paid to the full price of the plan, the difference is your Advance Payment of Premium Tax Credit.
    • If you are married then you’ll also need “Policy Number (Form 1095-A, line 2)”. So it’s a smart move to get the policy number from the Covered California or your insurer. You only need to enter the LAST 15 digits of the policy number (that’s all that show on a 1095-A sent to you as well).

    Now that you have all of that information, add the total amount in for each column.

    Affidavit as Proof of income?

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    Question: I have just opened up a new law office. I worked for an attorney for 13 years and would Gross over $200,000 per year. The practice is Social Security Disability appeals. The covered California said I cannot prove my income and must go on Medi-Cal. I do not want to do that. They gave me 90 days to appeal Any suggestions would be much appreciated. I do have three cases that are scheduled for hearing. I believe I will make $20,000.00 net after my first year as a solo practitioner. Thank you in advance for any help you can offer me.

    Answer: While you are getting your business started, the common forms of proof-of-income may not available to you. You can submit an Affidavit - a signed and dated statement with the word "Affidavit" on top - explaining how much income you can expect to make and how you will earn it 2016.

    Question: I read that sponsors of immigrants who sign the enforceable affidavit of support (Form I-864) may be required to repay the government for "means-tested" benefits used by the immigrant after he or she becomes a lawful permanent resident." and that "non-emergency medi-cal is a means-tested benefit". That says that if sponsored immigrants get on medi-cal, the sponsor should repay. Is that correct?

    Answer: Yes. The sponsor is legally liable. The enforceable affidavit of support (Form I-864) states: "If a Federal, State or local agency, or a private agency provides any covered means-tested public benefit to the person who becomes a permanent resident based on the Form I-864 that you signed, the agency may ask you to reimburse them for the amount of the benefits they provided. If you do not make the reimbursement, the agency may sue you for the amount that the agency believes you owe." However, it is very rare for the sponsor to be sued. States are not required to go after sponsors, and to our knowledge, no government agency in California has sought reimbursement from a sponsor up to now.

    Question: Can our sister, who is our financial dependent for IRS, federal taxes, also get benefits from California medi-cal and federal Medicare as her retirement income is insufficient to cover food, board and medical needs?

    Answer: Your sister is eligible for Medi-Cal if she meets residence and income guidelines. She should apply directly through her county Medi-Cal office, not Covered California. Here's a link for MediCal contact info: https://www.medi-cal.ca.gov/contact.asp

    Question: Does a new green card holder who stays in the US for 6 months a year only have to be covered by an ACA compliant plan? If yes, does it have to be for the entire year or just the duration of the stay in the US?

    Answer: Yes. You must buy health insurance or pay the IRS penalty. You can cancel your coverage when you leave the country and reapply under Special Enrollment provisions when you return.

    Can I Change My Health Plan Now?

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    Question: Please help me figure out if I can change my health plan right now. I'd like to change from Heath Net to Blue Cross, because the doctor I need only takes Blue Cross.

    Answer: Yes. You can change your plan selection any time before the current open enrollment period ends on Jan 30, 2016. The effective date of the new coverage will be February 1st, if you make the change by January 15th, or March 1st if you change between January 15th and 31st.

    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.

    Over 65, Never Paid into Medicare?

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    Question: I have a special needs brother who just turned 65. He has been getting medical insurance through Medi-Cal, but was told that now he is 65 he can no longer be covered unless he gives up all but $2,000 of his assets. He never paid into social security or medicare. Could you please provide some information on eligibility for those over 65?

    Answer: Your brother is eligible for Medicare even though he never paid Medicare taxes. People with less than the requisite 40 credits​ ​must pay the premium for Part A​ - $411/mo​ for those with less than 30 credits. Part B premiums are $122 per month for most people.​ Go to medicare.gov for more infomation.

    Obamacare Deadline?

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    Question: My fiancé was unable to apply by the deadline yesterday because the computer gave an error message when he tried to submit online. He doesn't want to get hit with the penalty, and he wants health insurance. Is there anything he can do?

    Answer: The Obamacare deadline for coverage effective 1/1/2016 has been extended two days - through midnight December 17th.

    Question: What is the advantage of signing up directly with Blue Shield PPO, as opposed to signing up through Covered California?

    Answer: Covered California is the only place to enroll for health insurance coverage if your household income makes you eligible for premium assistance. When you apply through Covered California you agree to file taxes each year and to allow Covered California to access your tax records through the IRS. When you apply directly through a California health insurance carrier like Blue Shield - referred to as an off-exchange enrollment - you are not asked to provide any income related information whatsoever. Off-exchange, you will find plans that mirror the covered California plans exactly in benefits and rates, but, you'll find plans that are unique to the off-exchange-market as well.

    Premium Assistance Now or Later?

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    Question: Will the premium assistance lower my monthly cost or simply give me a tax credit at the end of the year?

    Answer: Most people who receive premium assistance take it each month to reduce the net premium they have to pay. But that's not the only way to do it. You can also take a lesser amount monthly or none at all. In the later case, you will receive the remainder of the premium assistance you are due when you file your tax return for that tax year.

    Best Out-of-Network Coverage?

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    Question: I make about 18,000 annually and live in the 90021 zip code. I am looking for a plan that will give me the most out of network benefits, because I need a spinal surgery, and my surgeon is not part of any networks. Personal pay and medicare only. Can you tell me of any plan options that include out of network benefits?

    Answer: To receive out-of network benefits you must select a PPO plan. In your zipcode, there are two carriers offering PPO plans, Anthem Blue Cross and Blue Shield of California. Their out-of-network benefits are identical. Your income makes you eligible for a Silver 87 Plan with enhanced benefits, so here's how your surgery would be paid for. For all in-network costs - like hospital, drugs, and physical therapy - your in-network maximum-out-of-pocket expense will be $2,250 (Silver 87 plan). The out-of-network cost for you surgeon will probably meet the separate out-of pocket maximum of $9,250. Your total cost for this surgery will run $11,500. If you can find an surgeon in-network with whom you are equally comfortable, your total cost would be $2,250.

    Covered California and SIMNSA?

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    Question: My present insurance coverage is under Covered California through Health Net. My husband is the primary owner to this account but at this time he is unemployed. My employer is offering me a SIMNSA Insurance which has an office in Chula Vista California. The provider services are based in Tijuana, Mexico. I do not speak the language nor familiar in the Tijuana area. Crossing the border from U.S. to Mexico is a nightmare (the minimum is 2 hours going and 2 hours coming back in the U.S. This makes me uncomfortable since I don't speak Spanish. My question is can I legally reject/decline to the offered insurance? What will be the consequence in my part if I do reject this offer? (Note: SIMNSA is the only insurance company offered by the employer.) Will I lose my Health Net insurance since this is subsidized.

    Answer: SIMNSA plans offered in the US are ACA compliant and meet the meet the minimum value and provide essential health benefits. Most services require no co-payment at the time of treatment. Some select services require a $5 to $10 co-pay, after which all services are covered at 100%. Unfortunately. you have to cross the border into Mexico to see a provider (except for emergency coverage in the US). You can opt out of the SIMNSA offer from your employer, but you will no longer be eligible for premium assistance (subsidy) through Covered California because you have access to employer-based coverage. Assuming your employer pays all or most of your monthly premium, I advise you enroll yourself and your husband in SIMNSA and plan on using it for any major medical expenses that may arise. If you prefer, you can pay cash to see medical providers in the US side for routine care. That expense would be much less than carrying an additional health insurance policy without premium assistance.

    Must Dependent File Taxes?

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    Question: My family of four is covered under Covered California with premium assistance for 2015. Our 21 yr old daughter did not complete enough school to be considered a full time student, so we cannot claim her for our 2015 tax return. She did work, and earned about $9000.00. Will we be penalized because she should have had her own health care plan (MediCal). Should she enroll for 2016 for her own plan before I take her off ours?

    Answer: Single dependents must file a federal income tax return if their earned income is more than $6,100. So your daughter must file a tax return for 2015. She needs to create a Covered California application for her own 1-person household. Her income makes her eligible for Medi-Cal in 2016. You will need to update your Covered California account by removing her from your household. There are no penalties for either your daughter or yourself. If you received more premium assistance in 2015 than you were entitled to, you will pay some of it back to the IRS when you file your tax return for 2015.

    File Taxes with $0 Income?

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    Question: When I re-enrolled last November for Covered California I estimated my income about $1500/month (based on my income for the past 10 years). In January 2015, I became unemployed. I forgot to report my income change and been receiving premium assistance and been paying my adjusted premium. Since I had no income in 2015 do I have to file for taxes? Is there a penalty I have to pay since I forgot to report my income change and been receiving premium assistance? Thanks!

    Answer: For starters, because you enrolled through Covered California you have to file a tax return for 2015, even if you had no income. With no income in 2015, you were eligible for Medi-Cal, not Covered California. But, since you made no money, there is no taxable income from which the IRS can recover the premium assistance your were given. So you get to skate by this time - no penalty, no tax recovery. Your Covered California coverage will end at the end of 2015 and your Medi-Cal coverage will start January 1st, 2016.

    Opting Out of Covered California?

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    Question: I currently have a plan Blue Shield plan through Covered CA, but I want to change to a Kaiser Permanente plan OUTSIDE Covered California for 2016 since I don't qualify for any subsidy. If I do, do I have to notify Blue Shied so that they won't automatically renew my plan for 2016?

    Answer: Yes. It is your responsibility to notify Blue Shield that you are cancelling your coverage effective 12/31/2015. You can apply directly through Kaiser Permanente for 2016 coverage. You can "terminate coverage" in your Covered California account effective 12/31/2015. I believe a better option is to keep your Covered California account open, select Kaiser for 2016, but opt out of premium assistance. This way, should your income drop again, you can easily opt back in for premium assistance.

    Question; Do I include social security disability dependent benefits for my 2 minor children in the household income on the application?

    Answer: No, the Social Security disability benefits that your children receive in your name is their income and only would be reportable as income by them if they had sufficient income that caused it to be taxable. Social Security disability benefits are never taxed to you as custodian.

    Question: Can I buy coverage for my 19 year old son on the exchange. He is a student living at home and I am single, employed and have medical insurance at work, I make about 100,000 annually?

    Answer: Yes. Your son can purchase coverage through Covered California. He will not be eligible for premium assistance.

    Question: When trying to pick a dental plan on the CC website I am confused by the limited list of "benefits". There is a short list of services and their costs under each of 5 plans, such as fillings, root canal, pediatric filling, etc. However, it gives no costs for basic things like extractions and crowns. Is the list of services on the "Pick a Plan" page just for example? Is there someplace else to see the entire list of services covered and the cost?

    Answer: More detailed dental plan lists of covered expenses can be found at the carriers' websites. For example, here is a detailed list of Benefits for the Access Dental HMO Plan. Access DHMO Benefit Details.pdf

    Platinum Plan Rate Hike?

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    Question: I have Blue Shield Platinum PPO that is $415 now and will increase to $521.99 in 2016. Why such a big hike? That seems unreasonable. I live in Santa Monica, CA. Have all plans done this under Obama Care? Where should I look for more reasonable coverage? I don't want to go down to Silver because sen generic drugs are $50 under it.

    Answer: Platinum and Gold plan premiums went up more than Silver and Bronze plans on a percentage basis for 2016. The reason is "overutilization". That's insurance lingo meaning that there were more claims for those plans than anticipated in 2014 when the original rates were set. Platinum and Silver plans are usually purchased by people anticipating high medical expenses due to recommended surgeries or chronic medical conditions such as diabetes. Claims for these plans were higher than anticipated and the pricing had to be adjusted.

    Question: I enrolled for medical insurance through my job. But now after doing more research, I realize I would've been better off going through covered California. Is it too late to change my mind and switch to medical insurance through Coveted California?

    Answer: You are not eligible for premium assistance through Covered California coverage. It is for people who are not offered health insurance at work. However, You can purchase coverage on or off exchange without a subsidy.

    Question: My employer is no longer covering family members. My husband and daughter will be out of coverage and I am trying to figure out my best option. My daughter is 3 years old and my husband is unemployed. I was told they could both receive medi-cal. Is this true?

    Answer: If your employer does not offer coverage for spouses and dependents, they may be eligible for MediCal or Covered California coverage. If your household income is less than $27,000 per year, then both your husband and daughter will be eligible for Medi-Cal. If your household income is greater than $27,000 but less than $53,000, then your daughter will be eligible for Medi-Cal and your husband will be eligible for Covered California with premium assistance. If household income is over $53,000 but less than $80,000, both your husband and daughter are eligible for Covered California coverage with premium assistance. Over $80,000 per year, they can purchase health insurance without premium assistance.

    What is an HSA Plan?

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    Question: How does HSA insurance work? what are the advantages and disadvantages?

    Answer: A health savings account (HSA) lets you save money for future health-related expenses. It's essentially like an IRA savings account for your health. And after you turn 65, it's even more similar to an IRA, because you can take out money for non-health expenses. You can use money from your HSA to pay for all tax-deductible medical expenses, from contact lenses to acupuncture. The money you put in the HSA is tax-deductible. Also, the money you withdraw isn't taxed by the IRS, as long as you spend it on approved, health-related stuff. The HSA's interest income isn't federally taxed, either. You can't use money from your HSA to pay for your health insurance premium -- unless you're unemployed. There are limits to how much you can save. For 2015, you can sock away $3,3500 if you are an individual or $6,650 for a family.

    Out-of-Network Reimbursement Rate?

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    Question: I am trying to find a plan that will cover out of network mental health treatment. I have been seeing a very costly therapist and am hoping that by enrolling in an expensive insurance plan, i can decrease that monthly amount by a bit. It is very hard to find information about out of network coverage on insurance websites- i mostly find a line that says "copay will be higher". I was looking at blue cross blue shield ppo plans. am i correct in assuming that if my therapist bill is 250 a session- they will cover only 50%? so, i would pay 125+ office visit (35 for higher plans)? Are there any better options?

    Answer: Out-of-network benefits are reimbursed at a level much lower than 50% of the provider charges. The plan pays 50% of the carrier's allowable amount, not the provider's bill. For example: your therapist charges $250 per session. The insurance company's in-network allowable amount for this treatment could be as low as $75. Your benefit amount would be half of $75, not half of $250. In addition, out-of-network coverage has a separate deductible, usually 150% to 200% of the in-network deductible. Long story short, out of network coverage sucks. Better option? Find another therapist.

    Question: Hi - I'm currently unemployed and am considering signing up for an Enhanced Silver Plan for 2016. If I start making more income either before 2016 or after the year begins, if I get removed from the Enhanced Silver Plan, what will my options be at that point? Will I get to choose a new plan, or will I be switched to the same plan in a non-enhanced version?

    Answer: Covered California cost sharing reductions (CSR) are enhanced benefits such as lower copays and deductibles on silver plan benefits for those with income levels between 138% and 250% of federal poverty level (about $16,500 to $29,500 for a 1-person household). These enhanced plans come in three levels: Silver 94, Silver 87, Silver 73 - covering 94%, 87%, and 73% of covered medical expenses. Since the benefit is based on income, reporting an income change during the year may change one's level of benefits. If so, your coverage will automatically change to the appropriate CSR level or off enhanced benefits entirely to the Silver 70 level. A change of this nature does not trigger a Special Enrollment option so you cannot change plans either with the same or different insurance company. CSR benefits are not recoverable. Not reporting an income increase will probably result in an overpayment of premium assistance (subsidy) which may require payback to the IRS, but there's no payback for enhanced benefits.

    Question: The Covered California online renewal process was convoluted and did not provide me with an acknowledgement that I have renewed successfully. How do I know if I have renewed my coverage? FYI, I worked for 30 years as a Computer Scientist and still struggled with the Covered California web site.

    Answer: Here is how your Covered California homepage looks if you have completed your renewal Sample CC Home Page.pdf. Notice that all of the sections are checked, including Enrollment. If you click on the Summary checkbox, then from the next page, select Current Enrollment, you get a detailed summary of your coverage. Your 30-years of experience in Computer Science did not include government work apparently. It's a "different" world.

    Question: My employer offers dependent coverage that I can't afford for my dependents. What are my options on covered ca.

    Answer: You can enroll your dependents in Covered California coverage. However, they will not be eligible for premium assistance. If your income is low enough (for example: less than $27,000 annually for a 3-person household), you can enroll your children in Medi-Cal coverage rather than your employer-based coverage.

    Question: Can I decline my employers medical coverage and get covered California at a reduced premium rate?

    Answer: Generally, you cannot receive premium assistance with Covered California coverage if you opt-out of your employer's group health plan. Only if the employer-based coverage fails the "affordability test" can you be eligible for premium assistance through Covered California. To be considered "affordable" by IRS standards, the employee-only share of the cost has to be less than 9.5% of the employee's income.

    HSA Compatible Plans?

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    Question: I am currently enrolled in a high deductible plan with CCA. Can I start an HSA? If so how do I do this? And what expenses are eligible.

    Answer: You may have to change your high deductible Bronze plan to one specifically labeled HSA eligible. Once you have done that, you can open an HSA account at the financial institution of your choice.​ Any medical, dental, or vision expense that the IRS recognizes as deductible can be paid with pre-tax dollars from your HSA funds.

    Payback Cost Sharing Reductions?

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    Question: My wife and I plan to quit our jobs effective 12/31/15 and enroll in Covered California. I have done compare and shop and we will qualify for the Enhanced Silver Plan, probably the Silver 87. What happens if part way into 2016 I find a way to make income. If the increase in income puts me in a more expensive plan I can pay back difference in premiums, but what happens if I had medical care on the Silver 87 in say March 2016 but I later have medical care when I qualify for say the Silver 70 like in October 2016. Would I owe reimbursement for services rendered early in the year at rates later in year if income changes?

    Answer: I’m glad to put your mind at ease: there is no recovery of any cost sharing benefits​ you may receive. Only the premium assistance (subsidy) has to be repaid if an increase in income warrants. Since you will be making income adjustments to your Covered California account during the year, you would be well served to have a Certified Covered California agent to handle your initial enrollment and those income changes for you.

    Re-apply to Medi-Cal for Kids?

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    Question: My kids are already covered by Medi-Cal, they received their ID cards in the last 2-3 months. I am starting a new job without an employer health plan, so my wife and I will buy our own insurance through the state exchange. Do we have to re-apply for our children to be covered by Medi-Cal when my wife and I buy a plan through the exchange

    Answer: Getting a new job usually results in an income change. Since your kids' eligibility for Medi-Cal is based on your household income, they may or may not still be Medi-Cal eligible. In any case, the Covered California online application will include Medi-Cal eligibility information for your children once you complete the application for your entire household. If the children continue to be Medi-Cal eligible, you do not have to reapply with Medi-Cal. If they are no longer eligible, Medi-Cal will drop them automatically (at some point) and your children will be included under your Covered California coverage.

    Lost Subsidy. Why?

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    Question: According to the website I will be losing premium assistance in 2016. I received around 180 dollars of assistance per month last year and I make almost exactly the same as I did before. Why did I lose my subsidy?

    Answer: Probably because your 2014 tax return had an adjusted gross income higher than the estimated income you first entered. Covered California did not receive this information from the IRS until mid-2015, so the income adjustment was applied to the 2016 tax year.

    Question: Hi, I and my wife are new immigrants sponsored by my son in CA and our age is > 65. Our combined income is 3k. I have few questions. Can we file tax as "married filing jointly" as income 3K. If so, can we apply for tax credit/subsidy in coveredca for the premium and for cost sharing(deductible/out of pocket cost)vWe are 81 and 77, household size is 2. If our income is about 10K/year, what will be our premium and out of pocket costs, even if its an approximation?

    Answer: Medicare would be your first choice, but I assume because you did not mention it that you do not meet the 5-year residency requirement. Based on your income ($3,000 to $10,000 annual), you are eligible for MediCal (not Covered California). Medi-Cal requires only that you reside in California legally.

    Question: If I am receiving a Subsidy and become newly employed with an Employer that offers and Affordable Minimum Essential Coverage and continue being enrolled on Covered California for myself with or without my dependents, will I have to repay the subsidy?

    Answer: Yes. If you continue Covered California coverage after becoming eligible for employer-based group coverage, you will have to repay any subsidy received after that point. Even without a subsidy, dual coverage is not allowed. It is your obligation to notify Covered California once your employer-based coverage becomes effective.

    Are All Bronze Plans HSA Eligible?

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    Question: By definition it seems that ALL Bronze plans are considered HDHP. So, I’m confused by the fact that only certain plans offered actually say “HSA.” If I select a plan not specified as HSA but it is actually a high deductible plan, will I still be able to utilize an HSA account?

    Answer: No. All Bronze plans are not HSA compatible. Only those labeled as HSA qualified will work with the IRS. If you select a plan not specified as HSA, you will not be able to utilize the tax benefits of an HSA account?

    Find Medical Providers in My Area?

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    Question: How can I determine which Covered CA health provider plans will accept the particular medical group and doctor that I want? I also have difficulty because of the restrictions on the area in which I live. Will a PPO plan help resolve this issue?

    Answer: You will have to do an online search of providers - doctors and hospitals - at the website of each carrier you are considering. I have provided a list of links to some carrier provider directories below. If you are uncomfortable using the internet, you should contact a Certified Agent to help you locate the best plan including your provider preferences. In 2016, all counties in California will offer a choice of at least 3 different Covered California carriers: Blue Shield and Anthem Blue Cross PPO plans (no more EPO) are available in every county statewide. New this year, United Healthcare will offer a third PPO choice in even the most rural counties.

    2016 Rate Increase?

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    Question: I just received a mailing that states that our Anthem Blue Cross premium is going from $670 to $870 for 2016. We've reported no changes in income or family size (nor made any claims this year). As expected, the plan's deductibles, copays and OOP maximums have all increased. This is not the reasonable expected premium increases I've read about in the Covered CA press releases. We receive a subsidy. Our income for 2015 will be the same as for 2014 year. Is it safe to assume that the subsidy will not increase substantially to cover such a large premium hike? Hence our premium will now be an additional $200 out of pocket monthly?

    Answer: If you are eligible for a subsidy, the net amount you pay after subsidy is set as a percentage of your income, so if your income is the same as 2015, your subsidy will increase to cover most if not all of the 2016 health plan rate increase. While the average 2016 rate increase for Covered California coverage statewide is 4%, there are anomalies. For example if you have a Blue Shield PPO plan in Monterey, San Benito or Santa Cruz county your rate could increase as much as 44%. This year both Blue Shield and Anthem Blue Cross offer PPO plans in all California counties, so don't renew your coverage without shopping all other plans in your area.

    Question: Before I purchased my Covered California plan with Anthem last year, I carefully checked Anthem’s online provider directory (Covered California does not appear to have one) to confirm that my doctor, my wife’s doctors, and our preferred hospital were all in-network. When we visited our doctors a few months later, both of our doctors told us they do not take Covered California. This cost us significant out of pocket expenses. Is there any I can get reimbursed for their mistake? Is it any better now?

    Answer: Today’s provider directories are somewhat better than a year ago, but are still inaccurate. (For a complete picture on why this situation continues 2 years after ACA implementation read: Provider Directory Study 9-2015.pdf. Accurate provider directories won’t happen any time soon. We need the Department of Insurance and the Department of Healthcare Services to “grow a pair” and start aggressively enforcing existing standards with sanctions and fines for the carriers. Covered California should add an SEP trigger to include consumers that can show that they chose a plan based on inaccurate provider directories. That way at least, the consumer could switch plans and minimize the added cost and inconvenience caused by errors or misrepresentations in provider directories.

    Employee Dependents Opt Out?

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    Question: A new employee wants to negotiate a stipend for not enrolling his family members on our company health insurance plan. He says his covered calif plan for them is cheaper than the cost would be for the company plan (we have kaiser and pay for 50% of dependent coverage). I don't know if we can (as an employer) pay the employee a stipend if he opts out of our coverage for his family.

    Answer: Unfortunately for this employee, his dependents are not eligible for premium assistance at Covered California, because they are "offered" employer-based coverage. Should his dependents opt out of the group coverage, they can enroll in Covered California coverage but without a subsidy, making the Covered California cost much higher that 50% of the group coverage cost. To enable your employees to do what was requested here, your group plan would have to stipulate that no dependents will be offered coverage going forward.

    File Taxes with Zero Income?

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    Question: When I enrolled in Covered California a year ago, I was making about $1400 a month and received premium assistance. I became unemployed in January and did not report the change, but still paid the adjusted premium. Do I still have to file a tax return with almost zero income? Will there be a penalty or tax consequences for this at the end of the year?

    Answer: Yes. You must file a tax return even if your income is zero. You agreed to do so as part of your Covered California application. Get a form 1040EZ and you can easily fill it out and submit it yourself. The amount you have to pay back is limited to $300 in your scenario. If you did not file a 2014 Federal Income Tax Return, you are not eligible for a subsidy in 2016.

    Bronze HSA Better Than Platinum ?

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    Question: My wife and I are self-employed and have a family of 4. We don’t qualify for subsidy in Covered California. Can you help us understand why one shouldn’t always go Bronze with HSA vs. a lower co-pay plan e.g. Platinum? Doesn’t the tax benefit of an HSA and the lower OOP costs of Bronze always mean a lower maximum, after tax health care spend? Under what circumstances does it make sense to purchase the Platinum plan?

    Answer: People with chronic health conditions buy the platinum plan. For example, 40% of platinum plan users are diabetic. They know they will have significant medical expenses and they’d rather pay the higher insurance premiums than the out of pocket expenses. The out-of pocket maximum for platinum plans in 2016 is $4,000.

    Healthy, more affluent people, see the Bronze HSA compatible plan, as a better option. For these people the $4,500 deductible (2016) is not a deal breaker because they have the money, if necessary. Because they are healthy, their out-of-pocket costs should be very low most years. Then of course, there’s the tax benefits and lower premiums. The out-of pocket maximum for platinum plans in 2016 is $6,500.

    Will I have to Repay the Subsidy?

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    Question:nMy partner and I are not married, but we live together and we have three children together. In March, I lost my job and with it, our health insurance. Without my income, we qualified for premium assistance subsidies because we had a low estimated annual income. I just took and job (August). I immediately reported our income change to my Covered CA agent. My fear is that at the end of the year our annual income will put us over the limit for qualifying for subsidies and we will be penalized for the five months that we received them. Is that how the system works?

    Answer: If your 2015 adjusted gross income exceeds the premium assistance threshold of 400% of the federal poverty level (FPL) ($114,000 for a family of 5), you would end up repaying the IRS for all the subsidy you received for the year. Assuming your income was less than that, you will still repay a portion of what you were have been overpaid. Here’s the repayment schedule:

    • Less than 200% FPL ($57k in your case), the amount of the repayment is limited to one-half of $600
    • At least 200% but less than 300% ($85k in your case), the amount of the repayment is limited to one-half of $1,500
    • At least 300% but less than 400% (114K in your case), the amount of the repayment is limited to one-half of $2,500

    You did the right thing by reporting your income change to Covered California as soon as possible to limit the overpayment amount.

    Add Recently Immigrated Spouse?

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    Question: My wife just immigrated. Since immigration is a circumstance that allows enrollment outside the normal enrollment period, can I add her to my existing plan?

    Answer: Yes, if your spouse is "lawfully present" in the eyes of Covered California you can add her to your Covered California coverage. Lawfully present immigrants include:

    • U.S. citizens and U.S. nationals.
    • Lawful permanent residents or ("green card holders").
    • Lawful temporary residents.
    • Persons fleeing persecution, including refugees and asylees.
    • Other humanitarian immigrants, including those granted temporary protected status.
    • Non-immigrant Status holders (including worker visas and student visas).

    Individuals who are not lawfully present are exempt from the requirement to have health insurance. They must apply for an exemption directly with the Internal Revenue Service (IRS) on their federal income tax return.

    Question: If you withdraw $10,000 from an IRA, is that added to income amount to be calculated for Covered California.

    Answer: Yes. Withdrawals from traditional IRAs (not Roth), 401Ks, and company pensions are taxed as income and will add to your Adjusted Gross Income (AGI on line 37 of 1040 tax return) which is the number on which Covered California bases its premium assistance calculations.

    Question: We lost our employer coverage June 1 but were out of the country from early May until mid August. Are we just out of luck as far as buying insurance through Covered California until the next open enrollment?

    Answer: You are entitled to a special enrollment period of up to 60 days following the termination date of your employer-based coverage. Your SEP expired on August 1st. Your should be able to get covered however. I suggest you contact a Covered California certified agent. The agent will help you request an enrollment "exception" due to the fact that you were out of the country during your SEP.

    Question: I will need to buy health insurance due to job loss. I am going to be completely self-employed. I understand there is a regular Bronze plan and a HSA Bronze plan. Which is better for a healthy couple who expect little medical care? Please consider that self-employed deduct medical insurance paid on their income taxes.

    Answer: ​Yes. I recommend the HSA compatible Bronze plan for healthy self-employed people because you can take advantage of the added tax benefits. Your premium payments are tax deductible to the business and any money you contribute to your HSA account is also pre-tax - up to $6,750 per year for a couple. You can use your HSA savings to pay for out of pocket medical expenses - copays and deductible - with pre-tax dollars.

    Question: I have heard of the limit to tier 4 drugs. Can you elaborate on this as well any other changes like deductibles, co pays, coverage e passion etc?

    Answer: In 2016, all metal-tier plans will now have a maximum monthly out-of-pocket cost on specialty drugs (once the pharmacy deductible is met). For the Bronze Plans there is a $500 monthly maximum and for Silver, Gold, and Platinum the monthly out-of-pocket maximum is $250 after the pharmacy deductible is met. The other significant change in benefits for 2016 affects the Bronze Plan. The first cumulative three visits will not be subject to a deductible and can include a specialist visit in addition to primary care, mental health and urgent care visits. In addition, laboratory work is not subject to the deductible.

    Question: My daughter got Medi-Cal, as she was unemployed last year. She found a new, though, low paying, job about 6 months ago, but forgot to report the income change. Will this effect her ability to get Covered Ca in a timely fashion? She needs about 6 different prescriptions, and can't afford to be without her medicines. She also can't afford to buy insurance with any help. What should she do?

    Answer: If your daughter is making less than $1,350 per month, she is still eligible for Medi-Cal and doesn't need to make any changes. If she is making somewhat more, but not a lot more, she can wait for open enrollment to make her income change and next year she will be on Covered California with premium assistance. There will be no financial penalty for underestimating her income in 2015.

    Question: I put in incorrect information on my application which affects my eligibility for Medi-Cal. How and where can I change this? I don't see that option on the Covered California website.

    Answer: To amend a Covered California application, login to your online Covered California account. From your home page select "Report a Change. This illustration (Report Change.pdf) will help. Then select the section you want to change, for example "Household" or "Income" and update.

    Private Insurance for my Child?

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    Question: I am self employed. Acceptance by physicians for Covered CA plans are different for me and for my 8-year-old child: my child's physicians do NOT accept ANY Covered CA plans, while mine do. Can I stay on my Covered CA plan and purchase an off-exchange plan for just my child? We don't qualify for a subsidy.

    Answer: Yes. You can do that during open enrollment - November 1, 2015 through January 30, 2016 - when you may update your Covered California account to indicate that your daughter, though part of your household, is not requesting coverage. Then you can apply for coverage for her directly with an insurance carrier effective January 1, 2016.

    Question: what is the penalty if any for someone who claims more income than they actually achieve? If someone earns a income that qualifies them for Medi-Cal but they inaccurately predict a income that would qualify for a substantial subsidy, then what is the practical outcome of this error? What is the maximum that someone would be penalized for after overstating their income? I doubt that there would be any practical penalty. Prove me wrong.

    Answer: In the scenario you describe, you would be liable to repay no more than $300 for the year. The following is a more complete answer to the "clawback" question provided here in October 2013:

    The consumer is liable for repayment of any excess tax credit received in the calendar year. However the amount of the "clawback" provision is limited by the household income according to the ACA law. If the household income (expressed as a percent of poverty line) is :

      Less than 200% FPL, the amount of the clawback is limited to one-half of $600
      At least 200% FPL but less than 300% FPL, the amount of the clawback is limited to one-half of $1,500
      At least 300% FPL but less than 400% FPL, the amount of the clawback is limited to one-half of $2,500.

    Question: Husband on Medicare. Wife on CovCA. Income forecasts show we will be over the CovCA limit. Want to drop the Blue Shield plan (via Cov CA) and purchase new independent individual plan as wife's employer does not provide insurance. Can we do this? How? When? I assume deductibles won't be carried over (except for another Blue Shield plan maybe?)

    Answer: Your question highlights a couple of common misconceptions about Covered California coverage. The fact is that you can keep your Blue Shield coverage through Covered California even though you are no longer eligible for premium assistance. Just change your income with CC so that your subsidy gets turned off. During open enrollment, November 1, 2015 through January 30, 2016, you can drop your CC coverage and apply directly with an insurance carrier, like Blue Shield. However, there is no real benefit in doing so, as the rates and plans are the same when you go directly to the carrier. Additionally, should your income drop again, you would have to reapply with Covered California to get subsidized.

    Big Income Change?

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    Question: We're a household of 3, husband at 55, wife at 46 & son at 14. My husband is quitting his job by the end of Sept 2015. YTD income at that point is $250K+ but the last quarter will be zero. Because he's starting something on his own, he will have zero income in the coming year or so while starting something from scratch. We probably opt out of using COBRA (too expensive). Here are my questions: 1. Given we have high income for 3/4 of the year but zero for the last 1/4, will we qualify for Cvered CA? If not, any other option? 2. If we can apply for the last 1/4 of the year for Covered CA, will we get premium assistance now that we are at zero income level? 3. For next year 2016, my husband will continue having zero income while I will try to get "part-time" job. Do we need to report any new income in mid-year once I find a part-time job? Basically, how it works when our income change during the year? Thanks for your advise in advance.

    Answer: When your employer-based health plan terminates - let's say September 30, 2015 - you can sign up for individual health insurance through Covered California even though you will not be eligible for a subsidy in 2015. Then, sometime before December 15th, you will adjust your household income at Covered California to estimate your 2016 income. If that estimate falls within the premium assistance range ($28K to $80K for a 3-person household), you can receive a subsidy to help pay your premium until your income is once again beyond subsidy range. Your 2016 estimate does not have to be accurate, any excess subsidy you may receive will be returned when you pay your 2016 taxes and vice versa. In this case, you could really use a good agent to help you with the application process and subsequent changes as proper timing is key to maximizing your benefits and avoiding any gaps in coverage, not to mention a potential nightmare of governmental proportions if you do things incorrectly.

    Dropping COBRA?

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    Question: My wife's company is going to pay the COBRA premium for six months as part of termination agreement which is very expensive. Can I apply for individual coverage once they stop making our COBRA payments?

    Answer: You would not be eligible for a Special Enrollment Period simply because your employer stops paying your COBRA premium. However, you can apply for individual coverage either through Covered California or directly with an insurance carrier during open enrollment starting November 1, 2015 through January 30, 2016. As luck would have it, you should be able to take advantage of the former employer's largess for most, if not all of the 6 months before open enrollment closes.

    Question: My employer mandates insurance to all employees, however I am already covered by TRICARE when I retired from the military. I don't want my employers insurance and want my health and welfare portion to go into my retirement account. This adds up to over $8,300 a year which I feel I am entitled too. Can you please advise me.

    Answer: You can opt-out of your employer-based coverage option in favor of your Tricare coverage, however your employer is under no obligation to pay you the unused premium.

    Application for Dependent Only?

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    Question: My son recent lost his eligibility for medi-cal Now I need to enroll him in a plan. Can I get him enrolled in a plan without also enrolling me and my husband? When I go to my account, I only get options for family enrollment plans.

    Answer: When you enroll through Covered California, you will enter information about your husband and yourself as well as your son and any other household members. Further in the application process, you will indicate that only your son wants coverage. His eligibility for premium assistance is based on your household income.

    Question: What will my maximum Out of Pocket expense be for a knee replacement surgery? I am 64 years old. I have Covered CA Blue Shield Silver Level health insurance. My deductible is $5,000.00 I look forward to your answer. thank you.

    Answer: You can figure about $6,400, which is the maximum-out-of-pocket expense. Once you have paid out $6,400, your covered medical expenses are 100% paid by the plan. One thing to watch out for is extra charges for durable medical devices. In the case of a knee replacement, you are advised to go home with a device that flexes the repaired knee automatically. Make sure that the device you choose is covered by your plan.

    Change Insurance Plan Now?

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    Question: I am not happy with my Blue Shield of CA Platinum PPO insurance plan and I want to change to a less expensive plan and/or a different insurance company. I signed up for my plan directly with BlueSheild of CA not through the Covered California website (because it wasn't letting me due to computer glitches). I know you can terminate your plan through Covered California, but I'm not sure how to do it if I'm outside that system? Also, if I'm allowed to terminate my coverage with BlueSheild can I do so outside of the open enrollment period(now), and can I then enroll in some kind of other insurance through covered CA (also outside of open enrollment). Thanks so much for your help!

    Answer: If you were to cancel your Blue Shield coverage you would notify Blue Shield (customer service number on your insurance card) since you bought directly from them. But you cannot get replacement coverage until open enrollment, so you are pretty much stuck with what you've got until January 1, 2016.

    Question: Is income between 138-150% of FPL is the only condition? Would there be a problem that the person is 68 years old and does not qualify for Medicare? How is the 138% calculated ? Is it based on raw income or after tax income or else?

    Answer: If the person in question is not eligible for Medicare at age 68 and has legal status, then this individual is eligible for Covered California coverage. The income calculation is an estimate of 2015 adjusted gross income (AGI) (see line 37 of last 1040 tax form to help estimation). If the estimated AGI is over 138% federal poverty level (FPL) and less than 400% FPL, this individual could be eligible for premium assistance. Whether, he or she can buy coverage now or wait for open enrollment is dependent on other factors.

    Question: If my employer offers health ins without hospitalization can I still buy into the market place? I have a new job that gives Health Ins with no Hospitalization coverage. They meet the min requirements because they cover preventive care. But the min value part that covers hospitalization is not covered. You can purchase the plan and will not have to pay the penalty for not having insurance because they cover preventive care. But my concern is I will not be able to purchase health care on the market place because I am offered this by my employer.

    Answer: Apparently, your employer has a limited-benefit minimum essential coverage (MEC) employer-based health plan - a loophole to avoid penalties for not offering required health insurance - and it protects you the employee from individual mandate penalties. However, you are still eligible for enrollment in Covered California and you may qualify for premium assistance if you meet residence and income guidelines. If you enroll in Covered California, your employer may be fined $3,000.

    Question: If employer drops health insurance when can you apply for covered California?

    Answer: The law says that you have a 60 days from the date your employer-based coverageends to apply for individual health insurance coverage. In order to avoid a gap in coverage, you can apply for Covered California coverage up to 45 days prior to the date your employer-based coverage ends. For example, if your coverage were to end July 30th, you could apply as early as June 16th for an August 1st effective date.

    Insuring My 19 Year-old?

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    Question: My daughter is 19, a full time student, and lives at home. Do I have to cover her under my plan at work, or can she apply for covered California on her own? Thank you.

    Answer: Yes, you are generally required to cover your dependents with your employer-based coverage. There are alternatives for some people: (1) If your household income is low enough (for example, less than $42,000/year for a two-person household), your children would be eligible for Medi-Cal and she can enroll without considering the availability of group coverage through your work. (2) She can also waive coverage on your group plan and enroll in a Covered California, but that would be without premium assistance. (3) Student health plans are viewed as minimum acceptable coverage by the ACA so that could work too.

    Question: My wife recently learned that her employer will be offering coverage for her (50% employer contribution) and spouse coverage with no subsidy. It is a Silver plan and the premiums are going to be higher than if I just stayed with my Bronze plan on the exchange. We do not receive any premium assistance. Am I allowed under ACA to keep my Bronze plan through the Exchange, or do I have to accept the employer-offered spouse coverage Silver plan the my wife's employer?

    Answer: It is your responsibility to notify Covered California that your spouse has been offered employer-based health insurance. However, since you are not receiving premium assistance, there is no penalty for not reporting the change. You can remove your wife from your Covered California plan and continue on your own, if that works better for you. Know that you will be ineligible for premium assistance through Covered California, regardless of your household income, as long as your spouse is offered employer-based health insurance.

    Question: I Just received a corrected Form 1095-A from Covered California with the result that I received too much subsidy in 2014. What do I do now? Do I have to refile my tax return?

    Answer: No. You don’t have to file an amended return for 2014. The IRS says you don’t need to do anything if you already filed your 2014 tax return. Covered California says that this corrected Form 1095-A is “only for your own records”.

    Question: My two children are currently on medi-cal, but our income went up and they are no longer be eligible (annual review is pending, but I know they will be dropped). Will this be a triggering event for covered california just for the two of them or for the whole family? I ask because without the entire family enrolling, we don't qualify for premium assistance, so it becomes very expensive just to enroll them now separately. We are a family of 5 and made 92k last year. My husband has covered through work (self employed, but had to enroll himself to be able to get his employees covered), and myself and newborn daughter have private insurance. Thanks!

    Answer: Yes. You and your children will be eligible for a Special Enrollment when they loose Medi-Cal coverage due to your income change. Your Covered California share of the net (after subsidy) premium for an adult and 3 children will be about $725 monthly for a Silver Plan. Interestingly, your husband could be added to your Covered California family plan at no additional cost. I suggest he re-examine the rationale behind participating in or even having a employer-based health plan for his business.

    Out of Network Coverage?

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    Question: I have a Blue Shield of CA Platinum PPO purchased through Covered California. I am confused as to how much I would be responsible for if using a surgeon who is listed as in-network with Blue Shield not purchased through Covered California, but is not listed as in-network for Covered California policies. Would I be responsible for 50% of Blue Shield's contracted amount with the surgeon or 50% of the surgeons non-contracted fee? Also, how is the maximum out-of-pocket work when using in-network and out-of-network providers? I want to have an Anterior Approach total hip replacement, but none of the top surgeons who perform this approach are on my provider list.

    Answer: One of our readers, who prefers to remain anonymous, provided the following answer. I believe the information is accurate.

    You would be responsible for 50% of Blue Shield's typical contracted fee PLUS anything beyond what Blue Shield allows of the doctor's full bill. This is complicated, so let me explain. When it comes to out of network coverage, the devil is in the details, and the details of Blue Shield's implementation of out of network coverage is hell, where devils belong. Everyone is inevitably surprised by their paltry out of network coverage, because how it works is very obscure.

    Blue Shield's policy states that they allow for an out of network doctor what they WOULD HAVE ALLOWED had the doctor been contracted. (This implies that there is just one single fee that they allow all doctors providing a particular service/region- and that is most certainly a fabrication but is another matter.)

    Then too, Blue Shield allows its new "Exclusive Provider" network providers much less than it allows its older, full PPO network providers (the network which grandfathered individual plans, and corporate PPO plans, still use). So when Blue Shield says "What we would have paid had the doctor been in network," they mean "in YOUR network, which may be a network that pays doctors very little."

    So: If an *in-network* surgeon charges $5,000, since you have Platinum there is no deductible. Let's say Blue Shield only allows $2000 for the surgeon fee. In a platinum plan they would pay 90%, or $1800, and you would pay 10% or $200. The surgeon would be contractually required to write-off (that is, ignore) the remaining $3000 that Blue Shield disallowed.

    Out of network, they would allow a surgeon only that same amount - $2000, and would pay just 50% of that $2000, or $1000. You would owe the surgeon your half of the allowed amount, or $1000 - plus another $3000 for the rest of his $5000 bill. (That's the "balance billing" aspect of this.)

    Adding insult to injury, what have you paid "out of pocket?" Just $1000, not $4000. Blue Shield - all insurers - ignore anything you pay that is beyond your share of the amount they allow.

    FURTHER, if the facility is out of network and you have 1 or more overnight stays the cost is pretty ruinous, because of Blue Shield's extraordinarily stingy allowance for out of network facility charges. They allow no more than $500 per day for out of network hospital charges, and then pay 50% of that - or $250. Since an actual hospital facility can cost thousands of dollars per night, do the math! Stay out of out of network hospitals except for emergencies.

    Policies state "out of network, your costs may be higher." That's a very lame warning and it's amazing regulators allow that wording. (Or maybe it's not so amazing - the regulators don't do much in California.) Your costs will not only absolutely be higher, they will absolutely be MASSIVELY higher. All of this is in the Summary of Benefits and Coverage and in the policy documents. I am not making up any of it, but have the Blue Shield plan documents for every word of it.

    Question: My income dropped dramatically as a self employed realtor because my husband had a stroke and I became a full time care giver. My father in law took over our paying our monthly premium of $2,000 per month. He is running out of funds to help us out. Can I apply under special circumstances or do I have to wait for open enrollment. My insurance is through the California Association of Realtors group plan.

    Answer: Covered California will recognize that your the group health insurance is unaffordable, i.e your monthly cost exceeds 9.5% of your income. Therefore, you are eligible for Covered California individual coverage with premium assistance. However, to enroll outside of the open enrollment period, you will have to claim that your income change occurred within 60 days of applying. Whether your father-in-law pays or not is not relevant your eligibility.

    Question: What type of coverage is available if you can no longer pay your Cobra premiums and Covered California will not let you enroll with or without a subsidy because of having Cobra? My husband was laid of at the end of 2014 and accepted Cobra because the first 5 months were affordable at employee rates, but will increase to $2,300 a month which is not affordable (57% of our income). What can we do for the remaining 7 months of the year? There is no way to pay $2,300 a month until open enrollment.

    Answer: According to the ACA, if you have COBRA coverage you can enroll in Covered California under the following circumstances: (1) during open enrollment or (2) when your COBRA coverage expires. You missed the open enrollment period and can't afford to pay for COBRA to expiration because your COBRA coverage is unaffordable by any measure at your current income. If you can enroll in Covered California, your net premium after applying the subsidized premium assistance would be less than $400/mo for a Silver Plan (2-person household @ $48k/yr). So how can we make that happen? A significant change of income can trigger a "Special Enrollment Period" giving you 60 days to enroll in Covered California after the income change. Your income change after your husband's layoff was probably more than 60 days ago, but your employer continued to pay a portion of your COBRA premium - a form of income - for 5 months. When your employer stopped funding the premium, you experienced another change of income, significant enough to make your coverage unaffordable. I believe you can be enrolled in Covered California now, but this is a case where you would be wise to use a Certified Agent to submit your application and advocate for you.

    Question: I wish to open a health savings account with $5500 from a retirement fund. If I use pretax funds (which are fully tax deductible), must I report this as income to Covered CA, because if I must, then I would most certainly exceed the threshold for a subsidy. My actual question is this: Would I have to repay the entire subsidy for the year or only from the point at which my income exceeded the threshold (that is, December 2015, the month I intend to open the HSA)?

    Answer: Your plan won't fly. You can only open a health savings account (HSA) if you have a HSA qualified high-deductible health plan. That would be a Covered California plan labeled "Bronze 60 HSA". If you do not already have such a plan, you will not be able to change for one until 1/1/16. Secondly, if you take a $5,500 withdrawal from a qualified retirement account, the income will be reflected in your AGI and, whether or not you report it to Covered California, the IRS will adjust your tax due to reflect the added income and some of your premium tax credits will have to be repaid. If your AGI is above the subsidy threshold (400% FPL), then you would repay all of the subsidy you received.

    Question: I am under a Covered California Policy and turn 65 in August. Can I still keep my Covered California policy (and contribute to my HSA) for three months past my 65th birthday? Reason, I have reached my Deductible and Out of Pocket Maximum due to an unplanned surgery. Medicare allows me to enroll 3 months past my 65th birthday.

    Answer: No. You cannot keep your Covered California coverage once you are eligible for Medicare - the month you turn 65 - even if you were to delay your Medicare enrollment. Also, you cannot make contributions to a Health Savings Account after age 65.

    Question: I am self employed. after my adjustments for self employment and ira contribution, my agi is $18500. But, after that I take deductions for my real estate taxes and mortgage interest, and standard deduction, I am in a very low income tax bracket. Which figure should I use? the AGI or after real estate taxes mtg interest and standard deduction.

    Answer: For most of us, MAGI is the same as AGI - Adjusted Gross Income found on line 37 of the 1040. But more precisely, MAGI is the adjusted gross income plus any amounts excluded from taxation by section 911 (the exclusion from gross income for citizens or residents living abroad), any tax-exempt interest received or accrued during the tax year, and any portion of the taxpayer's social security benefits that are excluded from gross income.

    Do I Use 2014 Income?

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    Question: Next week I will be leaving my current job which provides health insurance. I am curious if covered california uses our income from 2014 to determine which plan we are eligible for or if they use an estimate for this year? I am returning to school and will make about 20,000.00 less than last year so I am a bit concerned?

    Answer: When you apply for Covered California coverage use an estimate of your income for 2015.

    Question: Is my income based on what I would make in a year if I hadn't lost my job or do I prorate the number for the year? Example. I was making $60,000/year. I got laid off at the end of April. do I prorate the number to $15,000 because that is what I will make if i don't get another job this year.

    Answer: If you did not receive another penny in taxable income for the rest of 2015, the amount you already earned - $15,000 in your example - would be your projected annual income. If you are eligible for unemployment income, estimate what you could collect for the rest of the year and add it to the income already earned for your 2015 estimate. If you were to get a job at some point, that income would be added to your annual projection. Any significant income change, such as you described, makes you eligible for a Special Enrollment Period (SEP) during which you can re-enroll and qualify for either Medi-Cal or Covered California coverage with premium assistance.

    Question: I received my 1095-a from CoveredCA back in January and noticed that it was not accurate. It showed policy dates of 4/1 to 10/1 with subsides for said months. The problem is that it included a subsidy for the 10th month when in fact it should not have. I filed my dispute over 60 days ago... I never heard from them. That said, I have been calling and have been told that they see the error and that the IT department needs to change the end date to the last day of 9th month. I've not been given a time frame with any certainty as to when this will happen. I have been told that the corrected 1095-a can't be issued until it does. So... my question is: Is there anyway I can get this resolved quicker? Is there a way for me to contact a rep that can actually get it fixed?

    Answer: Your don't need a corrected copy of the Form 1095-A to file your federal tax return. The Premium Tax Credit form used as part of your federal tax filing is the IRS Form 8962.pdf You know the correct amounts for total premium and premium tax credits from your monthly health insurance bill. Enter those amounts on the Form 8962 and get on with it.

    Sign-up an Unborn Infant?

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    Question: My independent 24 yr old daughter has Anthem insurance coverage through her father's workplace (Univ. of So Cal). My daughter is low income and it was our plan to enroll the infant in Medi-Cal through CC. We were under the impression that the infant would be covered by my daughter's plan for the first 30 days. Marin General, the hospital where her doctor delivers, has contacted her to let her know that because she is not the policy holder, the infant has no coverage at birth. They let her know that the infant will incur charges from the minute she is delivered and advised her to get coverage. We can't figure out how to sign up just the baby before birth without a social security number.

    Answer: You can't get Medi-Cal coverage for the newborn infant until after the child is born, but the baby's coverage will take effect retroactively to the date of birth. That means Medi-Cal will cover all of the newborn's expenses. Once the baby is born, the mother must apply on behalf of the baby using the Covered California online application even though you know the baby will be eligible for Medi-Cal.

    Married Filing Separatey?

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    Question: I filed married filing jointly in 2013. My husband moved out after Christmas 2013, & we have been separated. I qualified for assistance using our joint return 2013 for CoveredCA assistance for 2014. We filed married filing separately for 2014. I was accepted for coverage for 2014, but what will happen now? Will I still be covered? My income for 2015 will be less, as it was in 2014, but I am being given a penalty due to filing separately for 2014.

    Answer: Had you listed your tax filing status as "married filing separately​" on your Covered California application, you would not have been eligible for a subsidy. So it seems to me that you have disqualified yourself from the advance premium tax credits you received in 2014. If so, you are still covered and your premium assistance will continue until you notify CC of your tax status change. In order to continue getting premium assistance (assuming you still qualify based on income) you will have to change your tax status to single or married filing jointly.

    Question: If you have already been getting the credit, is the 4/15 2014 tax filing deadline firm that covered ca makes you agree to, or is an extension allowed until 10/15/15? what is the final consensus? thanks

    Answer: You must pay your 2014 taxes by 4/15/15 along with your application for an extension. In other words, even though you are filing for an extension, you still have to pay your taxes on April 15th.

    APTC over 65?

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    Question: Can a person over 65 receive APTC?

    Answer: Usually not, because most Californians over age 65 are covered by Medicare wich is considered Minimum Essential Coverage (MEC). Applicants who are eligible for MEC are not eligible for financial assistance unless they fall in this exception: If an applicant is eligible for Medicare part A coverage requiring payment of premiums, but is NOT enrolled in the program at the same time he or she enrolls in a Covered California plan (i.e., no dual coverage) will be eligible for financial assistance.

    Address Change?

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    Question: If I changed my address with Blue Shield and at my doctor’s office, will that the change also be updated at Covered California?

    Answer: No. You must change your address in Covered California account. If you don’t, you may not receive correspondence from Covered California - IRS Form 1095-A, important notices, renewal information, etc.

    Paying Back The Subsidy?

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    Question: I enrolled in Covered CA and opted to take all of the subsidy now rather than at tax filing time. Starting April, I will have a new job that provides insurance. When I file taxes next year, my income will be too high to receive a subsidy. Will I have to make up the difference for the full premium for the 3 months of Covered CA insurance?

    Answer: Yes, you will pay, but not that way. The subsidy paid to you in 2015 will be taxed as income based on the scenario you described.

    Question: If I enrolled in Covered California and received a premium subsidy, but recently got a new job with an employer whose coverage meets the requirements for affordable care, can I keep my Covered California insurance?

    Answer: No. You are no longer eligible for Covered California coverage because you have been offered employer-based coverage. You need to notify Covered California to cancel your coverage to coincide with the start of your group coverage.

    IRA Distributions as Income?

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    Question: I am going off my work insurance at the end of the month and am on Cal SDI from an injury as my only current income. Should I withdraw at least $16100 from my IRA to qualify for Covered California? I do not qualify for Medical. I anticipate my AGI to be about $20,000 this year, including IRA withdrawals. Is it OK to withdraw it as a lump sum and is it OK to convert to ROTH?

    Answer: Yes. If you withdraw money from your IRA it as taxed as income. That income will be included in your AGI. At $20k, for a one-person household, you will be eligible for Silver 87 coverage and cost-sharing reductions. Using some of that IRA income to fund a Roth IRA would be very smart if you don't need the money otherwise.

    Question: I own a company with 9 employees. They buy their own coverage through Obamacare. I started an HRA (Health Reimbursement Arrangement) four years ago to reimburse them for their out of pocket expenses, including their net premiums. Now i’m hearing that you can’t do that anymore. What’s the truth?

    Answer: What you are describing is referred to a standalone HRA - designed to work with individual insurance coverage. The IRS says, a standalone HRA cannot be used to reimburse employee premiums. The most recent guidance from the IRS - IRS Notice 2015-17.pdf provides additional clarity, but it provides no wiggle room for to those software vendors or third party administrators (think Zane Benefits) who continue to imagine ways to get around the standalone HRA rules. Employers with standalone HRAs have been giver until June 30, 2015 to get rid of them. Only HRA plans that are attached to a conforming group plan can be used going forward. Agents and brokers need to be very careful that they aren’t the ones left accountable for bad advice.

    Question: Does an employer document that spouses are excluded, may not enroll in group health plan, through the ERISA documents?

    Answer: The group health insurance agreement between the employer and the insurance company providing the coverage typically does not give the employer the option NOT to offer to insure spouses and dependent children or to put it another way - to offer "employee only" coverage. In California, the only 2 exceptions currently are SHOP and Kaiser Permanente.

    Question: My husband has employer group benefits offered to employee and family. However, his open enrollment period was Jan and we missed the cutoff to enroll family. Am I and my children eligible for tax credits?

    Answer: No. You were offered group health insurance by your employer, making you ineligible for tax credits. Whether you deliberately opted-out or forgot to enroll in your group plan does not matter.

    Medi-Cal Renewal Form?

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    Question: The Medi-Cal renewal form says "every member of your household who is living with you or is listed on your tax return". I am married filing separately (for a few years now) and qualified for medi-cal for myself and 2 kids last year through Covered California. At that time i was not living with my husband. My questions is should i list my husband or not? We live with him now, but file taxes separately and do not have medi-cal with him.

    Answer: Yes. His income is now a factor in your mutual eligibility, so if your household income is above $33k for 4-person household you and your spouse are no longer eligible for Medi-Cal and now eligible for Covered California coverage. But since you file taxes as "married filing separately", you are not eligible for premium assistance.

    Question: We are a family of 4 however my daughter, age 23,who I covered under the Covered California family plan. She files her own taxes. Do I have to claim her and her income on my taxes?

    Answer: No. If your 23 yr-old daughter files her own federal income taxes in 2015, she cannot be included as part of your household for CC eligibility. If she files fed income taxes for 2014 and you included her in your 2014 Covered California coverage, there is no penalty. However, you probably received excess advanced premium tax credits in 2014 which will be reconciled when you file your 2014 return. As for 2015, you have to remove her from your Covered California account and she needs to create a CC account of her own. She will be eligible for either Covered California coverage or MediCal based on her own income.

    Question: My mother came in May 2013. Up to today, she has lived in the U.S. for 1.5 years. She just got her green card couple weeks ago. Can she qualify for Medicare as she never works in US or lives in US for 5 years? If she can't qualify for Medicare, can she get any healthcare plan with good medical coverage (> $1million)

    Answer: Yes. You can enroll your 80-year-old mother in health insurance through Covered California even though she never worked in the US as long as she has legal residency in California. In fact, the only way to get her covered right now is through Covered Ca. She may be eligible for premium assistance otherwise the monthly cost will be pretty high as she will pay the monthly rate of a 64-year-old, the highest rate. Mom will be eligible for Medicare in 3.5 years, so she can use the Covered California coverage in the meantime. Longer term, she should apply for Medicare as soon as possible. Start at medicare.gov. She will have to pay for Medicare and cancel her Covered california coverage at that time.

    Replace COBRA Now or Later?

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    Question: If my COBRA coverage ends in July, do I have to enroll now or may I enroll in July?

    Answer: You can enroll in Covered California by 2/15/15 and drop your COBRA effective 3/1/15 if it is advantageous for you. Otherwise, you can keep your COBRA coverage until it expires and apply for Covered California coverage then as you will be eligible for a special enrollment period at that time..

    Kids in Medi-Cal Automatically?

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    Question: I was told that if I have Covered CA health plan, my child is automatically enrolled in Medi-Cal. Is that true?

    Answer: Not necessarily. It depends on the family income. If the household income is over 138% Federal Poverty Level (FPL) (approx. $33K for family of 4), but below 265% FPL (approx. $63K for family of 4), the children age 18 and younger are automatically enrolled in Medi-Cal. If the income is below 139% FPL, the parents are eligible for Medi-Cal as well. With income above 265% (and less than 400%) FPL, both the adults and children are eligible for Covered California coverage with premium assistance. If you or your children are eligible for Medi-Cal you can choose not to enroll, but you will not receive premium assistance.

    Question: When I initially applied for Obamacare through Covered California is was found eligible for Medi-Cal. Three weeks passed before I could correct the income figures in my application. At that time I was approved for Anthem coverage with premium assistance through Covered California which I recently removed. Now, over a year later, Medi-Cal started sending me enrollment questions. They still think I’m enrolling in MediCal! How do I put a stop to this?

    Answer: According to, Cathy Senderling-McDonald, Deputy Executive Director of the County Welfare Directors Association of California, county eligibility workers are unable to delete duplicate applications or remove applications upon a consumer’s request. Senderling-McDonald said, “Our county eligibility workers need to be able to tell the system, ‘This person is not eligible,’ or, ‘We need to withdraw this application,’” adding, “The computer can start that process, but our workers can’t and that was a huge oversight in the programming.” So I suggest trying to get your Medi-Cal enrollment cancelled by calling Covered California at 800-300-1506 and ask them to cancel the enrollment from their end.

    Question: Hi, I want to download my 1095-A as a PDF. I don't want to have to chase down the paper copy. Is it available online? Please make it easy and obvious to find once I log in.

    Answer: The Form 1095-A's have already been posted online. You will have to login to your Covered California online account. You may find the form in your Secure Mailbox (iffy) or more reliably on your Documents and Correspondence page. To get there, click on the Summary checkbox on the home screen and next click the Documents and Correspondence link, select and download the 1095-A document as PDF.

    Question: Will an immigration sponsor be responsible for Medi-Cal bills of the immigrant who is holding a permanent green card?

    Answer: No. To our knowledge, no government agency in California has sought reimbursement from a sponsor up to now.

    Debt Cancellation Distorts AGI?

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    Question: In 2013 and 2014 we had a debt cancellation (credit card settlements) since we were in financial hardship and weren't able to pay the credit card payments. We settled with creditors and paid off our debt but creditors have sent us 1099C forms and the amounts of cancelled debts were added to our income in 2013 and will be added in 2014 as well. This has raised our AGI tremendously for both years. Based on our actual income ,we are qualified but considering this phantom income (cancelled debt) seems like we won't be able to qualify. What do you suggest we should do? we need to send the 2013 tax return as proof of income. Can we to deduct the amount of 1099Cs from our AGI and report that amount? Please advise.

    Answer: In addition to submitting a copy of your 2013 federal income tax return, you will want to explain to Covered California that your 2013 Income Tax form includes an exceptional one-time lump-sum credit which distorts your adjusted gross income (AGI). Download a free online affidavit form and use it to explain your debt cancellation issue. Otherwise, I would leave your Covered California account as it is for now.

    Final Version of Form 8962?

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    Question: Phil, you posted a draft version of the IRS Form 8962 a while back. Do you have a download for the final version?

    Answer: Yes. Download IRS Form 8962.

    When you file your federal taxes, you or your tax preparer will use the information on Form 1095-A to complete IRS Form 8962. You will use Form 8962 to tell the IRS how much premium assistance was paid to your health plan on your behalf in 2014. Using the form you will:

    1. Calculate the total amount of premium tax credit that you are allowed to claim based on your coverage, income and family size.
    2. Compare the amount of premium assistance that was paid in advance on your behalf to the premium tax credit.
    3. Determine the amount by which the premium tax credit exceeds the amount of premium assistance received, if any. And, claim it as the net premium tax credit on your federal income tax return.
    4. Determine the amount by which your premium assistance received exceeds your premium tax credit, if any, and report it on your federal income tax return. You will have to repay some or all of this excess amount.

    How to Get IRS Form 1095-A?

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    Question: How do I get my 1095A form?

    Answer: You don’t need to do anything. Covered California will mail the IRS Form 1095-A to all consumers who got insurance through Covered California in 2014. They also send a copy to the IRS. The Form 1095-A has the information you or your tax preparer will need to file your tax returns. This form has information you gave about your family. The form also tells you:

    • How many months you had health insurance
    • How much you paid in monthly premiums
    • How much premium assistance was paid to your health plan on your behalf (if any)
    • Who was enrolled in your health plan

    Unemployed Adult Child?

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    Question: Adult non-disabled dependent is long-term unemployed. Parents are retired, on Medicare and income over $100,000. Is the dependent eligible for Medi-Cal if the parents do not claim the adult as a dependent on 2014 tax return?

    Answer: Yes. In this case, the parent's income is not a factor in the Medi-Cal eligibility determination. The unemployed adult-child is not a dependent for tax purposes, so he or she is considered a single-person household with no income for Medi-Cal eligibility determination.

    Question: I currently have private health insurance. I am looking at my options if I retire in 2015. My retirement AGI would be low enough to qualify for a subsidy under Covered Ca, and this may reduce my premiums by more than 50%. If I understand correctly, a low enough AGI might make me ineligible for this subsidy since I would qualify for Medi-Cal. Is this correct? What are the AGI thresholds for a single person in 2015? There seem to be many retirees in this same situation. They can afford to pay the subsidized plans, and they would rather not switch to Medi-Cal since it may not be accepted by their current doctor. Their options seem to be to either pay the full cost plan, or switch to Medi-Cal. Your thoughts?

    Answer: Since many retirees can control their income through investment withdrawals etc, it make sense to know what the Medi-Cal income benchmark is. The Medi-Cal threshold is set at $138% of Federal Poverty Level (FPL). In 2015, that's $16,105.

    Group Insurance or Medi-Cal?

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    Question: I have a family of 4 with gross income of $28k. My employer offers me affordable insurance for myself but no contributions to my dependents. Can I and my family go on Medi-Cal? Joe

    Answer: Medi-Cal eligibility rules do not conform to the ACA and IRS guidelines regarding access to affordable employer-based coverage. Your $28k income for a 4-person household makes you and your dependents eligible for Medi-Cal. You may opt out of your employer-sponsored coverage and apply for Medi-Cal.

    Question: I will become Medicare eligible 7/1/2015 and elect a Medicare Supplement or Adv plan. My wife has another year before Medicare Eligibilty. When/how should I notify CovCA and /or Blue Shield that I am going off but wife needs to stay on plan. I have heard of others who had both spouses cancelled and huge headache to get straightened out. Do not need that hastle! Thanks.

    Answer: You will need to cancel your Covered California coverage by June 15, 2015. You can remove yourself from coverage, leaving your spouse's coverage unchanged, through your Covered California online account. If you are not comfortable with the online method, your agent can handle it for you or you can call Covered California at 800-300-1506.

    VA vs Employer Coverage?

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    Question: I have had no medical insurance for 2014 except for how I am covered at the VA. The job I have for 2015 now offers insurance. Will I be penalized for using the VA and not acquiring CC insurance for 2014?

    Answer: VA health coverage is recognized by the ACA aa meeting the "minimum acceptable coverage" requirement, so you are not subject to penalty if you opt out of your employer-based coverage. If you take the employer's coverage and keep the VA coverage, your benefits will be coordinated with the employer coverage used first and the VA covering the gaps.

    Medi-Cal Managed Care Options ?

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    Question: Hi, I received a Medi-cal card, but no information on where to go, who to see!! It has been weeks, not sure who to contact. I had Kaiser prior which my parents were paying but it became too expensive. I would like to continue with Kaiser since i already have MDs there I am comfortable with. Is this a possibility?

    Answer: When you first qualify for Medi-Cal, you are covered under Medi-Cal Fee-for-Service. However, you must choose a managed-care health plan within 30 days. Managed-care plans like Health Net or Anthem come with their own provider networks. What that means to you is you don't have to struggle trying to find doctors that are accepting Medi-Cal patients. If you do not choose a plan within 30 days, the State will choose a plan for you. The county in which you live will determine your choice of Medi-Cal managed-care plans. For example, if you live in Los Angeles county you can choose between LA Care or Health Net while next door in Orange County you have one choice - CalOptima. Click here for a list of Medi-Cal managed care plans available in your county. If you find only one health plan, the county has chosen this plan for you. Please wait for your health plan information mailer in the mail. If you find multiple health plans listed, please explore each plan and choose the one that suits you and your family's needs. Remember, if you do not pick a plan within 30 days of receiving your health plan information mailer, Medi-Cal will pick a plan for you. However, you may also choose to stay in Fee-For-Service Medi-Cal.

    Should Have Been on Medi-Cal?

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    Question: I had a six figure income in 2013 and a 2 thousand dollar income in 2014. I work freelance and some years are very dry. I projected $29,000 in income when I applied for Covered CA. It didn't happen, but I left it as is because I thought one of the jobs would come through. So, I guess I should have been on Medi-Cal, though. What do I do now? And, will there be an issue since I received premium assistance in 2014? Thank you.

    Answer: You are obligated to notify Covered California of your change of income which would make you eligible for Medi-Cal, but there is no penalty for not doing so. If your 2014 income was under 100% FPL ($11,670), any excess tax due to over-payment of advance premium tax credit is limited to $0 for the year. For 1-person househol with income over 100%FPL but less than 200% FPL ($23,400), any excess tax due to over-payment of advance premium tax credit is limited to $300 for the year. Any cost-sharing reductions received through Covered California during the year are not recoverable. Covered California will receive your 2014 tax return data in the summer of 2015 and at some point after that, CC will require you to verify your claimed income if your 2014 AGI was more than 10% higher or lower the income you claimed.

    Switching from Cobra?

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    Question: If I end my health insurance with Cobra on 1/31/15 because it is to expensive and sign up for Covered CA when will the insurance start?

    Answer: If you apply through Covered California by January 15th, your new coverage will be effective on February 1st, 2015.

    Can I Get Private Insurance Subsidy?

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    Answer: I am fortunate to live with a daughter who has paid for my entire monthly insurance plan out of her pocket (she didn't claim me as dependent, so she also doesn't get any tax credit). For upcoming 2015 year, we feel that it is putting a lot of strain for her to pay close to $9000. Though Medical is an option for me, we both would prefer to stay with private insurance. I don't have any income. I live with my daughter who provides me with everything. If I can get CC subsidy, I wouldn't mind filing a tax return. My question is: is there any way I can go through CC and opt out of medical? My daughter is willing to pay me for housework, etc. Wondering if that's something I can report to IRS, thus I can become eligible for CC subsidized plans.

    Answer: You are eligible for Medi-Cal, but you don't have to take it. You can choose private coverage instead, but will not be eligible for a subsidy. Your daughter can pay you a salary, but you would have to earn over $16,500 per year for you to qualify for a subsidized private coverage rather than Medi-Cal.

    Change Plans after Dec 15th?

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    Question: Can I switch plans in 2015 if I decide to do so?

    Answer: Yes. The open enrollment period ends February 15, 2015. You can make changes until that date.

    How Long Does it Take?

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    Question: I signed up with KP and made the initial payment on CC over the weekend. I called KP today and it said it does not have the application nor the payment yet and may take 4 weeks for the info to show up in its system. Does it really take that long?

    Answer: No. This business of putting you off for 4 weeks is just lazy or incompetent, probably both. Call Covered California and confirm that your enrollment is correct in their system. When it is, ask them to resend the enrollment to Kaiser and get an incident number from CC. Wait a couple of days and call Kaiser back with the incident number. If you get the 4-week BS again, demand to speak to a supervisor.

    Deadline Extension?

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    Question: Does the recent extension for enrollment by Dec 21st ( vs Dec 15th) for 1/1/15 effective dates apply only to applications already started by Dec 15th? Or can agents/CIAs assist any New Individuals with applications/enrollments by then?

    Answer: Covered California has extended the deadline for January 1, effective date to midnight Sunday, December 21 for all applicants, agents and consumers.

    Children Forced into Medi-Cal?

    By on | 3 Comments

    Question: Why am I only being given the option for Medi-Cal for my children (age 5) on our CoveredCa application? We want them on our chosen plan (a Blue Shield PPO) but Covered Ca is not allowing that option. Our income is far above the Medi-cal limits for a family of 4.

    Answer: For a 3-person household, your income would have to be $50,000 or more for the children to be eligible for subsidized private insurance while it only has to be $20,000 or more for the adults to be eligible. Why is that? It's a lot cheaper to cover people on Medi-Cal than to subsidize them with private insurance. Ultimately, it costs the taxpayers less and reduces the overall cost of healthcare.

    Find Providers for Anthem Blue Cross?

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    Question: How do I find providers for anthem blue cross under covered california?

    Answer: To view a list of in-network doctors for your Anthem individual health plan:

    1. Go to www.anthem.com/ca.
    2. Under Useful Tools on the right, select Find a Doctor.
    3. Under Search by selecting a plan/network, go to Select a state.
    You can enter the name of your state or select it from the
    drop-down list.
    4.Under Select a plan/network, you can enter the name of your
    plan/network or select it from the drop-down list then choose
    Select and Continue.
    5. Using the drop-down boxes, select what type of doctor and the
    location you're looking for, then select Search.
    6. For more info about a provider (like skills and training), just select
    that name in the directory.

    Question: CC qualification is based on income only while Medi-Cal is based on both income and assets. So if a person with no income but has more than $2,000 in the bank would not qualify for neither CC nor Medi-cal?

    Answer: No. Qualifying for Medi-Cal no longer considers assets if one applies through the Covered California. So, no, a "low-income" applicant cannot be found ineligible for both. On the other hand, if one applies for Medi-Cal directly through the DHCS, assets are still considered. Go figure!

    Question: If an employer offers “affordable” coverage for the employee, but the family cannot afford the dependent coverage and the family income is below the Medi-Cal eligibility threshold, is the family still eligible for Medi-Cal? Is the employee disqualified from Medi-Cal by the “affordable” employer plan? If so, are the wife and kids eligible for Medi-Cal?

    Answer: Under the ACA, qualification for Medi-Cal is completely separate from subsidy-eligibility rules. Employees, will not be disqualified from Medi-Cal if their employer provides benefits, whether or not those benefits meet affordability guidelines. (This answer was provided by expert agent, Anne Kelley.)

    Reporting Border-Line Income?

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    Question: My income puts me on the border line of me getting premium assistance or Medi-Cal. It fluctuates greatly from month to month. Would I get switch back and forth between CoveredCA and Medi-Cal?

    Answer: If you estimate your income for 2015 to eligible for Covered California premium assistance, you will not be switched to Medi-Cal during the year unless you notify Covered California that your income makes you eligible for Medi-Cal. Conversely, if you start the year in Medi-Cal, you won't be switched to CC unless you report higher income to Covered California.

    How to Send Verification Documents?

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    Question: Where do I send covered ca requested verification documents?

    Answer: Send your documents in one of these three ways:
    • Online using your account at www.CoveredCA.com
    • By fax to 1-888-329-3700 (1-888-FAX-3700)
    • By mail to:

    Covered California
    PO BOX 989725
    West Sacramento, CA 95798-9725

    Do You Need Financial Assistance?

    By on | 4 Comments

    Question: One of the first questions asked in Cover California website is that "Do you need financial assistance?". If I answer "no" for now and it turns out that I'm qualify for assistance when I do my 2015 tax a year from now. Would I still be able to get premium tax credit?

    Answer: Yes. If you answer no th the question, "Do You Need Financial Assistance?", your Covered California account still include your tax information and you will be able to claim a tax credit later. However, if you enroll off-exchange, you cannot later claim tax credits.

    Current or Future Income?

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    Question: I'm 24 and living in my parents' home. I'm currently unemployed (since Nov '14) and have $0 current income. I will be starting a contractor position in January. Should I keep my current $0 income and make changes later or must my current application somehow reflect changes that will come about in 2015?

    Answer: In estimating your 2015 income, you would be more accurate to use your income from the contractor position as if it would continue for the year. You can change your income later, if you have a significant income change one way or the other.

    A Bird in the Hand?

    By on | 9 Comments

    Question: My income fluctuate from month to month. I prefer to pay the premium first then get the premium in tax credit, if any, in one lump sum after I do my tax for 2015. Can I do that? If so, what happens to the case if my AGI qualifies me for medi-cal? Would I still be able to get any tax credit in that case?

    Answer: Yes you can opt to take your tax credit at the end of the year. However, if your income makes you eligible for Medi-Cal you will receive no tax credit. On the other hand, should you take your tax credit as an advance and later be found eligible for Medi-Cal, your income tax liability will be much lower than the tax credits you received and your payback will be limited to a fraction of what you got. I'm not recommending gaming the system, but at least for now, that is the way it is.

    Tax Credit Reconciliation Forms?

    By on | 6 Comments

    Question: Where on the tax form is the Covered California premium reduction reconciliation done? As I was going through my taxes on TurboTax, it told me that based on my income, I was not eligible for the full premium reduction that I received, which means I owe some of that back. I can't see this reconciliation anywhere on the summary of my tax return. Where does this appear and where can I see how much I owe?

    Answer: There are 2 IRS tax forms that you are going to need. First, IRS Form 1095A (draft version of form here) is issued by Covered California to every household eligible for a subsidy in 2014. It will be sent to you by 1/31/2015. It documents your coverage by month including premiums paid and advance premium tax credits received in 2014. Then, you will use IRS Form 8962 (draft version of form here) to reconcile 2014 federal income tax due with advance tax credits received.

    Adult Child in Household?

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    Question; My daughter is 26 and will be needing her own insurance. She lives at home but files her own income tax and is not claimed on ours. Does she apply as a household of 1 or do all household members have to be put on her application.

    Answer: Yes. If your adult child files a tax return, she would apply for coverage through Covered California as a one-person household. Her income alone will determine her eligibility for premium assistance or Medi-Cal.

    No Way We Qualify for Medi-Cal?

    By on | 3 Comments

    Question: Our stated family income for a family of 5 was $80k for 2015 yet they sent us a letter that we all qualify for medi-cal. Letter says we can appeal but I see no way to do it on their website and cannot get through on the phones. Can't read secure mailbox due to some java issue. Advice?

    Answer: If you already have Covered California coverage and your status was recently changed to Medi-Cal eligible, it's because the IRS has reported that your 2013 AGI was $38,000 or less. So if you can show that your current income is closer to $80,000, then you will be able to to get your status changed back to subsidy eligible private coverage. If you are applying for for Covered California coverage the first time and you reported your income at $80K and are found eligible for Medi-Cal, you've probably made an error on the application. The most common cause for this error is by entering an incorrect "end date" when entering your income. LEAVE THE END DATE BLANK. (How a casual user would know to do this is beyond me as we only learned through trial and error.) As for how to get through to Covered California, I have no sure-fire advice other than to avoid the busiest times - normal business hours. Try calling just after 8:00 AM or just before 8:00 PM. Good luck.

    Question: Can a Self Employed person continue to deduct INDIVIDUAL Medical Insurance Premiums in 2014? Does it matter if they got their coverage ON or OFF the exchange?

    Answer: Yes. If you are self-employed, a tax deduction generally available for medical (on-exchange or off-exchange), dental or long-term care insurance premiums for yourself, your spouse and your dependents. (The insurance can also cover your child who was under age 27 at the end of 2014, even if the child was not your dependent.) You must have a net profit from self-employment. You would report this on a Schedule C, Profit or Loss From Business, Schedule C-EZ, Net Profit From Business, or Schedule F, Profit or Loss From Farming. You had self-employment earnings as a partner reported to you on Schedule K-1 (Form 1065), Partner's Share of Income, Deductions, Credits, etc. You were paid wages reported on Form W-2, Wage and Tax Statement, as a shareholder who owns more than two percent of the outstanding stock of an S corporation.

    Preventative Care?

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    Question: What is a preventative care appointment include? Labs, Pelvic Exams, Office visit?

    Answer: All ACA-compliant health plans and must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. (This applies only when these services are delivered by a network provider.) 1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked 2. Alcohol Misuse screening and counseling 3. Aspirin use to prevent cardiovascular disease for men and women of certain ages 4. Blood Pressure screening for all adults 5. Cholesterol screening for adults of certain ages or at higher risk 6. Colorectal Cancer screening for adults over 50 7. Depression screening for adults 8. Diabetes (Type 2) screening for adults with high blood pressure 9. Diet counseling for adults at higher risk for chronic disease 10. HIV screening for everyone ages 15 to 65, and other ages at increased risk 11. Immunization vaccines for adults—doses, recommended ages, and recommended populations vary 12. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk 13. Syphilis screening for all adults at higher risk 14. Tobacco Use screening for all adults and cessation interventions for tobacco users

    Newborn Coverage Gap?

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    Question: I am currently pregnant and have Blue Shield Silver 87. Based on my family income, newborn will be placed to Medi-Cal. I am worried that newborn's cost of staying/treatment in the hospital will not be covered by Blue Shield since the doctors and hospitals are not Medi-Cal network. Do you know if they have exception for this case and cover newborn? Truly appreciate your answer.

    Answer: Your Blue Shield policy will cover your newborn's medical costs automatically up to 31 days after birth. You should apply through Covered California as soon as possible after giving birth and if your infant is Medi-Cal eligible, his or her coverage will be effective immediately. In any case, you should not experience any gap in coverage for your child.

    Adult Dependent Coverage Options?

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    Question: I need to know if I am required to put my 21 year old son on my employer insurance now? He does not work and would qualify for Medi-Cal. Also, if I claim him as a dependant does that factor into if I must add him?

    Answer: Your son can opt out of your group health insurance plan and enroll in Medi-Cal even though he has been offered affordable, minimum-standard value health insurance through your employer if you do not claim him as a dependent in 2015. If you do claim him, his eligibility for Medi-Cal (or subsidized private insurance) will depend on your household income, not his.

    Question: My adult daughter is 24 and single. She is no longer our dependent for tax purposes. Due to the ACA, she continues to have insurance through her father's plan through USC until age 26. She is expecting a child in April 2014. Will the child be covered? And will the child continue be covered until our daughter turns 26?

    Answer: No. Your newborn grandchild will not be eligible for coverage under your husband's employer-sponsored plan. Your daughter must complete a Covered California application for herself right after the child is born, indicating that she has "been offered affordable, minimum standard value health insurance" and that only the baby will be enrolling. Depending on your daughter's income, her newborn child may be eligible for Medi-Cal or subsidized Covered California coverage.

    Help Select a Plan?

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    Question: I need to find live person to help me select a plan.

    Answer: Go to www.Coveredca.com, click on the Get Help menu, then Find Local Help, then Find a Certified Insurance Agent, then enter your ZIP code. Call one of those agents and you'll get the help you need. By law, only a Certified Insurance Agent is allowed to give you advice on selecting a plan, all other "helpers" can only get you to that point, but cannot advise.

    Question: My husband is insured through his employer here in California. There is a very small staff (under 10). I have not been offered health coverage, for my husband says that the employer is not obligated to offer it to me, or our son. Is this true? I have read conflicting items online. Thank you.

    Answer: It is virtually certain that your husband's employer-sponsored small group coverage includes coverage for dependents even though you may find it unaffordable because the employer is not required to make any contribution toward dependent coverage. That means you have "access" to small group coverage and are probably ineligible for premium assistance and cost-sharing reductions through Covered California. However, if you cannot enroll in your husband's plan now due to being outside the plan's open enrollment period, I see no reason that you can't enroll in CC with premium assistance until you can be added to his employer's plan at the next plan renewal.

    Currently in California, SHOP and Cal Choice are the only sources that allow groups to offer coverage to employees without including dependents. Your husband's employer should consider changing coverage to SHOP or Cal Choice and elect "employee-only" coverage. That will free all the dependents to eligibility for premium assistance and cost-sharing reductions through Covered California. If the employer goes with SHOP, the company may be eligible for small group tax credits as well. Employers should contact their broker for more information.

    How to Pay Now?

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    Question: I just signed up through covered CA for Anthem Blue Cross policy. I tried to make a payment on site but got nowhere. Now what?

    Answer: Log in to your Covered California account, go to the summary page and select the "Pay Now" button at the bottom of the page. If you can't do it, let your agent know. He or she can take your payment over the phone.

    Question: After having so many problems with Blue Shield through CovCA, I have decided to just go direct with BS during open enrollment for 1/1/2015. Can I just apply directly to BS now and when confirmed I have coverage starting 1/1/15- terminate participation in CovCA/BS eff 12/31/14?

    Answer: Yes, you can do that, but the carriers are not immune from screw-ups themselves. The safest way not to create problems for yourself is to do nothing. That way your coverage will renew without changes.

    When One Applicant is Over 65?

    By on | 3 Comments

    Question: I looked at rates for a 2 person household- age 67 and 63. Plan quotes seem to reflect both being covered although the 67 year old , while part of the household for premium subsidy amount, has Medicare and not eligible! Perhaps it would be settled out in application process but meanwhile quite shocking to see the huge rate for 1 person.

    Answer: I will assume that you are referring to the "Shop and Compare" tool at the Coveredca.com site. I'll also assume that your 67 year-old spouse is on Medicare. In that case, he or she is not enrolling in Covered California. The online tool has a checkbox that should be left unchecked for the 67 year-old. The silver plan rate for a 63 year old should be about $700/mo unsubsidized. If the older spouse is ineligible for Medical and must enroll in Covered California coverage also, then the premium for the 2 of you will be about $1500/mo unsubsidized.

    Question: I'm getting significantly different results when using the Shop & Compare tool versus logging in and using the Preview Health Plans tool. I put in identical data (zip, age, income), and get different premium assistance values from each tool. For example, the Shop & Compare tool gives me a final monthly amount of $80 for a plan I'm interested in (after premium assistance), whereas the Preview Health Plans tool gives me a total of only $17.54. Which number is likely to be correct?

    Answer: I don't have a definite answer, but the net premium result you get in the plan selection step of your online application would appear to be the correct number as CC provides a confirmation of coverage and premium at the end of the process. Ideally, they should be identical, but that may not be practical at this point.

    Add Dependent for 2014?

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    Question: My daughter has her own CC policy in 2014 but I want to include her with mine for 2015 as we will be filing taxes together. A cannot find any way to add a dependent using the CC website. Any suggestions on how I would add her as a dependent?

    Answer: Now that open enrollment has started, you can make the change yourself. If you know your username and password, you can use the "Account Sign-In" link (click image to enlarge) Sign-In.png. Once in your CC account, click on the "Renew" button. You will have to verify your identity by uploading a copy of your ID (license etc.) and then you can add a family member.

    Non Tax-Filer Refund?

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    Question: I overestimated my income for 2014. I do not pay any taxes, so I cannot get a tax credit. A Covered CA rep said I would get a refund check in the mail for the amount I over-paid on my insurance premiums. Is this correct?

    Answer: No. If you do not file a tax return for the 2014 tax year, you are not eligible for a tax credit. If you should decide to file taxes, the tax credits based on your income will be reconciled on your tax return. You will pay less tax, but there will not be a refund check.

    College Tuition Deduction?

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    Question: I find the area of tuition with regard to CC to be confusing. The paper application identifies tuition and fees as a deduction from income. In looking at drafts of tax forms like 1040, 8962 and 1095A, I don't see how this will work. The tuition deduction has been removed from 1040 and I have not seen anyplace where tuition will affect income as it relates to CC. Thinking it should be deducted as the forms continue to have that as a deduction from estimated income. Would you have any insight into how tuition will be deducted from income for purposes and can you confirm that it would be deductible?

    Answer: According to IRS Tax Publication 970, you can reduce your income subject to tax by up to $4,000 per year. This would apply to Covered California subsidy eligibility as well.

    Spouse Eligible for COBRA?

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    Question: I will be retiring at age 66 in February but will need to work part time as a self employed freelance electrical estimator. I will have Medicare, but my wife is only 63 years of age. The question is can she pick up the cobra plan for the spouse thru my company even though I will be retired and self employed.

    Answer: (Corrects previous response) Yes. Your wife is eligible for COBRA continuation. She can also purchase individual health insurance any time after December 15th for coverage effective February 1st 2015.

    Still Too Many Bugs?

    By on | 28 Comments

    Question: I've been trying to submit an income verification via the website for the last week. Every time I try to do so, I get an error message. I just trying calling CoveredCA, and got a message that said their call volume is greater than normal, goodbye. So all this time, and they still haven't gotten the basics working yet? Anyway, my question is, should I wait until the fix uploading verification on the website, or mail or fax it in? Last year I was never sure which method to trust.

    Answer: I would trust the online upload above fax or mail. If it doesn't work, wait until after 11/15/14 to try again. Let's review the online upload process, just in case it's not a bug. (1) Access your CC account and click on the "Eligibility" check-mark. (2) you will see the name(s) of each person in the household and the document requirements for each.(If you don't see a document verification required, then wait for after 11/15/14 to contact CC.) (3) Click on the "Upload Documents" link and select the type of item to be uploaded, (4) Browse your computer for the PDF file to be uploaded. (5) Click on the "upload" button in the lower right corner, The document should be received in a matter of seconds (look for a barely visible green verification of upload statement at the top of the upload window.

    Underestimated Income Penalty?

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    Question: I underestimated my daughters income thinking her college tuition would be deducted. Now, thinking it will not be which makes her income closer to 200% (around $22,000) which would put her in a bronze plan as opposed to the 94% shared plan she has had. Looks like her monthly payment would be similar for both. Should I contact Covered CA now to ask and potentially correct or just wait until next year when taxes are done? Will there be any charges if she no longer qualifies for the 94% plan she has had?

    Answer: Your daughter can choose a Silver plan or any other "metal" level of coverage regardless of her income. Her income still qualifies her for cost-sharing reductions (lower deductible and lower copayments) which are only available with Silver plan. If she is no longer eligible for the Silver 94, then she will qualify for the Silver 87 plan. In any case her share of the premium will be around $110 per month. If she was advanced too much tax credit as a result of underestimating her income, she'll give some back when she pays her taxes for 2014, but it should not exceed $600 if her income is 200% FPL or less.

    2015 Paper Application?

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    Question: Has anyone found a link to a Paper Application for 2015 Open Enrollments?

    Answer: The Covered California paper application used last year is still good. Here's the link to download:

    Error Code "000"?

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    Question: Got my renewal letter a few days ago. Have been trying to renew on my online account for several days, but when I get to the end to submit, I keep getting error code 000. It's allowing me to verify everything, its just at the end when I hit "submit" I get the error code - Does anyone know what this means?

    Answer: Covered California recognized a software glitch causing a "000 error code". They advised to try again later. If you continue to have the same problem, wait until November 15th, when all should be running well.

    Cedars Doesn't Take My Insurance?

    By on | 5 Comments

    Question: My son has a preexiting heart condition. He needs to continue with his cardiologist who as treated him his entire life. What can I do to get coverage that cedars will take?

    Answer: You can change plans during the annual open enrollment period. This year it starts November 15th. Your change of coverage will not be effective until January 1 2015. Work with your agent to find coverage that includes Cedars Sinai.

    Trouble Uploading File?

    By on | 1 Comment

    Question: I have submitted numerous documents to covered ca since April2014. This is the second time I am trying to upload and it is saying file type not supported. I have sent it in jpeg,bmp,and tiff all in grayscale. All of my other documents submitted were in jpeg. Online chat said to try another browser. tried google chrome, no go. using internet explorer. the last time this happened, I just kept trying daily till it was excepted. here we go again! the problem is with the website. What a horrible website!

    Answer: The preferred format is PDF. The image formats you have been using create much larger files than PDF. Scan and save your documents as PDF files. You should have no further problems.

    EPO and HMO Coverage Out-of-State?

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    Question: I have to be in another state for half the year but am a resident of CA. What I am seeing is all plans offered in my area for 2015 are going to be either EPO or HMO plans. In the past I had doctors in both states that I used that were in-network. What am I to do now for non emergency coverage when I am out of state?

    Answer: You are correct. EPO and HMO plans will only cover emergency medical care in another state. This is only an issue if you are eligible for a subsidy and must buy your coverage through Covered California. Otherwise, there are PPO plans available off-exchange that can provide out-of-network benefits at your second home.

    Close Covered California Account?

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    Question: I signed up one family member with the incorrect DOB (typo is off by one day). I cannot get it resolved and it is now causing rejected claims and billing problems. DOB can only be changed at CC by an IT tech person. We’ve gone that route twice in the past 5 months and neither the CC account nor the Anthem account is updated. Some insurance sites advise closing the account and starting over. The family member is undergoing diagnostic services and treatment at this time so I do not want them to be without coverage. But having the wrong DOB is like being uninsured as the claims are not being paid. Can any agent please advise on best way to reach a resolution at CC (who will then update Anthem)? Or is canceling and starting over the only way? Thanks for your assistance.

    Answer: Expert agent, Max Herr, says: DO NOT CANCEL THE ACCOUNT!! Doing this will terminate coverage and you won’t be able to get it back until January 1, 2015. You should be able to resolve this with a phone call to CoveredCA (800-300-1506). Although you will probably have to wait on hold for an hour or more, it should not take an act of Congress to get a CSR to make the change. Do you have a designated Certified Insurance Agent? If you did, that agent ought to be able to get the change made for you. I’ve been able to get similar changes made without difficulty.

    Question: My Husband took out 20,000 from his IRA, I believe it raised our income to 47000 which normally be around 27,600 with half of his SS and my rental income. I did not report this chanage as I am confused on what is Income, if we do not count on that money yearly nor will we 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: Yes.Based on what you've told me, your taxable income for 2014, will be about $47,000. Since you are collecting a monthly subsidy based on an estimated income of $27,000, your excess subsidy will be about $1,700 for 2014. What that means to you is, your tax bill for 2014 will increase by $1,700. I suggest save up the $1,700 to pay the additional taxes in April, but do not change your income with Covered California. That's because in 2015, your income will return to to about $27,000 and you'll be back on track will a minimum of complications.

    Split Coverage and Subsidy?

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    Question: If a spouse wants to stay on COBRA while the other spouse applies for Covered California during open enrollment, will the "household income" calculation still apply to both spouses' total income even though the coverage is for one?

    Answer: Yes. The combined income of both spouses is used in the subsidy calculation even though only one spouse will require coverage through Covered California. Of course, the subsidy will be less for the one spouse enrolled than it would have been if both enrolled.

    Medi-Cal Excess Charges?

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    Question: I recently scheduled an appointment with a doctor for a physical. This was a new doctor under Medi-Cal Anthem Blue-Cross that I had never seen before. The doctor had me sign something saying that no matter what my insurance was I had to pay extra to the doctor for whatever the insurance didn't cover. I was surprised they had a medi-cal patient do this as I thought the doctors agreed to accept what medi-cal paid. Now I am afraid to go back as I know I will not be able to pay anything out of my own pocket. Is this even legal? BTW I waited 3 weeks to see the doctor and was given the doctors PA to talk to. Never even saw the doctor at all.

    Answer: Since you are enrolled in a Medi-Cal Managed Care Plan through Anthem Blue Cross, you need not worry about the "excess billing" language in the standard Doctor/Patient Agreement. If your doctor orders a test or procedure that is not covered by Medi-Cal, he will tell you in advance. If you feel you have been taken advantage of, you can file a grievance against the physician with Anthem.

    Waiting for Medi-Cal?

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    Question: I called to cancel my Anthem plan because I lost my job and applied for Medi-Cal. I haven't heard much back from MediCal yet and Anthem is bugging me to pay the premiums. What do I do?

    Answer: At this point, Medi-Cal still has a backlog of about 300,000 applications to process. Let's say your application is in that pile. Medi-Cal will cover you retroactively to the date of your application. So if you let your individual policy lapse and have unavoidable medical expenses in the coverage gap, you can eventually be reimbursed for some of the money you had to put out. But it won't be easy.


    By on | 1 Comment


    Answer: Diane, your caps lock key is stuck. Health Net needs to know you are now on Medicare. Call them and tell them. The number is on your insurance card. You will not have to pay premiums after May 1st.

    Individual vs Agency Rights?

    By on | 1 Comment

    Question: This question comes up quite a bit especially when there are several agents working under an agency, Can a certified covered ca agent write business under another certified agent log on, using their id and password and pin? Is is ok for the entity business owner to demand an agent to write under to log in so commission's are paid to the Entity? What liable affect can this have on the agent who is write's under the other agent? Especially when all agents signed a contract direct with coveredca?

    Answer: If your employer has any sense at all, she told you before you accepted the job that you would not be paid commissions directly from the insurers, but according to some internal compensation plan for your agency. The issue of logging into another agent's Covered California account is not against any Covered California rules that I know of so in my opinion it can be done until someone tests it formally or perhaps legally. The contract you signed with Covered California is not a factor unless you enroll CC applicants through your own broker account.

    Estimating Income for Part of a Year?

    By on | 7 Comments

    Question: Currently enrolled in CoveredCA with a subsidy. When I turn 65 in August of 2015 I will change my plan to medicare, will my subsidy for the first 7 months of 2015 be calculated on my income from Jan 1 - Aug 31 of 2015 of will my subsidy for the first 7 months of 2015 be calculated on my income for the entire year of 2015?

    Answer: This seems tricky, but it's not. Your subsidy for the first 7 months of 2015, should be based on your estimated monthly income from Jan 1 to Aug 31 of 2015. The Covered California application software will convert this monthly average to an annual income number from which your subsidy is computed. This may seem to overestimate your subsidy eligibility, but since you will only drawing 8 months of the subsidy before moving to Medicare, you will not be drawing too much, or more importantly, leading to any unpleasant surprises on your tax return.

    Question: What can agents who are dissatisfied with Covered California service do to be heard by the people who run the agency?

    Answer: Max Her replies, "If you, like I, are dissatisfied with the performance of CoveredCA, the Call Center (FOUR hours on hold today pursuant to the notification that four of my clients' documents were not in order and that they are in jeopardy of losing their coverage -- none of which is accurate), $58 payments for Medi-Cal enrollments that have never materialized, and so on, please email me (max.herr@verizon.net) with your complaints and concerns."

    "I have decided to fly to Sacramento for the September 18 CoveredCA Board Meeting and will try to find a way to air our grievances with the Board in public session. We are, I believe, not being given the credit we deserve for effecting a significant percentage of both Medi-Cal and QHP enrollments for 2014, nor are we being asked for our input on how to make the system more efficient and accountable, and I believe it's high time to hold Peter V. Lee and the Board accountable to us for a change."

    I look forward to hearing from you. I will print your emails and deliver them personally to the Board at the meeting. Ideally, it will be a large stack of paper.

    Question: I currently have my children covered under my employers group plan. Our group plan open enrollment is now. I have been told that if I add my children now, I can't remove them on 1/1/15 to go to individual plans. Is individual open enrollment a qualifying event?

    Answer: Once enrolled in a group plan your cannot voluntarily drop your coverage without a qualifying event but you can drop coverage for your dependents anytime, no qualifying event required. There is no need to wait for open enrollment. Your children are not eligible for premium assistance (subsidy) because they are offered group coverage through your employer. You can purchase off-exchange individual coverage for them, or they may be eligible for Medi-Cal.

    Rate Change for All on Jan 1st?

    By on | 1 Comment

    Question: If a person signed up for a September 1st start date because of a special enrollment period due to loss of group coverage. Will their rate change on Jan 1st,2015?

    Answer: Yes. All ACA-compliant individual health insurance plans change rates annually on January 1st.

    Chargeback for Medi-Cal?

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    Question: I have a friend who applied thru Covered CA using her current income which put her into Medi-Cal...but she also received some alimony payments earlier in 2014 which she did not account for. She expects her 2014 MAGI to be about $30,000 which is too high for Medi-Cal. Medi-Cal won't release her back to Covered CA to choose a subsidize plan unless her current income changes. Is it a problem that when she does her taxes, her AGI will be too high for her to qualify for Medi-CAL?

    Answer: No. There is no chargeback, nor any other tax consequences, for one who is insured by Medi-Cal and subsequently reports income in excess of the Medi-Cal MAGI (modified adjusted gross income) benchmark. During the next open enrollment period, your friend should re-apply through Covered California and adjust her income to include the alimony income.

    Question: My sons ages 12 and 16 are enrolled in Medi-Cal because of my income. Their primary care doctor will no longer treat them while they are on Medi-Cal, and I can’t find one who will take him. What can I do?

    Answer: It was bad before the ACA (2011-2013), with only about 60% of the California primary care doctors accepting new Medi-Cal patients. It has gotten much worse this year as the ACA added over 1 million new cases to the Medi-Cal roles. However, the distribution of Medi-Cal visits among California physicians is highly skewed. About one-third (35%) of physicians accounted for 80% of Medi-Cal visits. Emergency doctors and others who work primarily in hospitals had the highest rate of Medi-Cal participation (82%). Physicians at community health centers and public clinics had the highest rate of Medi-Cal participation (92%), and those in solo practice had the lowest (54%). You may have better luck finding a doctor for your sons in a large multi-doctor practice or community health center.

    Reporting a Change?

    By on | 2 Comments

    Question: If after I completed my application and my QHP has been effectuated, I now need to change an incorrect birth date. Do I make that change through Covered California or through the QHP. If Covered California what is the process?

    Answer: To change a date-of-birth go to Covered California not the carrier. Login into your CC account and make the change yourself, have your broker do it, or call CC at 800-300-1506.

    Employer Offers No-cost Plan?

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    Question: Employer is offering what is exactly like the lowest cost bronze plan on covered CA and it would not cost me anything out of my monthly salary. In fact, they said that I would even get an extra 1300.00 at the end of the year from them. However, I have type 2 diabetes and would be paying 100% of lab and drs visits before the $5,000 deductible is met. I am in the 138% of poverty range and am not able to do this. unfortunately if I turn it down I cannot get any help from subsides because of their offer being considered affordable. Any ideas?

    Answer: Sorry, I have nothing. You cannot get any help from subsides because your employers group coverage offer is considered "affordable". You have to accept the company plan. However, the $1,300 you receive at the end of the year will go a long way in covering your out-of-pocket expenses for doctor visits and labs.

    Health Insurance Tax Deduction?

    By on | 6 Comments

    Question: Can I claim self-employed health insurance deduction (1040, line 29), if now part of my premiums are subsidized by Obamacare? If yes, what will happen after IRS reconciles the advance premium tax credits (subsidy) for 2014 and withholds certain amount, because my income is more than I projected? Will I be able to claim that I paid this extra amount as health insurance premiums and add it to 2014 deduction?

    Answer: You can only claim the net premium - the portion you actually pay after the subsidy - as an expense. Enter that portion as your self-employed health-insurance deduction. If there is a subsidy reduction for added income at the end of the year, that incremental net premium would also be added to your self-employed health-insurance deduction.

    Former Employer Won't Drop Me?

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    Question: Hi, my ex employer refuses to drop me from his group health insurance policy. i dont understand why he is doing this but it's barring me from getting my own independent coverage from the same provider. Should i just try to find a different provider or is there something I can do?

    Answer: Your former employer is breaking his contract with the insurance company that underwrites his company health plan. Group coverage is only for employees currently on the payroll. You can put a stop to it by calling the insurance carrier's customer service department and explaining what he is doing. In the meantime, buy coverage from another carrier if the value proposition is similar.

    Mid-Year Income Change?

    By on | 5 Comments

    Question: I estimated my income to be $24,000 for 2014 at the beginning of the year. As months are going by I am now estimmating it at $60,000. Should I make that change on my profile or wait?

    Answer: That's a pretty significant change of income. It makes a big difference to your bottom line. If you are a single person, you're net premium now is about $150/mo at $24K annual income. At $60k, you are no longer eligible for a subsidy, so you pay the full premium based on your age and zip code - anywhere from $200 to $800 a month. If you don't bite the bullet now and pay the higher premium, you'll pay the difference in a lump on April 15, 2015 tax time.

    Question: After enrolling in Brnoze plan on 3/14/2014, my income dropped down much in 8/14/2014. 1)What proof of income like Bank statement for that month to be submitted? 2)Only silver plan is to be selected for cost sharing? 3)Suppose after 90 days if proof of income could not be shown what happens.? Will the new revised plan be cancelled or will it continue but without subsidy?

    Answer: Your change of income can be verified in a number of different ways depending on whether you are an W2 employee or self employed. Covered California can help you with that if you call 800-300-1506. Yes, only the silver plans qualify for cost-sharing reductions. If proof of income to support the change is not supplied within 90 days, the new plan will continue without subsidy and cost-sharing reductions.

    Question: Does "ca covered" offer dental for adults? I have kaiser if it makes a difference.

    Answer: Adult dental coverage cannot be purchased during the Covered California enrollment process nor as an add-on later. You can purchase your adult dental coverage directly from your current carrier (Kaiser) or from a wide selection of other stand-alone dental insurers. Click here for a quote and online application.

    Two Residences?

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    Question: Adult lives approx. half the year in California and the other half in North Carolina. Currently has coverage in California but needs to see doctors in North Caroline as well while there. Do you have coverage for this?

    Answer: You could qualify for a special enrollment period in North Carolina if you claim NC as your home address. If so, select Blue Cross Blue Shield of NC PPO coverage (once you confirm that they offer Blue Card coverage outside of NC). You will be covered by in-network benefits while in California as long as you see a Blue Shield of California PPO network provider. If you want California based coverage, select Blue Shield of California PPO (only Blue Card in CA) coverage effective 1/1/15 during the next open enrollment period starting November 15th.

    Question: My family is losing COBRA coverage on 9/16 (expired). Anthem, Blue Shield, and HealthNet and Cigna all will only give a 10/1 effective date. Will anyone give a 9/17 effective date to avoid a gap in coverage?

    Answer: No help from the carriers on this loophole. Right now the consumer with expiring COBRA coverage may have to wait up to 30 days for the ACA compliant coverage to kick in. Eventually the feds will get it ironed out. In the meantime there's short-term coverage perhaps?

    Report Income Change?

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    Question: I estimated my 2014 income to be about $35,000. My 2013 income was $33,070. Due to a lay off of one of my jobs, it looks like I will make about $30,00 for 2014 if I don't find another part time job. I am being subsidized from the state for my Anthem Blue cross. If I don't make the money I estimated on, will I get a refund from the California Exchange if I don't have an adjustment made now? Or do they apply it to the next years premiums? (still looking for another part time job)

    Answer: The IRS will reconcile the advance premium tax credits (subsidy) you have received for the year on your 2014 tax return. In your case, there is no need to report a change in income at this point as the difference between estimated income and actual income is not very great. In cases where the taxpayer's income increases greatly during the year, reporting the change to Covered California will prevent a big tax bill come tax time. If income decreases significantly, reporting the change immediately may greatly reduce your net premium for the rest of the year.

    Question: Retired couple on Covered CA has husband turning 65. Husband is the only income in the household and they are APTC eligible. Now that husband is going to be eligible for Medicare and ineligible for Covered CA how is the income counted for the wife in Covered CA. Will his income be used to determine what her premiums will be in Covered CA? Will she now be eligible for Magi Medical since she has no income? Thanks

    Answer: The husband's income is still counted even though he will not be enrolled in Covered California. Since the premium assistance (subsidy) is based on a 2-person household, the wife in this scenario will continue to pay less net premium they were paying as a couple.

    Question: I know the 2013 Federal Poverty Level rates were used to determine the premium tax credit subsidy. However, when it comes to reconciliation at tax time will the 2013 or 2014 Federal Poverty Level rates apply? This could make a big difference if a single persons MAGI is $46,500 for the 2014 tax year. Which one? 400% of the FPL for 2013 is $45,960 (No subsidy) or 400% of the FPL for 2014 is $46,680 (Subsidy).

    Answer: The IRS will use the 2013 FPL standard to reconcile 2014 MAGI and advance premium tax credits (subsidies). See Fred's comment below for more detail.

    2015 Auto Renewal?

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    On Thursday, HHS announced that most U.S. residents who have health coverage through HealthCare.gov could automatically be enrolled in their existing plan next year, cutting the need to fill out a new coverage application form through the website, the New York Times reports (Pear, New York Times, 6/26).

    About 95% of current exchange enrollees could qualify for automatic re-enrollment if they do not change their coverage plans proactively (Radnofsky, Wall Street Journal, 6/26).

    While the automatic re-enrollment feature is designed for the federal health insurance exchange, it also could apply to state-run insurance exchanges, officials said. State officials will also have the option to submit an alternative renewal proposal (O’Donnell, USA Today, 6/26).

    While the proposed re-enrollment process would be automatic, consumers would be urged to re-evaluate their coverage benefits and needs during the next open enrollment period (HHS release, 6/26). In addition, enrollees would receive information about how to move forward if their incomes or other life circumstances have changed, which could affect their eligibility for future tax credits.

    According to Modern Healthcare, HHS drafted the proposed rule with input from the National Association of Insurance Commissioners and other stakeholders. The rule is open for public comment for 30 days, after which HHS will issue a final rule (Demko, Modern Healthcare, 6/26).

    2015 Covered Ca Rates?

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    Question: There’s confusing talk about how much Covered California will increase for the 2015 year. When will the new rates be published.

    Answer: Rates will be public in early August. As of June 1st, Covered California has been receiving submissions from the insurers in the exchange. An evaluation process will follow, and then a negotiation process through the month of July. Peter Lee announced at the June board meeting that Ca rates will be public “first week in August”.

    Question: My Medi-cal was terminated 5.28.14 with no explanation or warning. My pharmacist informed me. After several phone calls, everyone agrees I should have no been terminated but they have no advice (CA Calif. and Medi-cal reps). No one would escalate my call. I reapplied to CA Covered and they will recommend Medi-cal. Meanwhile I am without coverage of any kind. Is the re-instated insurance retroactive is there some protection from termination that was not my fault. The law 14005.37 states that I should have been notified and received a chance to advocate for myself. I have heard nothing. What recourse do I have. Aren't they effectively ignoring the law?

    Answer: You'll have to file for a hearing. You have 90 days from the date of the termination letter to request a state hearing. The form for that is on the back side of the termination notice or you can do it by phone. When you file you will receive "aid paid pending" meaning that your benefits will be reinstated pending the outcome of a hearing. When your Medi-Cal coverage is reinstated, coverage will be retroactive to the cancellation date. In the end, you shouldn't be out anything but the massive headache of getting your case back on the tracks.

    Non-Resident Child Covered?

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    Question: I am the non-custodial father of a child who lives outside the country in Australia. Court orders require me to add her to my health insurance as a dependent for occasions when she visits me in the U.S. (California). Can she be covered under my policy? I was told no because she is not a full-time resident of California. What can I do?

    Answer If your daughter is visiting you for a few weeks, international travel insurance will do the trick. If your daughter will be living with you for an extended period of time, you can add her to your health insurance coverage. Your daughter is eligible for a special enrollment once she resides in California. The is no minimum stay required. What might have confused you otherwise is the rule that people who reside outside the US more that 6 months per year are exempt from mandated coverage and penalties.

    Question: I am currently pregnant and I don't know how the process works for getting my newborn health coverage. I also have a one and a half year old who is covered under Medi-Cal. Please help!

    Answer: As soon as possible after your child is born, notify Covered California to add your newborn to your account. The newborn is covered under the mother's CC coverage during the first month after birth. You say you already have a child on Medi-Cal. If this is because your household income (less than 250% of FPL) makes all of your children under 19 eligible for Medi-Cal, your newborn will be covered by Medi-Cal retroactive to his or her date of birth.

    Subsidy Change?

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    Question: I qualified for a Covered Cal subsidy based on my estimated 2013 income. Due to higher than estimated investment income my tax filed 2013 income exceeded the subsidy qualification limit. However, my 2014 income will be considerably lower and under the subsidy qualification limit. Do I need to stop the subsidy due to the filed 2013 income?

    Answer: No. Your 2013 income is not a factor at this point. If you still expect your 2014 income to be reasonably close to the estimate you used on your application, there is no need to make any changes now. Remember, your advanced tax credits (subsidy) will be reconciled with your actual tax due when you file your tax return for 2014.

    Medi-Cal Ineligible?

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    Question: I'm a 31 yr old single mother. My 3 month old is eligible for Medi-Cal until he is 1. My 12 yr old is ineligible because of my income, yet I can't enroll him on Covered CA. I'm making $39,000 a year. What can I do?

    Answer: If your household is made up of 3 or more individuals and your income is less than $52k, then all of your children age 18 or less are eligible for Medi-Cal. Medi-Cal enrollment is open throughout the year. You may enroll through Covered California at 800-300-1506.

    Question: We were approved for Covered California but I chose the wrong health insurance plan. It has not yet take effect (it takes effect in 5 days). Can I change the health plan, or should I terminate Covered California and start over again? Thank you!

    Answer Don't terminate your current coverage. Open enrollment for 2014 has ended. You cannot change your plan unless you have a qualifying event which makes you eligible for a special enrollment period. Making the wrong plan selection is not a qualifying event. However, if you can make the case that you made the wrong choice "as a result of an error, misrepresentation, or inaction by an insurer or agent", then Covered California may grant you an exception.

    Question: When open enrollment starts Nov. 15, 2014, can I get off covered CA and look for my own private plans or do I have to stay on the plan I am on now for a full year?

    Answer: When you apply for another plan during the next open enrollment period starting next November 15, your new coverage will start January 1, 2015 at the earliest. You do not have to keep your present plan for a full year.

    Catastrophic Plans

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    Question: I have a client who is eligible under the federal guidelines for a catastrophic plan. He was recently approved by the federal marketplace and has the paperwork to prove it. To date, I have not discovered the mechanism to offer him anything other than the Bronze plan, either off or on- exchange. Is there now a streamlined process now by which I can help them enroll in a catastrophic plan?

    Answer: If the applicant is eligible for a catastrophic clan because of age (19-30), then the catastrophic plan will show an an option in the enrollment section of the online Covered California application. However, since catastrophic plan are unsubsidized, you can go directly to the carrier's online application. If the client is eligible for a catastrophic plan but 30 or over, I don't know of any online mechanism on or off the exchange to get the app started. You can submit a paper application to the carrier with your eligibility documentation.

    How to Verify Income?

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    Question: I was told to verify my income for the covered california insurance plan. How do I do that?

    Answer: You can upload documents from within your Covered California account, but few people seem to be able to do that so I have stopped providing directions. Instead, call Covered california at 800-300-1506 and talk to a customer service rep. He or she will tell you how to submit the relevant documents for your situation.

    Question: My family of four has a Covered CA plan, which we purchased when both my husband and I were unemployed. I am listed as the subscriber. I recently began work and have employer coverage beginning June 1. If I terminate the entire CC plan will that act as a qualifying event to get off-exchange coverage for my family? I don't want them covered on my employer plan due to cost.

    Answer: Once you and your family have been offered employer-based coverage, you are no longer eligible for premium assistance in Covered California. You are obligated to contact Covered California and change your status. You may opt out your family from your employer coverage, but they will only be eligible for unsubsidized individual coverage.

    Question: About a week prior to the deadline they gave me for my conditional 90-day acceptance, I mailed Covered California a monthly bank statement with the preface form they asked me to return, but I am not sure how/if this will truly prove my eventual 2014 income. What will happen if they still think this is not proof? Will they end my coverage completely, or give me another chance to help them determine what they need and re-establish my policy after a lapse?

    Answer: No. Your coverage will not be ended. If your income verification is not acceptable, your premium assistance will be recalculated based on the best information available.

    Question: I am currently enrolled in covered california, MediCal, for 2014. I have been job hunting for a while, and I believe that I may be getting a job soon that pays above 138% of the poverty line (the limit for covered california). If I get this job, will I be required to drop MediCal immediately? By the end of the year? Within a certain number of months? Thank you.

    Answer: Yes. it is your responsibility to notify Medi-Cal of your change in income. You will no longer be eligible for Medi-Cal once your household income exceeds 138% FPL. However, if your new household income is between 139% and 400% of FPL, you will be eligible for premium assistance and perhaps cost sharing reductions through Covered California.

    Question: Has Covered California officially decided to implement the Special Enrollment Period through July 1, 2014, whereby the Feds allow folks who currently are under COBRA to switch to ACA Marketplace health insurance plans?

    Answer Yes. Covered california adopted the COBRA SEP guidelines regarding SEP exceptions for COBRA beneficiaries on May 15. The SEP enrollment period in California will extend to July 15, 2014.

    COBRA SEP in CA?

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    Question: Is the COBRA SEP adopted by CA the same as the feds?

    Answer: No. The COBRA SEP in CA extends from May 15 to July 15 (SEP in fed exchanges ends July 1st)So people currently enrolled in COBRA coverage have until July 15 to apply for coverage through Covered California or off-exchange in a ACA compliant plan.

    Question: I currently qualify for premium assistance, falling just under the income limit for our 4-person household. My son expects to attain a full-time job with employer benefits in August. Will this reduce the income level to 3-person, meaning no premium assistance? If so, would it be effective in August or retroactive to Jan 1?

    Answer: You are committed to notifying Covered California when your son's coverage starts, so you will stop getting advance premium tax credits at that point - not retroactively. It remains to be seen whether the IRS system has the sophistication necessary to reconcile the annual tax credit to reflect the midyear change like this.

    Question: What will happen if I have not sent proof of income and request for social security validation by stated deadline, for my 90-day conditional acceptance?

    Answer: Your eligibility for premium assistance and enhanced benefits could be withdrawn.

    Premium Locked For How Long?

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    Question: If I purchased a Covered California health insurance plan for my family that was effective on May 1, 2014, will my premium stay "locked" at this level until May 1, 2015? That is traditionally how my health plans have operated in the past...with 1 Year Guarantees.

    Answer: No. The rates for individual health insurance purchased in 2014 will change on January 1, 2015.

    Question: I just got a rate increase on my grandfathered individual plan. It going up 24% effective July 1st. Can I still buy an Obamacare plan?

    Answer: Yes. This is a qualifying event for a Special Enrollment Period (SEP). According to Covered California, “You have a health insurance plan outside of Covered California, and your renewal date is not between Nov. 15, 2014, and Feb. 15, 2015, or future open enrollment dates and you would like to switch to a Covered California health insurance plan instead of renewing your current plan.” Here’s how it will work: You can apply for coverage either through Covered California or directly with the insurer of your choice when your non-calendar-year individual plan renews. You can report to your insurer that you will not renew their plan up to 60 days before the renewal date. Your current carrier must provide a limited open enrollment period beginning on the date that is 30 calendar days prior to the date the policy year ends in 2014 to select and ACA-compliant individual plan. If you choose to enroll through Covered California, you will have up to 60-days from the renewal date to select a plan in the exchange. Reference: https://www.coveredca.com/coverage-basics/special-enrollment/qualifying-life-events/

    SEP for COBRA Enrollees?

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    Question: I got on COBRA when I lost my job last month because my former employer pushed me to do it. I didn’t look into Obamacare because I thought it was over. Can I still switch to a Covered California plan?

    Answer: Probably, but not for sure yet. The Department of Health and Human Services is concerned that people newly-eligible for COBRA, as well as COBRA beneficiaries, may have had insufficient information to understand they only can enroll in the exchange during an open enrollment period, when initially eligible for COBRA or when COBRA coverage expires. So HHS is providing an additional special enrollment period based on exceptional circumstances so that persons eligible for COBRA and COBRA beneficiaries are able to select QHPs in the exchange. Affected individuals have through July 1, 2014, to select QHPs in the exchange. This is for federal exchanges. At this point, Covered California has not decided whether they will follow the recent CMS regs. Reference: http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/SEP-and-hardship-FAQ-5-1-2014.pdf

    Changing Doctors?

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    Question: I live in Amador County and my only 2 options thru Covered CA were Anthem PPO or Blue Shield EPO. The doctors/imaging specialists I saw all last year were in network with my Blue Shield PPO. Despite telling me they would take the EPO, turns out they don't and they don't accept Anthem. Can I get a PO Box in Sacramento and use that as my (mailing) address so I can have the option of getting the Blue Shield PPO next time around? Or do you know of any other way around such a dilema?

    Answer: Putting aside the fact that you would be breaking the rules, using a Sacramento mailing address to enroll on a Blue Shield PPO will not accomplish what you want. The "old" Blue Shield PPO network that was available in Amador County is not the same as the "new" PPO network available in Sacramento county.

    I have no doubt that this will touch a nerve with some of my readers and I invite you to comment to this post with your opinions, but I wonder if keeping the same doctor and imaging facility you used last year is of such great value. Obviously, using a different imaging facility is no problem at all but what about the doctor? How much does he know about you that could not be passed on to another equally competent doctor? Seriously, what's the big deal?

    Find Family Doc?

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    Question: I need family doc for my plan - Anthem Blue Cross Silver PPO

    Answer: To view a list of doctors that are in-network for your Anthem individual plan, go to:
    (Note: Copy and paste this link exactly as it listed here and paste it into the address bar of your internet browser. Other links will take you to a page that looks the same but is not.)
    2a. Leave "Name" field blank
    2b. Leave "Specialty" field set to "Family/General Practice, Internal Med"
    3. Enter your city or zip code
    4a. Enter state "California"
    4b. Select the network called "Pathway X - PPO / Individual via Exchange"
    4c. Select Plan "Anthem Blue Cross Silver DirectAccess"

    Qualifying Events?

    By on | 2 Comments

    Question: Back in December, I applied for an off-exchange Blue Shield plan because our household income was well over the income range for subsidies. But now we definitely are eligible for a subsidy, because my husband just lost his job a few days ago. Can I still apply through Covered California.

    Answer: Yes. A change of income that affects your eligibility for a subsidy is considered a qualifying event that make you eligible for a special enrollment period of 60 days from the date of the change - in this case his employment termination date. Here is a list of other qualifying events:

    • Getting married
    • Gaining a dependent or becoming a dependent through marriage, birth, adoption, or placement for adoption
    • Permanently moving to a new area that has different health plan options
    • Losing other healthcare coverage that is considered minimum essential coverage.
    • A change in income that would affect an enrollee’s eligibility for financial assistance
    • Becoming a U.S. citizen
    • As a result of an error, misrepresentation, or inaction by a QHP or agent

    How to Pay Kaiser?

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    Question: We were told to pay kaiser but whe we went to pay they needed a number for the account we didn't know it how do we pay the payment.

    Anawer: If you have not received an invoice by mail within 15 working days of your application, you can call Kaiser Member Services at either of these phone numbers: 800-464-4000 or 800-290-5000.

    CoveredCA HSA Qualified Plan?

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    Question: I signed up for an Anthem Bronze PPO plan in December. Although it is not designated as a HSA plan, it fits the IRS definition of an HDHP, i.e. it is $5,000/$10,000 deductible, out of pocket limits $6,350/12,700. I already have an HSA account set up from my prior insurance and I would like to continue to fund this for my expenses this year. Why would Anthem/CoveredCA not list this as an HSA compatible policy and would I be breaking any rules to claim my HSA contributions on my taxes next year?

    Answer: Only one plan in the individual market is designated as an HSA qualified plan, the Bronze HSA Plan. Apparently, you bought the other Bronze plan. You can try calling Covered California at 800-300-1506 to see if they will accomodate you with a plan change.

    Question: My Mom has been receiving health care under Covered California since January 1st. She can no longer afford the home she is in and must sell to continue to live. From the sale she will make some money which she will need to live. Will this be considered income even though this will be a one time occurance? If this is so, then she will become disqualified for assistance. Am I correct?

    Answer: Any profit above $250,000 will go into her adjusted gross income for the 2014 tax year. (Your mom can exclude from tax up to $250,000 in profit from the sale of her primary residence or $500,000 if she's married as long as she has owned and lived in the home for a minimum of two years.) So selling the home will have no effect at all. If the sale of the home raises her AGI, the advance tax credits she has received to help pay her 2014 health insurance premiums will be reconciled by the IRS when she files her 2014 tax return. Any undue advance tax credits will be added to her 2014 taxes due. This should not be a problem for your mom since she will have the cash from the sale of the home to take care of the additional taxes if there are any. She is not "disqualified" for health insurance premium assistance and she will continue to be eligible for subsidized coverage or Medi-Cal the following year based on her 2015 income.

    Employer Coverage Over 9.5%?

    By on | 4 Comments

    Question: How do I go to Covered Ca if my share of employer sponsored insurance is greater than 9.5% and receive the advance tax credits?

    Answer: Complete a Covered California application online before April 15th. When you get to the Health Care Information section and this question, "Does this person have or has this person been offered affordable minimum standard value health insurance for 2014?", answer "None of the Above".

    Medi-Cal Application Lost?

    By on | 2 Comments

    Question: My wife and I have been covered on a Blue Shield Obamacare plan since January 1st. Our two kids are supposed to be on Medi-Cal but we haven’t gotten anything from them yet. We called the county office, but they are no help at all. Should we apply again before the deadline on April 15th?

    Answer: No. I recommend against applying again. It could really mess things up for you at this point. Your children’s MediCal application is probably not lost. About 800,000 people who applied for Medi-Cal coverage through Covered California still are awaiting approval because of software glitches. State officials say the backlog of Medi-Cal applications was caused by problems with a system that was supposed to link county and state computers to confirm applicants’ eligibility for the program. Even though the glitches have been fixed, workers at the county social services offices face a large backlog of applications. Unfortunately, if your Medi-Cal applications are awaiting approval you could be foregoing needed medical care for your children or paying out-of-pocket for health care services. You do have the option of requesting a temporary Medi-Cal card from county services but some MediCal providers might not accept them because of concerns about whether they will be reimbursed for the care.

    Change EPO to PPO?

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    Question: I currently have Anthem Blue Cross (Silver Plan) EPO and it's come to my attention that my regular doctors only accept PPO. I can use the EPO except the service would be considered out-of-network. Do I need to wait until the next open enrollment cycle before I can change to a PPO? And, when would this be?

    Answer: You must make your plan change by April 15th, or wait until the next open enrollment period starting in November. Be sure to research the carrier provider networks for your doctor(s) before you change. Anthem Blue Cross does not offer both EPO and PPO plans in the same geographic area. You would have to select another carrier with a PPO available where you live.

    Still Covered After 90 Days?

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    Question: I received the conditional 90 day coverage from Blue Shield, through CC. I needed to verify my income, but was not able to pull together any of the required documents in time. I have been working as an independent contractor in this past year (for the first time ever) and am definitely on a learning curve for documentation. I have been billed (by Blue Shield) for the month of April, so I went ahead and paid it, but I am not sure if I am still covered from CC's point of view. I tried calling CC a number of times before the March 31st deadline to try to resolve the matter but was never able to reach anyone. As luck would have it, I have need to see a doctor now, due to injuries from a fall, but I am reluctant to proceed, for fear I will find myself without coverage and facing exorbitant bills which I cannot afford. Is there a grace period or a next step when the provisional coverage period ends?

    Answer: Yes. You are still covered. Neither Covered California nor Blue Shield will cancel your coverage for failing to comply with a request for income verification. At worst, CC could take away your premium assistance, but that would not happen until you have been given additional opportunities to comply. For starters, they have to start providing adequate customer service before they can hold you to your reporting obligations. Wait until you can get through to 800-300-1506 and ask the Customer Service Rep for assistance in providing the necessary documentation.


    By on | 29 Comments

    Question: I have enrolled and been conditionally accepted for 90 days and I have signed up and paid for a health plan. Now I am thinking of cancelling the plan and get out of the Covered Cal exchange altogether. How do I do that, and if I do, when will my current account with the insurance company end?

    Answer: If you applied on your own, log into your CC account and select "Terminate Coverage". You can cancel your coverage as soon as 14 days from that date. If an agent signed you up, ask him or her to do it for you.

    Is Employer Coverage Verified?

    By on | 4 Comments

    Question: How does Covered CA obtain information from individuals who have affordable employer coverage and submit application for coverage through exchange.

    Answer: There is no requirement for employers to supply information about their employees' health care coverage, at least for the 2014 tax year. Nor have I seen any verification requests from Covered California to applicants.

    Wait Two Weeks to Reapply?

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    Question: I had already applied and got a plan and payed, but my payment was not accepted. I had to terminate and wait 14 days to apply again, but this will take me past the march 31st deadline. Any advice? Can't get a hold of customer service.

    Answer: After terminating your current coverage at least 14 days from that day, you can choose a new plan immediately using the same application. You do not have to wait 2 weeks to reapply. I think that misinformation may have originated in our Q&A comments section, but that person was wrong.

    Question: I signed up for anthem ppo & paid for it on March 25 (which at that time appeared to be the deadline), then found out that my doctor has just been added as a provider on the blue shield epo. I am in the midst of some complex treatment issues and will be forced to pay out of pocket to see my current doctor about these matters (forced to put these payments on credit card because I am currently out on disability leave from my job). Is there a way to switch from Anthem to Blue Shield?

    Answer: Yes. You can terminate your Anthem Plan effective April 30th and choose the Blue Shield plan you want effective May 1st. This is a quirky process in the Covered California online application system. I suggest you delegate a Certified Insurance Agent to help you with it.

    Temporary Job and Subsidy?

    By on | 3 Comments

    Question: I was unemployed and getting a generous subsidy through CoveredCA for my health insurance. I recently landed a 6 month assignment that pays just enough to have my subsidy taken away. I really can't afford the insurance on its own. Is there anyway to average out what ill make these 6 months for the year so I can still have a subsidy? My plan went form 59 a month to 263 a month because I took a 6 month temp job.

    Answer: You could do nothing at all and save up for a larger than normal tax bill in April 2015. You could also change your Covered California account to reflect your new income from your temporary job by taking the total income for the 6-month job and dividing it by 12 if that would still make you eligible for premium assistance.

    Special Open Enrollment

    By on | 14 Comments

    Question: If a person is enrolled in an individual health insurance plan (not employer sponsored) outside the exchange and currently does not qualify for any subsidies because his or her income is above the threshold; what happens if he or she loses their job, becomes unemployed and now qualifies for subsidies, would this person be able to join Covered CA under the special enrollment rule and be eligible for advance tax credits?

    Answer: Since your individual coverage is independent of your employment, losing your job will not trigger a Special Enrollment Period. If you were to apply for coverage through Covered California during open enrollment - by March 31st - even though your income makes you ineligible for premium assistance now, you could be eligible if you do lose your job later in the year.

    Untaxed Disability Income?

    By on | 18 Comments

    Question: I retired as a Police Officer due to an industrial disability. The money I receive monthly is tax exempt(Fed and State)except for a small portion (190.00 a year currently) and that amount is my AGI for taxes. What amount do I enter as income? AGI per taxes or the monthly amount that is protected?

    Answer: Use your AGI of $190. You are eligible for Medi-Cal.

    Mixed Immigration Status?

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    Question: Husband stays in CA with a valid working visa. Wife and a child currently live in outside of the US and do not hold any valid US visa. They are going to come to the US with valid visa later this year. Can the husband apply for CoveredCA at this time? If so, should he apply as "single" or "married"? Should the income be calculated as 1 household or family of 3

    Answer: The husband should apply as a 1-person household. His wife and children are not part of the household at this time. When they arrive in the US with legal residence status, he should change his application to reflect the new household status.

    Question: I am trying to apply for Covered California health care. I am an adult (over 26) who is living at home with my parents. I am also listed as a dependent on my parents income taxes because they are helping to pay for my college tuition fees. Should I be applying as a household as 1?

    Answer: No. Since your parents are claiming you as a dependent, you must apply as a 3-person household of with them on the application and opting out of coverage and using the entire household's income. If you agree to file your own tax return in 2014, you can apply as an individual using your own income. Here are some things to consider if you do strike out on your own: (1) Unless your 3-person household income is less that $50K, you'd be better off buying coverage for yourself off-exchange, (2) if you estimate your own income to be less than $15,500 in 2014 you will be eligible for Medi-Cal, (3) your parents will give up a $2,000 tax deduction.

    Question: I have an individual grandfathered health insurance for my family. 1) Am I excluded from ACA tax penalty for 2014? 2) Can I change my plan in 3-6 months & get an ACA compliant insurance?

    Answer: Yes, your grandfathered plan exempts you from the tax penalty for mandated coverage non-compliance. No you cannot change your grandfathered plan to Covered California anytime it suits you. After this open enrollment (OEP) period ends on 3-31-14, you must wait until the next OEP, starting 10-15-14 for 1-1-15 effective date of coverage.

    Question: Family of 4 with an agi of $45,000. The Covered California online application says the children qualify for medi-cal. Family wants to pay the premium for their daughters. Can they still apply in Cover California for the four of them? If they receive medi-cal can they use it as a supplement for their Cover California policy?

    Answer Yes. This family should apply through Covered California because the husband and wife will get a substantial subsidy. Be careful to indicate that the children do not want coverage, otherwise they will automatically be enrolled in Medi-Cal. Then they can apply for the children off-exchange in the plan of your choice. Yes you can have both Medi-Cal and private coverage.

    Question: Phil please comment on the new CMS guidance on this subject. Here are the main points from the CMS bulletin:

    1. The health insurance exchange still is responsible for determining eligibility to obtain a marketplace plan and for financial assistance, and individuals must submit an application to begin the process.
    2. If an individual was unable to purchase a marketplace plan in time for the coverage to begin Jan. 1, the marketplace can set a date for retroactive coverage based on when the application was submitted.
    3. If an individual diverted the exchange and enrolled in a health plan directly through a carrier, and the health plan also is offered on the marketplace, the marketplace can treat the enrollees as if they made their arrangements through the exchange.
    4. In both of the above circumstances, if the enrollee also is determined to be eligible for premium subsidies by the marketplace, CMS will provide the tax credits retroactive to the policy start date directly to the insurance carrier. The insurance carrier would either credit or refund to the enrollee any claims or excess payments retroactive to the policy start date.

    Answer: The CMS Guidelines are just that - guidelines. The devil is in the details and once the i’s are dotted t’s are crossed, I think you’ll see these guidelines are a nonstarter in California. But some state exchanges are really in deep doodoo. The “Cover Oregon” exchange still (March 1) does not have a working online application. Paper applications are reviewed manually by state workers wearing green eyeshades. So Oregon Governor John Kitzhaber worked with the feds to figure out a solution for Oregonians screwed over by his state’s disastrous Obamacare rollout. Realizing the need, the Obama administration opened up alternative avenues for states like Oregon (the CMS Bulletin to which your refer above) to make up for lost coverage time and federal tax credits caused by the technical problems at their state health insurance exchanges.

    However, to answer your question directly: yes, applying through Covered California is still the only way to get a subsidy in California. To quote item 1 in the CMS Bulletin, “the health insurance exchange still is responsible for determining eligibility to obtain a marketplace plan and for financial assistance, and individuals must submit an application to begin the process.”

    While the California exchange rollout was anything but smooth, the technology was adequate to get most of those who met the December 23rd application deadline covered on January 1. So item 2, does not apply in CA and it follows that item 3 does not apply here either. For item 4 to work, items 2 and 3 would have to be met, so that doesn’t apply either.

    Admittedly, most of those January 1 enrollees were not able to actually use their health care coverage for most of the month of January for lack of insurance cards, but that was due to (a) extending the application deadline twice, (b) delays in handing off application data from the exchange to the carriers and (c) the carriers’ inability to get invoices out in a reasonable amount of time. Worst case, some people will have to go through the hassle of submitting claims to recover out-of-pocket costs after their effective dates of coverage. I guess we can be thankful, once more, that we don’t live in Oregon.

    Coverage for Dependent Parent?

    By on | 2 Comments

    Question: My mother (64) is an immigrant and lives with me and my family, and makes 0 income. I have claimed her as a tax dependent on my 2011 and 2012 returns, though she files her own returns with 0 income. When I created a CoveredCA account for her, I used MY income as the household income, which precluded her from receiving subsidized insurance either through the exchange plans or through Medi-Cal. The definition of household income here is unclear. Any insight on what's the right definition here for household income?

    Answer: Assuming your mother has legal resident status, she is eligible for Medi-Cal. Her application has to be changed to a 1-person household with $0 income and she has to agree to file a tax return in 2014 as "single" status. You need to stop claiming her as a dependent. You can't have it both ways.

    Undocumented DACA Immigrants?

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    Question: I have a two-year work visa under President Obama’s DACA law but I am not a citizen and do not have a green card. Can I get California Covered?

    Answer: You are definitely eligible for Medi-Cal, not sure about premium tax credits and or cost sharing reductions in Covered California. You have legal status under the Deferred Action for Childhood Arrivals (DACA) program and as such are eligible for Medi-Cal in California. Background: In 2012, President Obama developed DACA, which grants undocumented children legal status and authorization to work in the United States for two-year periods. To be eligible for the program, children must:

    • Have arrived in the U.S. before age 16;
    • Be under age 31 as of June 2012; and
    • Have continually lived in the U.S since 2007.

    While the expansion of Medicaid under the ACA specifically excludes undocumented residents, California ruled that DACA residents are eligible for Medi-Cal.

    Change Plans Now?

    By on | 9 Comments

    Question: I began coverage on 1/1/14 on the Blue Shield Bronze PPO. Can I change to the BS Silver PPO now or do I have to wait til next year?

    Answer: You can change plans until March 31st. After that you will have to wait for the next open enrollment period.

    Question: My doctor wants to know how to get into the Covered California network.

    Answer: Once again, there is no Covered California provider network. Your doctor must contact the provider services department for each qualified plan within Covered California - Blue Shield, Anthem Blue Cross, Health Net, Kaiser, etc. The Blue Shield Provider Services phone number is 800-258-3091. I try to get the other carriers’ numbers and post them here.

    Deductibles Individual or Aggregate?

    By on | 7 Comments

    Question: There are 2 members in my family, a 59 y/o and an 18 y/o out-of-state college student. We are looking at the BS Silver 70 PPO plan. If one of us is hospitalized, is the deductible $2,000 (individual) before the 20% starts or would it be $4,000 since we are a family? Likewise, is the same true for maximum out-of-pocket expense? If it is the $4,000, it seems wiser to go with the Gold 80 plan at $100 more per month rather than risk the deductible. Your thoughts?

    Answer: Nearly all of the ACA-compliant individual plans (the only plans you can buy now), have individual deductibles. So in your example (if one of us is hospitalized...) once the $2,000 deductible is met the 20% coinsurance goes into effect. The Bronze HSA plan is the only plan in the new portfolio where the deductible is collective or aggregate, meaning the family deductible of $10,000 would have to be met before the 20% coinsurance goes into effect. The out-of-pocket maximum is individual as well. Also, the Blue Shield PPO is the only Covered California qualified plan that will cover your college student "in-network" while out-of-state.

    Question: Hi Phil, if a husband is offered insurance through his job (employee portion paid at 100%) and the wife/kids waive because they are on Medi-Cal, would they be required to leave Medi-Cal immediately (or would they have to notify them) because they are offered affordable insurance through the husband's job? Or would they just wait until Medi-Cal says something?

    Answer: Medi-Cal beneficiaries are obligated to inform that agency of any changes of status that will affect Medi-Cal eligibility. So yes, you would have to notify them though I don't think that being offered employer-based spouse and dependent coverage would exclude you from Medi-Cal eligibility by itself. But then I'm not a mediCal expert. Keep an eye open for comments to this post as I'm sure some of our Medi-Cal gurus will provide added perspective.

    Covering Child with 50% Custody?

    By on | 3 Comments

    Question: If a person has 50% legal custody of a their child, can the child be covered by both parents that live in different states?

    Answer: No. The child cannot be covered by both parents. The child should be covered by the parent who claims the child as dependent for tax purposes.

    Question: I (age 27) make 23K a year and I claim my Mom (age 58, 0 income) as dependent in my tax. Do you know why I am eligible for the plan(silver 94) but my Mom is not ? She was transferred to MediCal.

    Answer: That's interesting. It seems that even though you claim your Mom as a dependent, her eligibility was determined on her $0 income rather that yours. Yet your benefit level (Silver 94) is based a 2-person household. In that case, it seems as if they are regarding her as if she were a dependent under the age of 18. Might be worth filing an appeal if your Mom wants off of Medi-Cal.

    Income changes and CSR?

    By on | 6 Comments

    Question: I'm currently on a Silver 94 PPO with Blue Shield. I'm sort of expecting to make more money than I anticipated around midyear. The way I understand it is that I have to report changes on income to Covered CA. Will this bump me out of the Silver 94 plan and force me to a plan with full deductible at mid year whenever I make the change?

    Answer: Yes. Higher income will change your eligibility for cost sharing reductions (silver plan benefit enhancements) as well as advance premium tax credits (subsidy).

    No Prior Tax Returns?

    By on | 8 Comments

    Question: My daughter has not made sufficient income to be required to file tax returns. She is enrolled with a plan but has received a Covered California request for a copy of her W-2 or prior tax return, her birth certificate and social security card. We have the card and birth certificate. How do we respond to the request for proof of income?

    Answer: I'm surprised they didn't ask for her high school transcripts? I mean, these CC requests for verification are wildly off the mark. Here's the scoop. You have 90 days to comply. Wait until you can get through to CC on the phone without waiting 30 minutes or more to talk to someone - probably another month. Once you can conveniently talk a CSR, he or she will sort out what you really need to provide and tell you how to submit it. They will also remove the unnecessary requirements from your account. As for your daughter not filing taxes in the past, that's not a requirement. She only has to agree to file taxes for the 2014 tax year and beyond.

    Getting Off Medi-Cal?

    By on | 2 Comments

    Question: I got onto Medi-Cal last year becuse I lost my job. My income will soon go up and I really want to sign up for Anthem or Kaiser, etc. My agent says CC will NOT let me sign up for a plan unless I "disenroll" first, from Medi-Cal. Is that true?

    Answer: Yes. The CC system can now instantly access Medi-Cal data during the application process. Applicants currently on Medi-Cal will automatically be found ineligible for Covered California coverage, with or without advance premium tax credits. The individual(s) must get off the Medi-Cal system before becoming eligible for CC coverage.

    Negative AGI?

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    Question: How about a loss carry forward that comes from a theft loss? This creates a net loss on line 37 of our 1040. How do we enter it on the Covered California website or the Medical website. It doesn't allow us to enter a negative number for AGI.

    Answer: The CC application asks for your current income whether W-2 employed or self employed. Jeeze Louise! What did you make last month? If you start making a lot more, or a lot less, you can correct later. After personally assisting on over 300 CC applications, I can tell you that for most people, the whole AGI thing makes things more complicated than they need to be. Fuhgeddaboudit!

    Employer Mandate Delayed?

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    Question: I read in the news that the requirement for employers to provide health insurance has been delayed another year, but when I got into the details I just got more and more confused. Help?

    Answer: Under the latest regulations, only employers with more than 100 full-time workers will have to pay fines next year and only if they do not cover at least 70% of their workers. In 2016, when the full mandate takes effect, employers with more than 50 full-time employees will have to provide insurance to at least 95% of their employees.

    Question: When I enrolled in Covered California Anthem Gold PPO in December, I first called all my doctors offices, twice, and asked what CC plans they would be participating in. Each time they all told me if I picked a “Blue PPO” I’d be fine. As Anthem is the only PPO available in Alameda County (Blue Shield is an EPO), I signed up for Anthem. Yesterday I looked on the website and my large internal medicine group had dropped. I emailed them and my doctor confirmed, saying it would “Be Prudent” for me to find a new doctor ASAP. What are my options? I could try to get back on my HealthNet high-risk pool plan ($1080/mo, $4000 deductible, cancelled Nov. 1 then reinstated, but it’s so infuriating when I’m eligible for a significant subsidy on the exchange. I work 3 jobs to be able to pay for health insurance. What do you recommend as a pathway to finding the cheapest insurance that does cover Alta Bates Medical Group, Hills Physicians Med Gp, Sutter East Bay Med Fndn, or multiple of those groups)? Advice welcome.

    Answer**; You seem to be someone who is receiving ongoing treatment for multiple conditions. So I understand that changing providers is a bitter pill to swallow. However, think of it as a trade-off. You couldn’t even get regular health insurance a couple of months ago because of pre-existing conditions - paying over $1,000 monthly for a high deductible risk pool plan. Now you can get covered for the same rate as a triathlete. Now you are “eligible for a significant subsidy” making a no-deductible Gold plan available at a fraction of what you were previously paying for substandard coverage. Narrow networks are necessary to keep costs down - one of the trade-offs for all the good stuff you now enjoy. You welcomed advice - pick new providers in-network for the plan you selected and move on.

    Question: My husband and I are both self-employed so our income varies. Likely we will fall around the $60,000 mark for 2014 and qualify for a subsidy. The problem arises because we would like to choose two different plans based on different medical needs. Both plans are offered on “Covered California.” We want to choose a bronze plan for him, and a platinum plan for me. According to some info on the web, this should be a possibility, if so how would we do it?

    Answer: The CC online application allows for multiple plan selections for households with 2 or more applicants when applicants are eligible for CC coverage without subsidies. Ths plan selection screen Plan Selection.png (click image to enlarge) is in the Enrollment Section. This would require overestimating your income on the application so as not to be eligible for advance premium tax credits and getting full tax credit due when your tax return for 2014 is filed.

    Question: There are 2 members in our household. I am self-employed, with an 18 y/o dependent, with an AGI of $55,000. My 18 y/o attends college out-of-state and has no income. She will turn 19 October 2014. My understanding is she will be covered out-of-state under a family plan if I purchase BS PPO Silver 70. What happens mid-year when she turns 19? Does she have to go on Medi-Cal? If so, will it cover her out-of-state? Would it be better to purchase a catastrophic PPO policy for her now and for me to get my coverage through CC?

    Answer: No worries. Your income $55K is high enough that your dependent under 19 will not be eligible for Medi-Cal and your Blue Shield Silver 70 PPO Plan will provide her with excellent coverage out-of-state. When she turns 19 she would be ineligible for Medi-Cal in any case as long as she is included in your household as your dependent. If your income was below $38,775 (250% FPL), she would be eligible for Medi-Cal until age 19 with only emergency health care coverage out-of-state.