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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.

Recently in Healthcare Reform Category

Have you ever stepped up to the pharmacy cash register only to learn your new prescription will cost you hundreds of dollars — instead of your typical $25 co-pay — because your insurance doesn’t cover it? Or received a painfully high bill for a medical test because your health plan didn’t think it was necessary? Most people have, but only a tiny fraction ever appeal such decisions. In 2017, for example, enrollees in federally run Affordable Care Act marketplace plans appealed fewer than one-half of 1% of denied medical claims, according to an analysis by the Kaiser Family Foundation.

If you do appeal, your chance of getting the health plan’s decision overturned is a lot better than you might think. “About half of appeals go in favor of the consumer,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a healthcare consumer advocacy group.

There’s no sugarcoating it, though: Getting to “yes” with your health plan can be an ordeal, and you may need help from friends, family members, your doctor, insurance counselors, even legal aid societies. In California, health plans are supposed to help facilitate the appeals process. When they deny coverage, they must inform members in writing how to appeal. And when they receive enrollee complaints, they are required to acknowledge them formally, which sets the clock ticking on a series of steps to resolve the dispute.

Regardless of the type of insurance you have, you can do several things to strengthen your position even before you file an appeal.

Get organized You will need up-to-date medical records, as well as all communications with your doctor and health plan and any other paperwork that might bolster your case. “Don’t do anything over the phone. Do everything in writing. You need a paper trail,” says Maria Binchet, offering her hard-earned wisdom from the trenches. Binchet, a resident of Napa County, has a rare, disabling illness called myalgic encephalomyelitis, or chronic fatigue syndrome. Because none of the doctors in her Medicare HMO network has expertise in the disease, she says, she has requested referrals to outside specialists on numerous occasions over the last 22 years, been turned down each time and appealed nine times. After one of those appeals, the health plan allowed her a single visit to a specialist — but he wasn’t taking new patients.

“You have to be persistent and resilient,” she says. Binchet also advises that you request from customer services the unredacted notes of the health plan’s internal discussion about your case. The notes can help you determine how extensively your case was considered, who made the decision and whether that person was medically qualified to do so. A letter or phone call from your doctor to the health plan can provide valuable support. “It’s important that you get someone involved who can talk about the medical evidence, because that’s what this is really about,” Fish-Parcham says. Clock is ticking When your paperwork is ready, you must appeal first to your health plan. For most private plans, your deadline for filing the appeal will be 180 days after care is denied. The insurer then faces a deadline — usually 30 days — to render its decision. If it upholds its initial decision or doesn’t meet the deadline, you can take the matter to the agency that regulates the plan within 180 days. If your health is in imminent danger, you can generally get an answer in a matter of days rather than weeks. Unfortunately, different plans have different regulators, with varying appeal procedures. If you don’t know who regulates your health plan, call customer services and ask. A large majority of Californians have policies regulated by the Department of Managed Health Care, but millions of others are in plans regulated by other state agencies, such as the California Department of Insurance or the federal government. A good place to start is the Department of Managed Health Care (888-466-2219 or HealthHelp.ca.gov ). Even if it is not your regulator, it can direct you to the right place, Rouillard says. If you are one of the 26 million Californians in plans regulated by the department, you can request a free review of your case by outside medical experts if your appeal to the health plan failed or was not answered by the deadline. These independent medical reviews are for cases in which a health plan doesn’t think a type of treatment is medically necessary or refuses to cover it because it is experimental — or won’t pay for emergency medical services after the fact. An archivewebsite on the department’s allows you to search past decisions for cases like yours. The summary language in those decisions might help you frame your arguments. You can also request an independent medical review through the California Department of Insurance (800-927-4357). If you are one of the 5.5 million Californians in a federally regulated employer plan, your regulator is the U.S. Department of Labor’s Employee Benefits Security Administration (866-444-3272 or askebsa.dol.gov ). Help is available As you wade through this process, there are organizations that can help. One of them is the Health Consumer Alliance (888-804-3536 or www.healthconsumer.org ), which can assist people in public and private health plans. It offers free advice, can help you get your documents in order and provides legal services. Medicare enrollees can receive free assistance from the Health Insurance Counseling and Advocacy Program (800-434-0222 or cahealthadvocates.org /hicap ). Wolfson writes for Kaiser Health News, an editorially independent publication of the Kaiser Family Foundation.

Question: I work the the State of CA and my Wife works for the County. We both have covered HMO coverage, Kaiser, which is offered through our work. We filed our taxes and received a response from the IRS asking for a 1095-A. Why are we getting this and how do we get our taxes filed?

Answer: ​I​f you received coverage through a fully insured employer-sponsored health plan, you'll receive a Form 1095-B from the insurer​ (Kaiser)​. If you received coverage through a self-insured employer-sponsored health plan, your employer will complete Part III of Form 1095-C. You need to file the Form 1095-​B or 1095-C with your individual federal income tax return to prove compliance with the individual mandate.

Age 26 and ACA

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Question: My child is younger than 26 and i want to remove him from my health insurance. Can i do that under the affordable health care act?

Answer: Yes. Covering your child to age 26 is an option provided by the ACA. It is not a requirement. In 2014, everyone will be required to have health insurance. If your child does not have coverage, they may have to pay a penalty.

Payroll Tax Increase

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Question: Is the 2% payroll tax increase for 2013 part of Obamacare?

Answer: No. It has nothing to do with Obamacare. Actually, FICA payroll taxes were cut 2% in 2011 and 2012. That cut will expire, effective Jan. 1, 2013. Although the increase is on employee contributions, the increase also affects an employer’s withholding obligations.

Obamacare or Bust!

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Question: My daughter is currently on my group insurance from work. I am spending almost $600 a month just for her. I would like her to get on an individual plan, but she is overweight and I am told she will be denied (they cap it at some point). Can you advise me where I can turn? How does Obamacare fit it here?

Answer: My response to your question was forming slowly until you asked how Obamacare fits in here. Obamacare makes your problem go away, but not until January 2014. That’s 14 months from now. In the meantime, you’ll have to stick with what you have.

Question: My wife is 52 and is diagnosed bi-polar, paranoid schizophrenia, ptsd, multiple personalities and depression. She has been in psychiartric hospitals off and on since about 1995.The insurance I have at work changed around 2005 and now each family member has a lifetime cap of 50 days inpatient psychiatric. My wife hit her limit in november of 2011. She has been hospitalized twice since then. She never worked enough to get her minimum credits for social security and hasn’t worked much at all since 1979. I live in PA and was told I made too much money for her to get medicaid. The last hospital bill was for 28 days and costs about $25,000. Two months earlier it was 10 days and costs $9000. I don’t make enough money to pay these bills, I don’t want to abandon her or divorce her and sadly, she will probably have problems her whole life. Is there any help she can receive in the form of medical coverage for her psychiatric stays?

Answer: (Please take this to your HR Representative) The Affordable Care Act (ACA) prohibits the imposition of lifetime and annual benefit limits for essential health benefits. Mental health and substance abuse disorder services, including behavioral health treatment are included under essential health benefits. Federal regulations provide for a three-year phase-in period—September 23, 2010 to January 1, 2014—during which a group health plan or health insurer offering group or individual health insurance coverage may establish an annual limit on the dollar amount of benefits that are subject to specified dollar amounts. While any health plan or insurer offering group or individual health insurance coverage may establish a higher limit or impose no annual limits at all, the annual limit on essential health benefits for each of the three years may not be less than the following:

  • $750,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2010 but before September 23, 2011;
  • $1,250,000 for a plan year (policy year in the case of individual coverage) beginning on or after September 23, 2011 but before September 23, 2012; and
  • $2,000,000 for plan years (policy years in the case of individual coverage) on or after September 23, 2012 but before January 1, 2014.

Group health plans must comply with the ACAs provisions prohibiting annual limits on essential health benefits—including the restricted phase-in limits— whether or not the plans are grandfathered.

Question: I’m currently 24 years old and my parents include me on their health insurance. There insurance renews in October. If I get married after October, will I still be included on their insurance through October 2013?

Answer: Your marriage does not affect your parents’ right to include you as a dependent on their health insurance coverage to age 26. Your husband, however, may not be included on your parents’ coverage.

Question: My employer has told me that he is changing to a defined contribution plan in July. He said that my healthcare it will cost me the same as it did this year but that I will have more choice of plans. Is it a good deal for me or am I getting screwed?

Answer: Compared to the old “defined benefit” plan where employers determined a set of health-insurance benefits, under “defined contribution” plans employers pay a fixed amount for each employee, and employees use the money to buy or help pay for insurance they choose themselves. It’s a good deal for employees in the sense that it puts you in the driver’s seat as far as selecting the plan you want, but if the defined contribution amount doesn’t go up to match the inevitable premium increases for health insurance, it will leave the employee holding the bag for more and more of the costs. It’s a better deal for employers because it puts them in control of their health benefit outlay regardless of health plan rate increases.

Health-Care Reform will push the transition to defined-contribution health insurance in 2014. If most employers do retain their health plans, the state health insurance exchanges created under the law will make the basic idea of a defined-contribution health plan more prevalent, and thus may speed its adoption. If defined-contribution plans that are sufficiently generous count as employer-based coverage — as is generally expected — the trend toward such plans will probably accelerate.

Question: I am currently covered by the VA. My benefits will stop in 2013 due to income. I have pre-existing conditions, high blood pressure and cholesterol. My spouse checked with her employer and can get me coverage for around $650/ mo. Will this be the best and most inexpensive choice for me with my conditions?

Answer: When your VA healthcare benefits end in 2013, you probably will not have any other health insurance options than your spouse’s group plan because of your preexisting conditions. Your wife’s employer-sponsored health plan is expensive because it’s probably very comprehensive coverage and that’s why the monthly premium is so high. If you had other coverage options, you would probably choose less comprehensive coverage - a high deductible plan with potentially more out-of-pocket expenses - for a lower monthly premium.

Fortunately, you will not have to pay such a high premium for very long. Thanks to the Affordable Care Act, you will be able to purchase individual health insurance through your state health insurance exchange in January 2014 without being declined or rated-up for your preexisting conditions.

Question: I have a question about the new health care reform. I have a son that just graduated from college and he was on my health insurance where I work (in massachusetts). He will be accepting a new job in california but his company has a "waiting period" of 180 days. So my question is can he remain on my health insurance under the "age 26" law even if he is moving to another state and the fact that even tho hie employer offers health benefits..he cannot get the insurance till the waiting period of 180 days has been completed? Thank you in advance.

Answer: Health care reform - the Affordable Care Act - allows insured parents to keep their sons and daughters on the their health insurance plan (individual or group) to age 26. Since it's a federal law it affects all states equally. When your son moves to California he can stay on your health plan for a few months until he is covered by his CA employer. However, if you have an HMO in MA it will only cover emergencies in CA. PPO works fine out of state. He can get the in-network coverage in CA if he is careful to select the right provider. If HMO, I recommend he purchase short-term health insurance coverage in CA. It's relatively cheap and easy to qualify.

Question: Do California employers have to provide health insurance to their employees?

Answer: The is currently no requirement for California employers to provide health insurance for their employees. Health care reform places no requirement on small business employers (less than 50 employees) to provide employer-sponsored health insurance in 2014 and beyond.

The Affordable Care Act (ACA) mandates that larger employers (50 or more employees) provide health insurance starting in 2014 or pay a penalties called the play-or-pay tax. The play-or-pay tax is one of the most significant tax consequences of health care reform. The tax will take effect in 2014, and it will have a significant impact on large employers subject to it. Both applicable large employers that offer coverage, and those who do not offer coverage to their employees will be subject to this tax. Employers will face another big decision due to this tax. Their question will be, “Should we offer healthcare coverage to our employees at all, or just simply pay the applicable tax?”

Ex-wife is Uninsurable

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Question: Husband company not insuring divorced spouse who is uninsurable

Answer: Your ex-husband’s employer no longer has an obligation to offer coverage to the ex-wife under the company’s group health insurance plan. In fact, the insurance company would not allow it even if the employer wanted to. However, the ex-wife does have some coverage options even if she is “uninsurable” due to pre-existing conditions. My first suggestion would be the Pre-Existing Condition Insurance Plan (PCIP), one of the early benefits of health care reform. It’s very good coverage at a fair price.

Question: I read in the newspaper that the Preexisting Conditions Health Insurance Plan was a bust. What happened?

Answer: It's not a failure by any means, however enrollment is less than expected so far.

Several months ago, the special insurance pools became one of the earliest facets of the new health-care law to take effect. They are intended as a temporary coping mechanism for people with preexisting medical conditions that traditional insurance companies do not want to cover. The program is temporary, because, starting in 2014, the law will forbid insurers to reject customers based on whether they are healthy or sick.

One must be a resident of California, have a pre-existing condition as shown by a
Rejection letter from a health insurance company in the last 12 months, or coverage offered with premiums higher than those of the state risk pool, be a U.S. Citizen, U.S. National or lawfully present foreign national, and have been uninsured for 6 month prior to application for the plan.

A fundamental problem is that insurance for people with existing medical problems remains too expensive for many. Monthly premiums range from $350 to $600 for a middle-aged individual in California.

Another hurdle is the requirement that an applicant must have been uninsured for 6 months prior to applying for the special risk pools. The thinking behind this requirement is to prevent a wholesale migration of insureds from existing state major risk pools to the new pools where rates and coverage are better. HHS needs to take a look at removing that requirement.

Question: Obama claims health reform will lower health insurance rates. The Republicans say they'll go up. Who's right?

Health Care Reform Funding at Risk?

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Question: The Health Reform law is very unpopular among voters. It looks like the Republicans could successfully block funding for health care reform. What do you think?

Today, the six month anniversary of the enactment of the Affordable Care Act, some of the law's key provisions go into effect. Here's a look at how the law affects people who get their health insurance at work, people who buy their own individual health insurance or are enrolled in Medicare.

Q: I get my coverage through work and the "open enrollment" period for next year is approaching. I'd like to keep my current health plan. Will it be affected by the new law?

A: Your plan will feature some new consumer protections. For example, your plan won't be able to set a lifetime limit on coverage. And if you have an adult child up to age 26 who can't get health insurance at a job, you'll be able to keep him or her on your health plan. These changes kick in for plan years beginning on or after Sept. 23. If your employer makes significant changes - like cutting benefits or raising your out-of-pocket costs beyond a specific amount - the plan is considered a new plan (rather than an existing "grandfathered" one) and must include a wider set of consumer protections.

Q: Like what?

Patients will get, for example, certain preventive services such as breast cancer screenings and cholesterol tests without paying deductibles or co-payments. In addition, they'll be able to see obstetricians and pediatricians without getting prior authorizations. Recommended immunizations also must be provided at no cost.

Q: What if my employer offers a new plan and I want to switch to that?

A: In that case, your coverage would include the wider set of protections.

Q: Will my health insurance cost less?

A: Probably not. Health insurance premiums have been increasing steadily over the last decade and that trend is continuing. According to a new report from the Kaiser Family Foundation and the Health Research & Educational Trust, workers nationwide on average are paying 14 percent, or $482, more for family health insurance coverage in 2010 than in 2009. Employers, struggling with the recession, aren't increasing their share. Instead, they're shifting more costs onto employees, according to the survey. A recent study by the National Business Group on Health found almost two-thirds of employers planned to ask employees to contribute more toward their premiums.

Q: I'm a small business owner. Do I have to offer coverage to my workers this fall? And if I do, will the government help me pay for it?

A: No business owner - small or large -- is required to offer coverage. But small businesses with 25 or fewer full-time employees who earn an average yearly salary of $50,000 or less will qualify for a tax credit up to 35 percent of the cost of premiums. The credit increases to 50 percent in 2014 for most small employers. To qualify for the credits, businesses must cover at least 50 percent of the cost of workers' insurance. Starting in 2014, businesses with 50 or more employees that don't provide health care coverage and have at least one full-time worker who receives subsidized coverage in the health insurance exchanges will have to pay a fee of up to $2,000 per full-time employee. (The firm's first 30 workers would be excluded from the fee.) Businesses with 50 or fewer workers would be exempt from the requirement.

Q: I buy my own health insurance coverage. How will the health law affect my coverage?

A: For policy years starting after Sept. 23, all health insurance policies in the individual market will be barred from cancelling coverage once you get sick -- a practice known as "rescission" - unless you committed fraud when applying for coverage. Insurers will be prohibited from setting lifetime limits on your coverage. The plans must allow you to keep an adult child up to age 26 on your health plan. New policies can't deny coverage for children up to age 19 based on a pre-existing medical condition. But "grandfathered" plans can; they can also set annual dollar limits and require cost-sharing for some preventive services. Most people in the individual market are expected to move to a new plan by 2014. Other provisions of the law will kick in later. For example, as of 2014 insurers won't be able to refuse to cover adults with pre-existing medical conditions. That same year, individuals whose incomes are up to 400 percent of poverty -- $88,200 for a family of four at the current poverty level - will qualify for subsidies to help purchase health insurance on exchanges, marketplaces where consumers can shop for coverage. At that point, most people will have to have health insurance or pay a fine.

Q: I'm on Medicare. Will my benefits change?

A: Your basic package of Medicare benefits won't shrink and in fact will expand under the law. But if you're in a Medicare Advantage plan - a private plan that offers Medicare benefits - you might lose some extra benefits at some point. In terms of the overall Medicare program, let's start with prescription drugs. As of late August, one million Medicare beneficiaries received a $250 check to help cover prescription drug costs in what's known as the doughnut hole. That's the gap in coverage where beneficiaries must pay the full cost of their prescriptions until catastrophic coverage kicks in. Starting next year, beneficiaries will receive a 50 percent discount on brand name drugs and a 7 percent discount on generic drugs while they are in the coverage gap. The health law closes the gap entirely by 2020. In addition, beginning next year, Medicare beneficiaries won't have to pay co-payments or deductibles on many preventive health care services, including diabetes and cervical cancer screenings. Medicare will also pay for an annual wellness visit to the doctor. To help pay for the health overhaul, Congress is cutting payments to Medicare Advantage plans, beginning the year after next. Beneficiaries won't lose any of their basic Medicare benefits as a result of the reductions but some Medicare Advantage insurers could decide to stop offering additional benefits, such as coverage for eyeglasses or gym memberships.

Q: Many Republicans have criticized the health care law as too intrusive and too expensive. If they pick up seats in the November election, how could the law be affected?

A: Some Republicans have threatened to block funding for the implementation of the law; others have called for its outright repeal. But accomplishing either would be tough unless they win large majorities in both the House and Senate. President Barack Obama would likely veto any legislation to gut the law, so Republicans would need a veto-proof majority - two-thirds of both chambers - to override such an action. Also, some Republicans might be reluctant to repeal provisions of the bill that are popular with the public, such as keeping a child up to age 26 on their parents' health care plan or outlawing rescissions and lifetime and annual limits.

Many questions continue to come in about covering young adults to age 26 on their parents' health insurance coverage. Officially, the regulations governing this issue go into affect on September 23rd, 2010. I've taken the liberty of including an excellent Q&A page from the U.S. Department of Health & Human Services website - www.hhs.gov. It's very comprehensive and covers all the bases.

Need Help with Doughnut Hole

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Question: I have prescription drug coverage under Medicare and will be hitting the "doughnut hole" pretty soon. What will the new healthcare bill help me pay for my drugs?

I'm signed over my Medicare to Secure Horizons, which I like. I heard these type plans are to be cancelled by the new healthcare reform?

Question: Is anything being done to control skyrocketing health care costs?

Question: My older son will be 23 on July 4th. He's now on our family insurance because he's a student. We have received notice that he will he have to get his own coverage. Also, my daughter will be 19 on October 16th. She will not be a full time student at that time. Can she stay on our insurance?

Question: How do you think all this health insurance reform change will impact our premiums? I do understand that you can only give me an opinion, and please allow yourself to speculate if you have to, but the bottom line is that most people I know are just worried about the economical impact of this change in their budgets, and we would like to know what possible scenario are we going to be confronting. From HealthcareShopper customer, Renee Sanudo

The New Insurance Plan

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How do I sign up for my new insurance?

Question: I hear that most of the Health Reform changes won't happen until 2014. What, if anything, changes right away?

Is Healthcare Reform Dead?

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Kim Geiger - LA Times
So is a healthcare reform deal really dead?

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