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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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Question: I currently have insurance through Covered California. I have KP Silver 94 HMO plan. I’m trying to predict if I’m going to be dropped into Medi-Cal based on my tax return for year 2019. It looks like my AGI will be around $18,000. Will I still qualify for Covered California or will I be dropped into Medi-Cal?

Answer: In 2020, the annual income limits for Medi-Cal eligibility for a one-person household is $17,237, a two-person household is $23,336, a three-person household is $29,436, and a four-person household is $35,535.


Subsidy Payback Blues?

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Question: I’m shopping for an insurance plan after not being covered for a number of years. The years I had Covered California subsidized insurance I had to pay back the entire amount they subsidized. My concern is whether this will happen to me again come tax season, and what’s the point of seeking financial assistance if I will just have to pay it back in a year.

Answer: Things have changed in California for 2020, namely there’s a penalty for not being insured and subsidies are available for higher income households. Only those taxpayers whose actual AGI exceeds the top eligibility limits (600% of Federal Poverty Level) will have to pay back the entire amount of premium advanced. It’s always better to take the money and give some of it back, than not take it at all. Consider it an interest-free loan.


Question: I will be getting laid off effective 12/31/2019, so if I elect, my COBRA coverage would begin on 1/1/2020. Can I get covered under Covered CA instead? When would I need to sign on with Covered CA if my job and coverage ends on 12/31/2019?

Answer: Yes. You can choose Covered California instead of COBRA. You must apply by December 15, 2019 for your coverage to begin on January 1,2020. If you already chose COBRA you can cancel it. You don’t have to wait for COBRA coverage to end.


Question: My dad is going to retire at the end of the year since he is turning 66. My mom is under his employer sponsored insurance. He will get Medicare and my mom would lose her insurance. Their income annually is ~90k but now that he is going to retire, their annual income will be about 36k. It would be from his social security and pension. My mom would still be 60 years old and taking care of my baby (her grandson). Would she qualify for covered California? We are confused if they will consider their previous years income or 2020's income which would be 36k. Please let us know.

Answer: Yes. Your mother will be eligible for Covered California coverage with significant premium assistance based on $36,000 annual income for a 2-person household. The only income that matters is their 2020 Adjusted Gross Income. If you use the $36,000 figure as an estimate and it turns out they actually have an AGI of $40,000, the IRS will take more tax to make up for the subsidy overpayment.


Question: I no longer get a subsidy. Is covered California just for people who qualify for subsidies? If so, how do higher income people apply?

Answer: If you are not eligible for financial assistance, it would be better to shop for coverage directly from an California insurance company (referred to as “off-exchange”). The reason? Silver plan rates are higher through Covered California. While Covered California Bronze, Gold, and Platinum Plans are the same price, you will pay more for Covered California Silver Plans. Click here to shop and apply for off-exchange health insurance coverage


Question: I recently retired and my dependent minor child receives Social Security benefits based on my retirement. She will be required to file a tax return in her name, although she will not pay any tax because her income is not high enough. How do I handle this income on the Covered California application?

Answer: Your daughter's taxable income is included in your household income. When she files her tax return, she should not take a personal exemption (0 exemptions) that will allow for you to continue to claim her exemption on your tax return


Question: I don't want Medi-Cal. I just want to pay for health coverage at subsidized rate. What should I do? Where do I need to apply for it?

Answer: You can start an online application at www.CoveredCa.com. Your eligibility for subsidized Covered California coverage will depend on your income.


How to Renew Medi-Cal Coverage?

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Question: My son is on Medi-Cal. How do I make sure he is renewed for 2020?

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. Click here for list of County Services Offices


Question: How do I recover my login password for my CoveredCA account?

Answer: You can recover your username and password at www.CoveredCa.com. To recover your username, click the “Sign In” icon at the top of the page, select “Forgot Username” and type in your email address and date of birth. If you ever created a username it will be provided. If no username, create an account. To recover password, select “Forgot Your Password?” link. Enter your user name and date of birth. 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.


Question: Covered California took my monthly premiums for 8 months. When I went to the doctor, they cut my benefits. When I asked them why they said because the law had changed in January 2019 and insurance was no longer mandatory. Then I asked for a refund for a refund of my premiums and they said no because I saw the doctor once!

Answer: Apparently your Covered California coverage did not renew on January 1, 2019. Most likely causes include non-payment of the monthly premium or loss of eligibility due to an income change. The premiums you paid prior to that date was to pay for coverage before January 2019, that’s why you can’t get a refund even though you only “saw the doctor once”. Do you get a refund of your auto insurance premiums when you don’t have an accident or your home insurance when your house doesn’t burn down? Health insurance works the same way. You pay for the protection against a major financial loss. Health insurance is mandatory in California in 2020. Now’s you chance to get it right, Sign up during Open enrollment October 15m 2019 to January 31, 2020.


Why an Open Enrollment Period?

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Question: Why is there an open enrollment period to buy health insurance? Wouldn’t anytime be better?

Answer: Wouldn’t it be great if you could purchase health insurance on Amazon when you need it — when told you need an MRI or from your hospital bed right after the accident. But if we all did that, the insurance company would not collect enough money to pay for everybody’s claims. So everybody has to put money into the pot all year long to make it work. The young and the healthy help pay for the old and sick.

Outside of the Open Enrollment Period (October 15 - January 31), people who need health insurance can enroll through Special enrollment with a qualifying life event such as loss of work related insurance, marriage, birth of a child. etc.. Those who are eligible for Medi-Cal can enroll anytime during the year.


Age 26 Enrollment?

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Question: Our son turns 26 in April 2020. Can he enroll in his own medical insurance during the current open enrollment period or must he wait for 2021?

Answer: Your son will qualify for a Special Enrollment Period triggered by his 26th birthday. He can wait until then to enroll in his own plan. Or he can enroll in his own plan during this Open Enrollment Period and have his own coverage start on January 1, 2020.


Changes to Income Impacting CSR?

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Question: I'm going to start 2020 unemployed, so estimating income is tricky. I understand the premium assistance gets trued up at the end of the via taxes. What happens with CSR (silver 73 vs 87 vs 94) based on income changes. If I had short term income, would that move me to a different co-pay structure right away?

Answer: Cost Sharing Reductions (CSR) are not charged back at year end due to unplanned income changes. The CSR level at the start 2020 will not change unless you manually adjust your income in your Covered California account during the course of the year.


Question: My wife petitioned her mother who lives in Mexico to live come to the US to live with us as a resident, but I heard there is a new immigration law that's going to be in effect starting November 3rd for all new immigrants have to have health insurance before or within 30 of entering the US. But they can not use the exchange's or Medi-Cal assistance. Where can we purchase health insurance for her. She won't have Medicare either.

Answer: Right. The White House issued a presidential proclamation on October 11, 2019 requiring many future immigrant visa applicants to show they can afford health care. The action, which is set to take effect in 30 days, would require immigrant visa applicants, including people with ties to family members in the U.S., to show they have health insurance or prove their financial ability to pay for medical care before being issued a visa that could lead to a green card.

The most affordable option for health insurance coverage for a visa applicant is international travel insurance for foreign nationals traveling to the United States. Shop Patriot America® Plus. The policy can cover up to two years with renewals for additional two years at a time. Monthly rates as low as $300 per month. Option number two is individual health insurance from a California insurance carrier at a minimum of $600 per month. Immigrant visa applicants are not eligible for premium assistance through Covered California or Medi-Cal.


Question: I have my health insurance with Blue Shield through Covered California. If I want to keep my current plan do I have to do anything during Open Enrollment?

Answer: Blue Shield will automatically renew you for 2020 coverage in the health plan you have now. If your current plan is no longer available, Blue Shield will automatically enroll you into a similar health plan. Even if you have been automatically re-enrolled you can still make changes to your health plan coverage until January 15, 2020.

If you receive premium assistance for your health insurance coverage through Covered California you should validate your enrollment online at or by phone at 800-300-1506 between October 15 and December 15, 2019 to maintain your financial assistance.


Will I Get a Subsidy in 2020?

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Question: I hear Covered California is providing state subsidies for people with higher incomes than before. Hoe can I find out if I’ll get a subsidy in 2020?

Answer: That’s true. In California, the upper income thresholds have been extended to 600% of the Federal Poverty Level for 2020. Use the new Subsidy Estimator to get a quick answer.


When Can I Find Out My 2020 Rates?

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Question: I read that Covered California health insurance rates will be about the same for 2020. When can I check my actual rates?

Answer The Open Enrollment Period for 2020 starts on October 15th. At that time you can check your renewal rates or apply for coverage for the first time if you were not previously qualified.


Question: In my area, Covered California only offers one insurance company. I would like to have another health provider. Can I register in another county where they have a choice?

Answer: You should have a choice of carriers next year. Covered California says, “More than 99% of Californians will be able to choose from two carriers or more for insurance in 2020”. That’s because three of the eleven insurers participating in the Covered California exchange, including giant Anthem, will expand their footprint in the state.


Question: As minimum wages increase it puts me in a different wage bracket. Is there going to be a adjustment with Covered CA as wages increase? So many things are going up right along with the wage increase in which I am paying out more and saving less.

Answer: The increase in minimum wage in California for 2020 is $1.00 per hour. Assuming you work a full 40 hours for 50 weeks next year, your annual income will increase by $2,000. Your share of the cost for your insurance premium will go up by about $25 per month if you are a single taxpayer or less if you have dependents.


Question: I've sponsored my parents for green card through my citizenship. They receive total $3,000 per month for retirement from their native country. They are both 65 and over. I understand there is a 5 years waiting period for Medicare. Would I be able to purchase Covered by California for their health insurance needs?

Answer: Provided they are legal residents of California, immigrants are eligible to apply for health insurance coverage through Covered California regardless of age. They may also be eligible for premium assistance based on their taxable income.


Question: I get a subsidy but I still have to pay about $100 a month. How much will it go up next year.

Answer: Your share of the cost may not go up at all. If you are one of the lucky ones, it could even come down. Covered California, the state’s Affordable Care Act exchange, announced some good news a few weeks ago. They said average premiums would rise an average of 0.8% for 2020, the lowest annual increase in its history. In some regions, rates would increase even less or fall. Customers who shop around when enrollment for 2020 plans opens October 15 could reduce their premiums by as much as 16.5%, depending on where they live.


Question: If i am out of a job, with no income, can i get Covered California insurance, as long as I can pay the premium?

Answer: Absolutely, you may even be eligible for a subsidy to help pay the premium if you lost your employer coverage due to job loss.


Do I Have to Reapply?

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Question: Do I have to apply again to Covered California or simply continue to make same payments and same coverage I had last year, if my income has not significantly changed from last year.

Answer: You are probably automatically renewed, but there is an exception as follows: If you enrolled in 2018 by special enrollment and have not selected a 2018 health plan prior to December 13, you will not be automatically renewed. You must select a 2018 health plan and then actively renew that plan for 2019 coverage to avoid a break in coverage.


Married Filing Separately?

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Question: I'm recently married and will be filing married/separate tax returns for 2019 tax year as he owes the IRS. However when applying to renew my covered cal insurance it states I must file married jointly. I've had covered cal insurance since it was offered and received the tax credit towards my premium and filed and paid taxes every year.

Answer: You will be ineligible for premium assistance if you're married and file separately, no exceptions.


Question: I am a small employer (two employees) who earn less than 50,000 per year. I am looking into covered ca small business plans. My quotes are coming in at 2500-3500 per mo. I can't afford to pay that amount. They mention possible tax credits to help offset costs. Would the credits reduce my monthly premium, or be assessed at the end of the year?

Answer: You would have to pay the entire monthly premium before earning the credit of up to 50% for two years. You claim the credit on the employer's annual income tax return, with a Form 8941, "Credit for Small Employer Health Insurance Premiums", showing the calculation of the credit.


Question: How much can you have in IRA's or savings accounts to be eligible for Covered CA tax credit?

Answer: Your assets, whether savings, retirement accounts, or real estate do not affect your eligibility for premium assistance. Covered California considers only your adjusted gross income (AGI).


Question: I sponsored my 84 years old mother when she got her green card a year ago. She is getting health coverage through Covered California, with a subsidy (as her annual income is around 35k). Can the government or state at some point ask me to repay that money? Is this a "means-tested public benefit"? Thanks

Answer: You will not be asked to repay your mother's benefits because you sponsored her green card application. Covered California (Affordable Care Act) premium assistance benefits are not considered means tested benefits.


Question: My 38 year old son lives with us and has zero income. We cover him 100%. He has medical insurance through Covered California (Medi-Cal) and he pays no premium and almost never any fees. Should I claim him as a dependent or will my liability for his medical cost me more than I save.

​Answer: Covered California requires him to file a tax return even if his income is $0. He needs to claim zero dependents on his return. If so, you can claim him as a dependent on your return without affecting his ​health insurance eligibility through Covered California.


Question: I have a very small business (s-corp): 2 employees (myself + full-time employee). The employee currently has a subsidized plan under covered california. I would like to help pay for the employee's health care, but it seems like the employee would lose their subsidy if I did so. When getting quotes I saw that even if I paid 65% of the premium (of the employees current plan), the employees would still be losing over $100/month. Is there any way I can contribute via a cafeteria plan (IRS 125) or similar and they can keep their individual plan? Basically, some way I can contribute that will maintain their subsidy eligibility but not increase their taxable income. Note: my employee is full time and earns > $18/hour. I am covered by my spouse.

Answer: A Health Reimbursement Arrangement (HRA) would allow the employer to reimburse premium and/or out-of-pocket medical, dental, and/or vision expenses up to $4,950 for employee-only coverage and $10,000 for family coverage. Employer contributions under an HRA are pre-tax to the employee so wouldn't increase their reportable income. Employees participating in a small business HRA can access the ACA premium tax credit, but the amount of the credit will be reduced dollar for dollar by the HRA amount, so the employee can't double dip.


Does Rental Income Count?

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Question: We didn't make any money besides on our rental properties. And I'm not sure if that would apply towards our income. Would there be a penalty if we were supposed to be in Medi-cal instead of Covered Ca plan?

Answer: Your net rental income after expenses is taxable and counts toward your adjusted gross income (Line 37 of Form 1040) which is what you report to Covered California. If your adjusted gross income makes you eligible for Medi-Cal, your Covered California coverage will be terminated, but there is no penalty.


Domestic Partnership Eligibility?

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Question: I now quality for health insurance assistance. If I enter into a domestic partnership with someone who is over 62 (opposite sex) who does not qualify for assistance, would I have to include his income to determine if I still quality for assistance?

Answer: In general, California now affords the same rights and responsibilities to registered domestic partnerships (RDP) as married individuals. However, because the IRS does not recognize RDPs as married individuals for federal tax purposes, domestic partners will continue to been seen as unmarried individuals by Covered California. Your eligibility for premium assistance is based on your income alone.


Question: My child is a full time dependant that lives at home and works part-time. This year she earned over the limit of nonreportable income and had to file taxes. My question is this, do I report the income earned through the part- time job that is over the threshold or the entire 9k? Secondly, is it okay to include under entire household income (my income, self employed) estimate, or should I list the income for my dependant alongside the dependant name?

Answer: This is the easy part of your question: all of your adult child's $9,000 income must be reported, not just the amount over the threshold. Part two: If you wish to continue claiming her as a dependent, you must add the $9,000 to your household income. In that case, your dependent must opt out of her personal deduction when filing her income tax return. Otherwise, she can apply for coverage as a one-person household. The income of $9,000 makes her eligible for Medi-Cal, no cost insurance, but you would give up the dependent deduction on your taxes.


Question: My spouse & I are renewing our health plan coverage for 2019, but he will be going on Medicare in April. When he cancels his Covered California plan, how will that affect my rate?

Answer: You and your spouse have individual rates which are now combined. When your husband goes on Medicare, you will pay only your individual rate.


Question: My wife and I sold our primary residence in 2018 with a capital gain of $100,000. We meet the certain conditions to exclude the first $500,000 of gain from the sale of our home from our income and thus don't have to pay taxes on it to the IRS. Because of this fact, is this $100,000 capital gain not counted as income from Covered CA stand point and not affecting the Advance Tax Credits we receive? Thanks

Answer: Covered California considers only taxable income in establishing your eligibility for premium assistance under the Affordable Care Act. Your taxable income is your adjusted gross income (AGI) which can be found on Line 37 of IRS Form 1040. AGI includes capital gains, but since the capital gain from selling your home is excluded from tax in your case, it will not affect your taxable income.


Question: If I divorce before the end of the year I understand I have to file my taxes separately but my annual income to determine coverage was based on both of our incomes as a married couple. My coverage was based on household income of 40K with 2 people, married. If we divorce and I have to file taxes separately as a single person my reported income would only be about 18,000. How does that impact my covered California? My email is below

Answer: In your case, your individual income of $18,000 will qualify you for more premium assistance than you qualified for as a couple. You will receive the added premium assistance as a tax credit when you file your 1040 for 2018 as a single taxpayer.


What is Considered Income?

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Question: What is considered "income" Is savings or proceeds from retirement investments "income"?

Answer: In determining eligibility for premium assistance and cost sharing benefits, Covered California considers only taxable income. A quick way to check your "income" is to look at line 37 of your Form 1040 tax return. This is your Adjusted Gross Income or AGI. It includes interest earned on your savings account and withdrawals from your retirement account.


Question: When is open enrollment this year?

Answer: The Covered California 2019 Individual Health Insurance Open Enrollment Period starts on October 15, 2018 and runs through January 15, 2019. To purchase new coverage effective January 1st 2019, you must apply by December 15, 2018. During Open Enrollment you can apply without a Qualifying Life Event.


Question: I have Blue Shield silver 87 but it turns out very few doctors in my aria accept Blue shield, and the few that do take forever to get an appointment too see, So I'm was wondering if I could change my plan I was thinking of Kaiser Permanente gold hmo, even though my monthly payments would be considerable more at least when I had Kyser I could see a doctor in a timely fashion when I needed one!

Answer: No. You can't change your health insurance plan until the next open enrollment period which is November-December 2018. You can switch to Kaiser then and the new coverage will be effective on January 1, 2019.


Question: If my child is offered an insurance at his college, will he no longer be eligible for subsidized Covered California insurance? He is a high school senior now and is planning to attend a college in California this fall.

Answer: Your son can remain on your Covered California health plan and the household will remain eligible for premium assistance even if student health insurance is offered.


Question: I would like to know what website I can go to, to print out my Tax Form 1095A? Can I print it online? Please advise.

Answer: The web address for the Covered California Account Login is: https://apply.coveredca.com/apspahbx/login.portal

If you don't have a login and password call 800-300-1506.

After logging in, you'll be on the Consumer Home Screen. Look for the list of links in the bottom-center of the page.

Click on Eligibility Results
Click on Summary
Click on Documents and Correspondence
Click on _IRSForm1095A_2017


Income Guidelines?

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Question: What are the salary limits for a family of 3 which includes one adult child that turned 26 years old in 2017. What type of income is included in the calculation for Covered California subsidies.

Answer: The adult child, age 26, must apply for his or her own coverage even though he or she lives in the parents household. Eligibility for public insurance or subsidized coverage is based on his or her income alone. Here are the key income guidelines for a single person.

$16,644 - below this annual income, you are eligible for Medi-Cal. Income above this number may make you eligible for premium assistance through Covered California.

$48,240 - below this annual income, he or she is eligible for premium assistance through Covered California, with no assistance above that number.

The parents are a household of two. Here are the key income guidelines for them.
$22,412 - below this annual income, the couple is eligible for Medi-Cal. Income above this number may make them eligible for premium assistance through Covered California.

$64.960 - below this annual income, they are eligible for premium assistance through Covered California, with no assistance above that number.


Roth IRA Withdrawal Income?

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Question: I am 62 years old. My total annual gross income for 2018 is $62,000 for my wife and I. We live in Northern California and qualify for subsidized premiums. If I withdraw $10,000 in 2018 from my Roth IRA, do I lose my eligibility for subsidies for 2018?

Answer: No. Since Roth IRA withdrawals are not taxed, the income from a Roth IRA does not increase your Adjusted Gross Income and does not affect your eligibility for premium assistance.


Question: I want to buy a Blue Shield PPO plan. What are the advantages of signing up through Covered California versus applying directly with Blue Shield>

Answer: If your household income makes you eligible for premium assistance, Covered California is the only place to enroll. 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. Click here for an off-exchange quote.


Question: My family of four gets subsidized Covered California insurance. My 24 year-old son is included in our household. He earned about $9,000.00 this year. Will we be penalized on our taxes for 2017? Should he enroll for 2018 for his own plan?

Answer: Your son must file his own tax return for 2017 since his income was over $6,300, but you can continue to include him in your household if you wish. When he files his tax return for 2017, he can opt out of his personal exemption. If so, all you have to do is update your Covered California household account to include his income. The added income will reduce your premium assistance, so you will pay some added tax for 2017. If he takes his own personal exemption for 2017, you must update your CC account by removing him from your household. This will reduce your household size to three going forward, but you do not have to include his income. You will have added taxes to pay for the 2017 tax year, because your tax credits were based on a four person household. You will probably need an accountant to figure out which path leads to the best financial outcome for your family.


Obamacare Sign-up Deadline?

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Question: My wife read that the deadline was December 7th. I thought it was December 15th. Who’s right.

Answer: You’re right this time. December 15th is the deadline for individuals and families in the under-65 health insurance market. You must enroll or make changes to your plan by December 15th to affect coverage on January 1st whether you enroll through Covered California or directly with an insurance company. Open enrollment in California extends until January 31st for new enrollments or changes to existing plans with effective dates to March 1st 2018.

Your spouse is correct if she is on Medicare. The deadline for changes to 2018 Medicare coverage is December 7th.


Out-of-Network Coverage?

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Question: I see a holistic medical doctor who is not in any Covered California networks. It is very hard to find information about out of network coverage. I was looking at Blue Shield PPO plans. Am I correct they will cover only 50% out of network?

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: if your doctor charges $250. The Blue Shield’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. Don’t look for out-of-network benefits to help much if at all on minor medical expenses.


Lower Income, Repay Subsidy?

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Question: I had Covered California with a big subsidy in 2016 because of my low income. I lost my job in October, so my income will be even lower than it was when I applied for coverage. I am now eligible for Medi-Cal. Will I have to repay the premium tax credits that got this year?

Answer: No. You are still eligible for the tax credits you received last year. If your income later fell below the Medi-Cal eligibility level, you will not be required to repay the premium tax credit when you file your tax return.


Question: What is the advantage of signing up through Covered California, instead of directly through through Kaiser?

Answer: Your income may make you eligible for premium assistance and Covered California is the only place to enroll for health insurance coverage with 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 Kaiser Permanente - referred to as an off-exchange enrollment - you are not asked to provide any income related information whatsoever. Off-exchange, you will find more available health plan, some that mirror the Covered California plans exactly in benefits and rates, and other plans that are unique to the off-exchange-market.


Question: My son, age 23, got hired and enrolled in a PPO health plan at work, because they told him had to. He is still our plan. Can he drop his insurance through work and stay on our plan?

Answer: Your son can be included in your household health coverage through Covered California until age 26, even though he is employed. However, if he is included with your family coverage, your household is not eligible for premium assistance or cost sharing enhancements from the time he was offered health insurance at work.


Recover Covered Ca Password?

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

Answer: Go to the Covered California Online Account, click here. Enter your username if you know it, if not click on “Forgot Username” You can recover your username with your email address and date of birth. To reset your password, click “Forgot Password”. 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.


Covered California for 65+?

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Question: I turn 65 in February and I will be eligible for Medicare. Can I stay in Covered California instead?

Answer: You cannot purchase a Covered California health plan with premium assistance if you are eligible for Medicare. Without premium assistance, coverage through Covered California for a 65 year-old is much more expensive than Medicare. However, if your income is very low, you may be eligible for Medi-Cal in addition to Medicare. 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.


Am I Renewed or Not?

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Question: I received a renewal notice from Covered California a while back. It seemed to say that I needed to renew my coverage by November 15th, but it also seems to say that I don’t have to do anything and I will be renewed. Which is it?

Answer: If you take no action to actively renew or change plans, you will automatically be renewed into the same plan you had in 2017 if available. However, you still have until December 15th, 2017 to make changes to your coverage or switch health plans.


Adult Child Coverage?

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Question: I thought my daughter could stay under Covered California plan until she is 26 years old? I was told that she had to be a dependent on my taxes. Is this correct?

Answer: If you are eligible premium assistance (a subsidy) for your family and wish to include your daughter as part of your household, she must be a dependent on your income tax return. If you are not eligible for premium assistance, your adult child can be financially independent and pay their own taxes and still be included on your family coverage to age 26.


Avoid Subsidy Overpayment?

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Question: My income went up during the year, si I guess I’ll have to pay some of the subsidy back. How do they handle that?

Answer: If you are paid too much premium assistance during the year, the IRS will recover some of it through your tax return. The subsidy overpayment is added to your taxes due for the year. You can avoid having to repay excess premium assistance in several ways.

    • 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.
    • You can elect to take less premium assistance on a monthly basis or
    • you can take all of your premium assistance in a lump sum at the end of the year.

Quit Covered California?

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Question: I have an Anthem Blue Cross plan through Covered California, but I want to change to a Blue Shield plan outside of Covered California for 2018, since I don’t qualify for premium assistance. Do I have to notify Anthem so that they won’t automatically renew my plan for 2018?

Answer: Yes. It is your responsibility to notify Anthem that you are cancelling your coverage effective 12/31/2017. You must also terminate coverage in your Covered California account. To apply directly to Blue Shield, click here.


Question: I no longer get a subsidy. Is covered California just for people who qualify for subsidies? If so, how do higher income people apply?

Answer: If you are not eligible for financial assistance, it would be better to purchase coverage outside of Covered California (referred to as “off-exchange”). The reason? Silver plan rates for 2018 are 13% higher through Covered California. While Covered California Bronze, Gold, and Platinum Plans are the same price, you will pay more for Covered California Silver Plans. Click here to shop and apply for off-exchange health insurance coverage


Instead of COBRA?

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Question: I will be getting laid off effective 12/31/17, so if I elect, my COBRA coverage would begin on 1/1/18. Can I get covered under Covered CA instead? When would I need to sign on with Covered CA if my job and coverage ends on 12/31/17?

Answer: Yes. You can choose Covered California instead of COBRA. You must apply by December 15, 2017 for your coverage to begin on January 1,2018. You don’t have to wait for your current coverage to end.


Drop Company Plan for Covered CA?

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Question: I make $50,000 a year and my husband makes less than $20,000 a year. 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.

Answer: Your spouse is ineligible for premium assistance (subsidy) through Covered California because he has access to your employer’s health plan. He can off exchange insurance coverage without a subsidy, but the cost may be similar to spouse coverage under your employer-based coverage. Your incomes have no effect in this case.


Question: I am covered under COBRA from my former employer, but I pay the full premium. It’s more expensive than Covered California. Can I cancel my COBRA before it expires and buy Covered California instead?

Answer: Yes. You can cancel your COBRA coverage effective December 31, 2017 and enroll in a Covered California plan to be effective January 1, 2018. If you wait until Open Enrollment ends (January 31,2018), and drop your COBRA coverage or stop paying premiums before the COBRA coverage expires, you will not be eligible for a special enrollment 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 confused about how to renew coverage through Covered California. The renewal notice I got 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, you will automatically be renewed in the same plan you had this year. During open enrollment, November 1st through January 31st, 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.


Does HRA Nix Subsidies?

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Question: I receive an HRA monthly payment from my last employer (now retired) of around $270 per month. In 2017 I used Covered California to select a plan. At that time I did not apply for any Tax credits against my plan. For 2018, based on my income, I would qualify for about $550 tax credit. Can I apply for Tax Credits when I receive the HRA payments?

Answer: Your HRA benefit does not affect your eligibility for Advance Premium Tax Credits through the Affordable Care Act. You must update your 2018 income estimate in your Covered California account either online or at the call center 800-300-1506. Make sure that your profile indicates that you want help with your premium payments. No need to cancel your HRA benefits as long as your former employer chooses to keep paying. You can use it for out-of pocket medical expenses other than the monthly premium - things like dental care, chiropractic care, and acupuncture that are not covered well on your health plan.


Question: If our income drops mid-year to become Medi-Cal eligible, does Covered Ca give us the option to pay the full premium or will they automatically send our info to Medi-Cal? Will that be considered a qualifying event to enroll in other private health plans during the year?

Answer: If you lower your annual income on your Covered California account into Medi-Cal eligibility, Covered California will automatically enroll you in Medi-Cal. If that change takes place outside of the Open Enrollment Period, it is not considered a qualifying event that would allow the purchase of unsubsidized health insurance coverage either through Covered California or direct from an insurance carrier.


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.


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.


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: 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.


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.


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

  • Adult Child Tax Status?

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    Question: I heard is you cannot include your child under age 26 in your Covered CA application unless he/she is your dependent on your tax or by court order. Is this correct? I thought a child is allowed to stay under his/her parents' plan until 26?

    Answer: You are confusing two different ACA guidelines. (1) The ACA has ruled that you can include adult children to age 26 on your family health insurance coverage. This rule has nothing to do with tax status. Your adult child may be financially independent and pay their own taxes. (2) If you are seeking premium assistance for your family through Covered California and wish to include a child under age 26 as part of your household, that child must be a income tax dependent.


    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: Is Covered California an insurance company? If so why dies it sell other insurance company products?

    Answer: No. Covered California is a health insurance exchange governed by the State of California. Covered California has the power to regulate the insurance companies who participate in the state exchange. It provides a platform for Californians to get brand-name health insurance under the Affordable Care Act. Covered California is the only place Californians can qualify for financial subsidies from the federal government to help them pay their monthly premiums.


    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.


    Is Medi-Cal Any Good?

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    Question: What is the difference between Covered California and Medi-Cal?

    Medi-Cal is good health coverage. A recent survey of Medi-Cal members by the California Healthcare Foundation found that 90% of the members who answered rated Medi-Cal as a good or very good program. Medi-Cal emphasizes prevention-oriented health care that promotes health and well-being and works to ensure that members receive the right care at the right time. Your health care will be free or at a lower cost to you and your family. You can apply online at CoveredCA.com. A single application will let you know if you qualify for Covered California or Medi-Cal coverage. You can also apply in person at your local county human services agency or over the phone by calling (800) 300-1506. If you are determined eligible, Medi-Cal will mail you a packet of available health plans to choose from.


    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.

    #CoveredCaliforniaAdvice


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

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

    #CoveredCaliforniaAdvice


    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.

    #CoveredCaliforniaAdvice


    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.

    #CoveredCaliforniaAdvice


    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.


    Question: HI! I'VE ENTERED THE 4 HOUSEHOLD MEMBERS AND CLICKED CONTINUE ON THE APPLICATION, BUT IT KEEPS RE-ROUTING BACK TO YOU MUST FILL IN ALL THE INFORMATION FOR AN ADDITIONAL MEMBER, THERE ARE NO MORE. NO MATTER WHAT I'VE TRIED, IT'S NOT LETTING ME CONTINUE PAST THAT PORTION! HELP!!! THANKS!

    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 estimated my wife's self employed income at 30 k but so far she has only made around 3k. She gets paid sporadically and it is very possible that she will end the year with the estimated income. If she does not, we would become eligible for premium assistance. If I do not report the change now in the hopes of her making that money, will There be some sort of penalty. Right now we are not eligible based on the estimate and have not taken any assistance. Also, is one required to take premium assistance even if one qualifies for it. My wife has her own private health insurance, and I have covered california which, even without assistance, is cheaper than what I had off the exchange. Can I say I do not want premium assistance and skip the hassles of reporting income change ges, proving income, etc. Or would I still be subject to all of that

    Answer: If you enrolled through Covered California, you can receive premium assistance retroactively. For example, let's say your estimated you household income (both you and your wife) for the 2016 tax year above the amount that would make you eligible for premium assistance (subsidy). However, at the end of the year your actual income is lower than you estimated (there is no penalty for overestimating your income) and now your actual income makes you eligible for a subsidy. You will get that money as a lump sum tax credit on your 2016 tax return. However, there is a potential snag in your situation. You say, "My wife has her own private health insurance". I take that to mean that your wife has off-exchange health insurance. If that is the case, her portion of the premium assistance will be lost. She has to be enrolled through Covered California in order to be eligible for a subsidy now or later.


    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,”.


    Did I Make the Obamacare Deadline?

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    Question: I just completed the application and asked me to upload a form for the manage verification page, which I did. After it does not ask me anything else and says someone will contact me after reviewing my form. My question is, today is the last day to enroll, if someone does not review my form by today, can I not get anything? Or did i do everything already on my part for the deadline.

    Answer: As long as you started your application today - 31 January 2016 - you made the deadline for a 1 March 2016 effective date of coverage. However your application may not be complete. You have until 6 February 2016 to get a Certified Agent of Covered California representative to finish it for you.


    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.


    Gap Between Kaiser and Medi-Cal?

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    Question: My roommate is moving from Kaiser to Medi-Cal with Kaiser (she just got her packet from the state yesterday, and will sign up with Alameda Alliance). My question is, will there be any gaps in her coverage? At some point she'll have to stop with Kaiser and get on Medi-Cal, but I'd like for her coverage to not be interrupted. She can pay her Feb premiums-can she elect to start Medi-Cal coverage on March 1st? The Alameda Alliance person I talked to indicated she'd have to cancel her plan with Kaiser first, but couldn't one just stop and the other start right after? She has a lot of health issues and would like to keep her health insurance through any gaps.

    Answer: Medi-Cal coverage starts immediately once the application is approved. Your friend is already covered by Medi-Cal. Electing Alameda Alliance as your managed care provider within Medi-Cal should be done immediately as well. She should not continue to pay insurance premiums for her previous coverage.


    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: I am single with no dependents , I am currently covered by med I cal. I recently started getting more hours at work. my pay before taxes is now averaging around 900.00 to 1,100.00 every two weeks .Work can also slow down but for now that is my average. What is the rate that tells me if I qualify for med I cal or need to apply for insurance other than med I cal? do I need to ask med I cal? or is there a rate chart? Confused…

    Answer: For a one person household that number is $16,243 per year or $1,354 per month. So it seems that your income is high enough now to move to Covered California with premium assistance. First, you have to get Medi-Cal to release you. You will do that by proving to them that you are now earning what you claim. That may take some time. Here’s a chart others can use who have the same or similar issue. Household Income Subsidy Guidelines.pdf


    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?

    By on | 2 Comments

    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?

    By on | 3 Comments

    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?

    By on | 1 Comment

    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?

    By on | 1 Comment

    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?

    By on | 1 Comment

    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?

    By on | 2 Comments

    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?

    By on | 1 Comment

    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?

    By on | 3 Comments

    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?

    By on | 1 Comment

    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?

    By on | 1 Comment

    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.


    Why Did I Get a Premium Rebate?

    By on | 8 Comments

    Question: I just received a check from Blue Shield of CA for my 2014 health insurance premium rebate. However, my premiums in 2014 were fully reimbursed by the ACA subsidies. Shouldn’t this check be going to the government, not to me?

    Answer: One of the provisions of the Affordable Care Act (Obamacare) is the requirement that insurers, like Blue Shield of California, spend at least 80 percent of premiums on medical expenses to help make certain that consumers get value for their healthcare dollars. If carriers do not meet this Medical Loss Standard (MLR), they are required to pay rebates to eligible subscribers. Blue Shield of California missed the 80 percent target by 3.3 percent of premiums for its Individual and Family Plans in 2014. By law the rebate is paid to the consumer, not the IRS, regardless of the consumer’s net premium.


    Are All Bronze Plans HSA Eligible?

    By on | 2 Comments

    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?

    By on | 4 Comments

    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?

    By on | 5 Comments

    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?

    By on | 3 Comments

    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?

    By on | 2 Comments

    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 ?

    By on | 6 Comments

    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?

    By on | 9 Comments

    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?

    By on | No Comments

    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.

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