Frequently Asked Questions

Frequently Asked Questions About Covered California

  1. My income changed since my tax-return. What should I do? Payment stubs, termination letter, resignation, new job, etc?

Covered California uses your estimated 2014 income to determine your eligibility for tax subsidies, cost saving reductions, and Medi-Cal eligibility. Whatever documentation you have to verify your current income should be provided. If you’re not currently receiving income, then no documentation should be needed, unless you have recent proof that you were laid off with no unemployment benefits.

2. What do I need to bring with me to enroll? Why are they asking for my bank statements?

If a client is a natural born citizen they only need to bring proof of income and proof of California residency, such as a Driver’s license, for all adults in their household that are applying for coverage, along with the SSNs and birthdates of all members of the household. If the client is a naturalized citizen or legal permanent resident they will need to bring their citizenship and/or residency documentation. A copy of their Certificate of Natuaralization is required if they are a naturalized citizen. Covered California and expanded MAGI Medi-Cal should not be asking for bank statements; however MSI and traditional Medi-Cal may require this documentation to determine benefit eligibility.

3. Can I apply for coverage if I have a work or student visa?

Lawful permanent residents (also known as green card holders); people with temporary work and student visas (such as H-1B, J and F visas); refugees and asylees; Cuban/Haitian entrants; and others can all buy from the exchange and apply for tax credits. Legal permanent residents of five years or more may qualify for Medi-Cal.

4. What if I am an immigrant that is sponsored by someone? Can I apply, even though my sponsor stated he will take care of all my costs?

If this person is a legal permanent resident then they can apply for Covered California, but I would encourage them to talk to their immigration attorney before applying for tax subsidies to determine what ramifications this might have on their application for citizenship.

5. How is the household configured? Is it simply anyone who is claimed on a tax return?

For Covered California, the household is comprised of the tax filer, their spouse and their dependent children 18 years of age or under, unless they are in school full time then they are included up to 21 years of age.

MAGI Medi-Cal has slightly different way of determining household composition. The Tax filer, their spouse and all persons they claim as dependents are included in the family size. The Dependent’s household size is the same as the Tax filer’s unless the tax dependent is not a child or spouse of the tax filer, the children are living with unmarried parents, or the children are claimed as a tax dependent of a non-custodial parent. In these cases, the adult’s household is considered the individual plus the spouse and children living with the individual, while the child’s household is considered the child plus siblings and parents, including step-parents, living with the child. Additional considerations: children are considered those under age 19 or under 21 if they are full-time students, married couples living together are always included in each other’s household, pregnant women count as one plus the number of expected children.

6. What does it mean if my child can remain on my plan until 26 if he can still be added as an adult over the age of 26?

If you have an employee-sponsored plan with dependent coverage, that plan must offer dependent coverage up to age 26. However, some employer sponsored plans have opted to extend this coverage further. After this coverage ends, they can apply for Expanded Medi-Cal for Adults or Covered California as an adult. Children can remain on a Covered California plan until they turn 21 if they are full time students.

7. What if I get paid cash? Will that get counted in my MAGI?

Yes, applicants must report any income they receive and report and their taxes.

8. If I am a contractor, do my expenses get subtracted from my total income for which my rates are based upon?

Report income to Covered California as you would report it on your taxes. This means that self-employed individuals do deduct their expenses from their profits when they are calculating their income for Covered California eligibility.

9. Is non-recurring income counted in the MAGI?

The MAGI determination takes all income into account that is being received at the time of the application. This amount should be as close as possible to what will be reported on the client’s 2014 taxes. If a recent one-time gift changes a client’s income more than 10% then it should be included. If this gift is received after the application is submitted and increases the client’s income more than 10% then it needs to be reported to Medi-Cal / Covered California.

10. What if, due to one-time rewards, the MAGI is more than the actual income? Will the rates still be based on MAGI or on the actual income?

Tax subsidies are based on the Modified Adjusted Gross Income (MAGI) submitted when applying for coverage; however you want this income to reflect as closely as possible your estimated 2014 income. Income reported and subsidies received will be reviewed on your 2014 tax return and an income difference of 10% or higher may result in a penalty and a need to repay excess subsidies received. If the current income without the rewards will be the more approximate income in 2014 then that should be the income used, unless another one time gift is expected.

11. What is the difference between the deductible and out-of-pocket costs?

The deductible is the total amount the client must pay before the health plan begins to pay their portion (60%, 70%, 80% or 90%). The out-of-pocket maximum is the most a client will pay before the health plan covers the healthcare costs 100%.

12. What is co-insurance and when is it applied?

Co-insurance is a percentage of the healthcare costs that a client must pay for the services rendered after they’ve met their deductible. What services it applies to depend on the health plan selected, but the co-insurance breakdown is specified in the Summary of Benefits. Co-pays are the cost for routine services to which your deductible does not apply.

13. How do I purchase dental insurance through Covered CA? What about vision?

Currently adult dental and vision insurance are not available through Covered California, but are planned for 2014. Dental and vision plans they are available for children through Covered California.

14. For Medi-Cal, what is the cutoff age, 18 or 19?

Medi-Cal has several different programs and the age restrictions depend on which Medi-Cal subset the family or individual qualifies for. In the new expanded MAGI Medi-Cal, children are included in their parent’s household until their 19th birthday, or 21st birthday if they are in school full-time. After they reach this age they can then apply for Medi-Cal as an adult if they are still within the income guidelines.

15. Rates are not based on assets; but what if I own property and I’m receiving income from those properties?

Any income received needs to be reported and factored into the eligibility determination. Property income is factored into the client total income.

16. Does Medi-Cal look at assets, or just at income?

MAGI Medi-Cal only looks at income; however some traditional Medi-Cal programs do take assets into account when determining eligibility.

17. Do I still have to pay a $95 fine if I sign up later than March 31st, like July?

Yes, or 1% of income, whichever is greater.

18. What is a grandfathered plan and what is a non-grandfathered plan? I’ve been in my plan since 2005 – why isn’t it grandfathered?

Grandfathered plan are only those that have existed since March 23, 2010 without changes or alterations. If your plan premiums or co-pays have increased “significantly” or any benefits were reduced then the plan is no longer considered a grandfathered plan.

19. Why am I paying for maternity care if I’m 60 and can’t have kids? Or if I’m a man?

The ten essential health benefits are guaranteed to all healthcare coverage beneficiaries, regardless of whether you use them or not.

20. What if I want to estimate my rates for only a certain amount of individuals in the household?

You can use the Shop and Compare tool to find prices and plans for children only.  Enter the family size of only the individuals applying, and only include the ages for those that are interested in applying.

You can also begin an application for only the individuals planning to apply and if they choose not to move forward then you can leave the application without submitting it and mark it as in-active in your CEC account.

21. I have Medi-Care – can I purchase Covered CA plans for myself?

Individuals who are eligible for Medicare will not be eligible to receive premium assistance through Covered California. Additionally, Medicare supplement insurance (Medigap) plans will not be offered through Covered California. These clients may be eligible to qualify for Medi-Cal coverage, know as dual-eligibles, which they can also apply for through the county.

22. I don’t want Medi-Cal because I don’t like the services and limitations associated with that governmental entity – can I instead opt for Covered CA?

If you chose not to enroll into Medi-Cal then you are not eligible for tax subsidies through Covered California, but you can purchase the plans at full cost by declining financial assistance.

23. Why is my Covered CA plan more expensive than my private insurance employer’s?

Most likely because it covers the ten essential health benefits and has no lifetime maximum coverage cap, like many existing private plans. (The specifics of the price difference in plans vary greatly depending on the private plan in questions).

24. How can those people who don’t file taxes get fined the $95? For example, those who make less than the threshold amount?

These people most likely qualify for the penalty waiver because the cost of purchasing health insurance would be more than 9% of their income. Moreover, they would most likely be eligible for no cost Medi-Cal coverage.

25.  Can two individuals in a family opt for two different plans? For example, can the husband purchase Silver and the wife Gold?

Yes they may choose to purchase different plans through Covered California. In addition, some family members may be eligible for Medi-Cal, while others need to purchase plans through Covered California.

26.  What happens when a baby is born into a family with regards to coverage? Are all incurred costs covered by the family until the coverage changes? If so, should the family inform Covered CA a month in advance of the baby’s delivery so the plan would accommodate the new child? If not, who covers the baby’s costs? Or, are they covered by the Essential Health Benefit “newborn care”?

Maternity and newborn care will cover the child for a short period after the birth, but the family needs to report the child’s birth within 30 days in order to purchase coverage for the baby, or they will have to wait until the next open enrollment period.

27.  What if someone hasn’t reached their out-of-pocket maximum, but did reach their deductible, would they have to pay their out-of-pocket total before costs of a significant medical expense (like a surgery) are covered?

The clients would still need to pay to out of pocket costs that are not counted against the deductible, but the deductible eligible services should be covered 100% and most significant expenses like surgeries and inpatient services would fall into this category.

28.  What do the tier divisions mean exactly? Or are they only meant to serve a symbolic and representative purpose? As in, does 40% of the Bronze Level mean you will pay 40% of your total medical costs…and 20% the same? Or is it just representative of the copays, coinsurance, and deductible?

The tiers equate to the percentage of the cost a client will need to pay for the services they receive. In the Bronze plan, the client will cover 40% of the cost and the health plan will pay for 60% of the services rendered; Silver is 30% Individual/ 70% health plan; Gold is 80% Individual/ 20% health plan; and Platinum is 10% Individual / 90% health plan. This is considered co-insurance. The co-pays apply to primary care and specialty visits and most prescriptions. The co-insurance is typically applied to inpatient services and some outpatient services and labs, depending on the plan you choose, once the deductible is paid.

29.  If I just purchased insurance, but I need a surgery and I haven’t yet paid any sort of out-of-pocket costs (OPC), do I have to pay the entire OPC before the policy begins to cover my medical expenses?

The client will need to pay their full deductible before the health plan starts to pay their portion of the coverage. Once the deductible is met then the portion of the care the client pays for begins to count against their total out of pocket annual maximum. If the clients portion of the services rendered after the deductible is paid exceeds to total annual out-of-pocket cost for the year, then the client will not need to pay any more for services rendering throughout the year.

30.  Are unemployment benefits counted as income?

Yes.

31.  Does being a part of a PPO mean you can visit any specialist (x-ray, skin test, etc) without being referred by your primary doctor? And following that, does that mean having an HMO mean you can only visit a specialist after being referred?

Yes, as a PPO (Preferred Provider Organization) member a client does not need a referral to see any providers in that network. They can also see providers outside of the network without a referral, but these services would incur a higher cost for the client. Being a member of an HMO (Health Maintenance Organization) means that clients will need referrals from their Primary Care Provider to see specialists, unless they are a female in need of their well woman exam, in which case they can see an OB/GYN without a referral. In an EPO (Exclusive Provider Organization), a client must use network providers, similar to an HMO, but they do not need a referral to see a specialist that is in their network.

32.  Can you purchase health insurance for your kids even if they aren’t claimed on your tax return?

Yes but they are not eligible for tax credits.

33.  Is there a Covered CA representative for the Orange County area who could help with the complaint process and other questions?

There is not a dedicated representative at this time; they should call Covered California Customer Service at 1-800-300-1506

34.  If someone’s current income falls under 138% FPL, but this person projects over 138% FPL for the following year in order to qualify for Advance Premium Tax Credits, what happens if the person actually does only make less than 138% FPL.  Normally, during the reconciliation process, making less would mean more of a tax credit when filing taxes.  But in this case, the person should have been on Medi-Cal based on the actual income.  Would the IRS likely just let it go?

Covered California does not have an answer for this question at the moment. They stated that this will fall under the prevue of the IRS and they will be making the determinations. They encouraged clients to be as accurate as possible when predicting their income for 2014.

35.   If they qualify for Medi-Cal, but their processed application is for Health Net, what should the Coalition do to make a change?

The client can simply report the change of circumstances and request a reevaluation of eligibility based on those changes.  Reporting of changes can be made directly to Covered CA or SSA, whichever the client prefers.

36.   How can I pay my Covered California premiums?

The tables below were provided by Covered California to help guide new clients needing to pay their premiums in order to ensure that their coverage is effective. This information is available at https://www.coveredca.com/getting-covered/how-to-pay.html. Questions regarding specific plans can be directed to the respective phone numbers below.

Health
Plan
Pay by Phone Pay Online Pay by Mail No Invoice
Received?
Anthem
Blue Cross
January dealine
extended to 1/31
(855)
634-3381
Have your Subscriber ID or Social Security number
Visit
the payment landing page
www.anthem.com/ca/
paymentlanding

for further detailsIf you have your Application ID, go to:Anthem
Payment site
Please
reference the information found on the payment letter.
(855)
634-3381
Blue
Shield of California
The payment deadline for February coverage is 2/14.
(855)
836-9705
Have your Case # or Social Security number
Blue Shield CA website
Have your Social Security Number
P.O.
Box 60514
City of Industry, CA
91716-0514your Certificate Number from your Invoice to payment; add
your invoice stub
Go to http://service.healthplan.com/
Have your Social Security Number available
Chinese
Community
Health Plan
The payment deadline for January coverage is 1/31. The payment deadline
for February coverage is 2/14.
N/A For
first-time payment: log in to your CoveredCA.com account; follow
payment instructions
445
Grant Avenue, #700 San Francisco, CA 94108
Add your invoice stub
(877)
224-7808
Contra
Costa
Health Plan
Payment deadline for February coverage is 2/14.
(855)
957-2247
Select Option 2
include Covered CA ID
Covered
Contra Costa website

include Covered CA ID
Contra
Costa Health Plan
P.O.Box 2390
Omaha NE
68103include Covered CA ID
(855)
957-2247
include Covered CA ID
Health
Net
Payment deadline for February coverage is 2/15.
(877)
200-9260
Have your Subscriber ID and payment method. (If you don’t have your
Subscriber ID go to www.healthnet.com/getmyid to
obtain one)
Online
payments accepted only after first payment
P.O.
Box 60515
City of Industry, CA
91716-0515Add Subscriber ID to payment
Go to www.healthnet.com/
getmyid
to obtain your ID and call (877) 200-9260
to make your payment
Kaiser
Permanente
The payment deadline for January coverage is 1/31.
The payment deadline for February coverage is 2/24.
Have
Account number, invoice number, and subscriber last name from invoice
available.
Northern California
(866) 475-3920
(866) 733-7787 Spanish
Southern California
(866) 450-5648
(866) 733-7775 Spanish
www.kp.org/paypremium P.O.
Box 7192
Pasadena CA 91109-7192Follow the directions on your invoice.
Northern
California
(866) 475-3920
(866) 733-7787 SpanishSouthern California
(866) 450-5648
(866) 733-7775 Spanish
L.A.
Care
Health Plan
Payment deadline for February coverage is 2/21.
(855)
270-2327
(TTY/TDD 1-855-576-1620)
Have your Case # or Social Security number
LA
Care Covered website

Have your Customer and Invoice Number
L.A.
Care Covered
P.O. Box 515389
Los Angeles, CA
90051Add Case # to payment
(855)
270-2327
Molina
Healthcare Inc.
(888)
858-2150
Have your Covered CA ID or Social Security number
Molina
Health Care website
P.O.
Box 7010
Pasadena, CA
91109-7010Add Case # to payment
(888)
858-2150
Have your Covered CA ID or Social Security number
Sharp
Health Plan
(800)
359-2002
Have your Sharp Member ID # or Social Security number
Sharp
Health Plan website
P.O.
Box 57248
Los Angeles, CA
90074-7248Add Case # to payment
(800)
359-2002
Valley
Health Plan
N/A Valley Health Plan website Los
Angeles Lockbox
County of Santa Clara
PO Box 740300
Los Angeles, CA
90074-0300Only taking money orders and checks – follow directions on
invoice
(888)
421-8444
Western
Health Advantage
(888)
442-2206
Have your WHA ID #, or Social Security number
For
first-time payment: log in toyour CoveredCA.com account; follow payment
instructions
WHA,
DEPT 34668
PO BOX 39000
San Francisco, CA 94139
(888)
442-2206
Have your WHA ID #, or Social Security number

Pediatric Dental Only Plans

Dental Plan Pay by Phone Pay Online Pay by Mail No Invoice Received
Delta Dental of California N/A N/A Mail a
payment form to:
P.O. Box 660138
Dallas, TX 7526Add Case # to payment
(800)
765-6003
Liberty Dental (888) 844-3344
Have your case # or Social Security Number
Liberty
Dental Plan website
Attn:
Accounts Receivable
P.O. Box 26110
Santa Ana, CA
92799-6110Add Case # to payment
[Printable payment form available atwww.libertydentalplan.com/ccpay]
(888)
844-3344
Have your case # or Social Security Number
Premier Access/Access Dental N/A Premier
Life website
Attn:
HBEX Payment
8890 Cal Center Dr
Sacramento, CA 95826
(877)
702-8800

 

**As legislation is constantly changing, these answers are not guaranteed. They are our best understand of the health care reform mandates at this time. If you find that any of these answers are out of date, please notify Amy DeMarco at ademarco@iha4health.org or 562-690-4001 ezxt 203**