Explain out-of-pocket costs. Do clients have to pay for medical services first to the out-of-pocket maximum of $6,350 for individuals before insurance kicks in?

Out-of-pocket costs are the consumers’ expenses for medical care that aren’t reimbursed by insurance. Out-of-pocket costs include deductibles, co-insurance and co-payments for covered services plus all costs for services that aren’t covered.

The out-of-pocket maximum is the most consumers pay during a policy period (usually one year) before their health insurance or plan starts to pay 100% for covered essential health benefits. This limit must include deductibles, coinsurance, copayments, or similar charges and any other expenditure required of an individual which is a qualified medical expense for the essential health benefits. This limit does not have to count premiums, balance billing amounts for non-network providers and other out-of-network cost-sharing, or spending for non-essential health benefits.

Other than the 8-training, is there any other training or online instruction that needs to be done before getting the certification?

There is no other training or online instruction. However, in order to become certified, agents need to pass the certification exam by 80% or better, sign the Certified Insurance Agent Agreement, and pay the $60 appointment fee.

If we do business out-of-state, will we have to be certified through that state as well?

Yes.

If someone just moved to California, do they have to reapply for insurance in California or can they keep the insurance they had in another state?

It depends on their plans out-of-state benefits.

Are employers required to get Covered California for Small Business for employees if not they’ll be penalized?

The Affordable Care Act does not require small employers to offer health care coverage. Employers with 1-100 eligible employees will not be subject to penalties for not providing health coverage. Small employers that do offer coverage are not required to get it through Covered California for Small Business, they can purchase coverage inside or outside of the Exchange. However, eligible small businesses can secure the small business tax credit only if they purchase coverage for their employees through Covered California for Small Business.

Why would anyone purchase coverage outside of the Exchange, even high income earners? Do the benefits change outside of the Exchange? Can insurers offer richer plans outside of the Exchange?

Consumers may want to purchase outside of the Exchange for more options. There may be plans outside of the Exchange that have richer benefits or better meet the consumer’s needs. However, any plans in Covered California that are also offered outside of Covered California have to have the same benefits and premiums.

Does Covered California cover dental?

All individual health insurance plans sold through the Covered California exchange will now include pediatric dental benefits for members younger than 19. Additionally, Covered California is offering new family dental plans to consumers who enroll in health insurance coverage in 2015.

The optional stand-alone family dental plans, which offer coverage for adults, will not be available at the beginning of open enrollment, which starts Nov. 15, but are planned to be added in early 2015. Covered California will offer both dental health maintenance organization (DHMO) and dental preferred provider organization (DPPO) plans, giving consumers a choice in the type of plan that will work best for them. There is no financial assistance available for the optional adult dental benefits.

There is no requirement to enroll children in a family dental plan. The family dental plan is optional and is primarily intended to offer affordable dental coverage to adults that was not available in 2014. Families should consider that adding their children to a family dental plan will result in an extra cost for the same dental services they already receive in their standard health insurance plan. The most likely reason to enroll a child in the family dental plan is if a dental provider they prefer for their child is not offered through their embedded coverage.

Below is a list of the pediatric dental coverage embedded with Covered California’s individual health insurance plans.

Family dental plans are offered from the companies listed below.

What is the waiting period for grandfathered plans?

On Friday, August 15, 2014, the Governor signed into law Senate Bill (SB) 1034, which prohibits a health benefit plan for group or individual coverage from imposing a waiting or affiliation period before coverage becomes effective.

The intent of SB 1034 is to prohibit a health care service plan or health insurer offering group coverage from imposing a separate waiting or affiliation period in addition to any waiting period imposed by an employer for a group health plan on an otherwise eligible employee or dependent. Furthermore, the intent of SB 1034 is to permit a health care service plan or health insurer offering group coverage to administer a waiting period imposed by a plan sponsor in accordance with the provisions of the Affordable Care Act (ACA). Hence, an employer may impose a waiting period, however it must comply with the ACA, which prohibits waiting periods that exceed 90 days.

SB 1034 will be effective January 1, 2015, however, carriers may choose to incorporate this change prior to the effective date. This applies to non-grandfathered and grandfathered plans.

Can Claremont assist agents with clients eligible for the Covered California for Small Business market?

Claremont Insurance Services is authorized to represent Covered California for Small Business.

As an authorized Covered California for Small Business general agent, Claremont offers you:

• Education via the web, publications, live seminars, and access to experts
• in-depth knowledge and personalized guidance
• assistance with group sales, enrollments, and renewals
• benefit and cost comparison for Covered California for Small Business plans
• Covered California for Small Business broker kits: a toolbox with checklists, product information, and an interactive, searchable FAQ on Covered California and ACA
• Unparalleled responsive service and support

What if income lowers and the person doesn’t notify Covered California?

If a tax filing unit’s income changes, and the filer should have received a higher amount, this additional credit would be included in their tax refund for the year. On the other hand, any excess amount that was overpaid in premium credits would have to be repaid to the federal government as a tax payment. However, there are limits on the excess amount to be repaid for those below 400% of the Federal Poverty Level.

Consumers are required to self-report changes in income to Covered California within 30 calendar days from the date of the change.  Consumers can report these changes via the online application or by calling the Covered California Service Center.