What can I provide to clients who are eligible for Medicare, but are interested in Covered California?

See below a link to a Covered California Medicare FAQ:
https://www.coveredca.com/FAQs/FAQ-PDFs/FAQ_Medicare.pdf

2-person, husband/wife group: the group is a C-Corp. The wife receives a W-2 as an employee of the corporation. Would they be eligible for Covered California for Small Business coverage?

The group would need at least one W2 non spouse employee to be an eligible group.

Eligible for Covered California for Small Business: Two partners plus one part-time employee?

A three-person group where two are partners and one is a 20-hour/week employee (who’s not the spouse of either partner) is a group eligible for Covered California for Small Business if the group offers coverage to that employee.

If the group does not offer coverage to that employee, then it would not be eligible for Covered California for Small Business coverage.

The rule is that at least one eligible employee must be extended coverage. An employee that averages 30 hours/week or more is considered eligible automatically as a full-time employee. A part-time employee that works 20-29 hours/week is considered eligible only if the employer extends an offer of coverage to part-time employees that work 20-29 hours/week.

Employees that work less than 20 hours/week or are 1099 or are seasonal are not eligible.

What coverage is available for out-of-state employees through Covered California for Small Business?

The Blue Shield Bronze PPO 60 plan, with out-of-state coverage through the Blue Card, is available to out-of-state (OOS) employees IF the employer is located in the service area where the plan is offered. Below is the list of counties and/or partial counties where the Blue Shield Bronze PPO is offered.

Normally, employers can only offer two tiers of coverage (Silver and Gold, for example), however, if an employer located in one of the above service areas needs to accommodate OOS employees, Covered California for Small Business (CCSB) will permit the employer to offer the Blue Shield Bronze PPO 60 to OOS members. If the employer is not located in one of the above service areas, then other coverage would need to be considered for these employees.  For instance, the employer can opt to offer the eligible OOS employee coverage through the SHOP in that employee’s primary out-of-state worksite.

Note: CCSB had sold plans from Health Net that provided coverage to OOS members, however, in April 2016 Health Net announced that they would no longer cover OOS members. For groups that have existing OOS members on the Health Net plan, they can stay on the plan until the group comes up for renewal. For groups that did not have existing OOS members, they would not be able to add any OOS members after April 2016 so other coverage would need to be considered.

At the group’s renewal, the OOS members do have the option to move to the Blue Shield Bronze PPO 60 plan IF the employer is located in one of the service areas where the plan is offered (see above).

How long can grandfathered plans remain in effect?

As long as the carrier continues to offer it, and the plan continues to meet the grandfather requirements.

When would a child-only plan be suitable?

A child-only plan would be suitable, for example, in the following situations:

• if the parent’s employer-sponsored plan doesn’t offer dependent coverage
• where the child is cared for by grandparents who are covered by Medicare

Are premium tax credits and cost sharing reductions available outside the exchange?

No.

My client works for a company with a health plan and he is concerned about the cost of adding his unemployed wife and baby to his plan. Can his wife and baby enroll in the exchange while he stays with his employer plan?

Yes, the wife and baby may enroll in Covered California. Eligibility for subsidies would depend if the employer plan is considered affordable, among other factors.

Can a health plan charge more to a member with health problems (Diabetes, Heart Disease)?

No. In California, only age, family size, location and plan design can be used to determine rates.

“In some areas, premium rates are so low that the premium assistance tops out below 400 percent of FPL.” Explain please.

Premium tax credits are calculated based on an individual’s “fair share” of premium. “Fair share” increases with income, and ranges from 3.5% of income at 139% of FPL to 9.5% of income at 400% of FPL.

Individuals will pay their “fair share” of premium, or the total premium, whichever is less.