Are plan changes permitted by Covered California for Small Business after coverage has started?

Yes. Plan changes are permitted under the following conditions:

• The plan change must be with the same carrier;
• The change must be requested within the first 30 days of coverage;
• Plan changes submitted between days 1-15 will be retroactively effective to the first day of the same month;
• Plan changes submitted after day 15 will be effective the 1st of the following month.

This policy applies to both new and renewing CCSB groups.

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.

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.

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.

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.

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 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).

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

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.

What are the metal tiers?

Covered California plans are organized into categories of coverage, called metal tiers,
based on actuarial value. The idea is to make it easier for consumers to compare coverage
options and tradeoffs. More information on metal tiers can be found on pages 8 and 9 of the Covered CA Plan options participant guide.