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Covered CA Questions

Covered CA Questions

Quickly get a comprehensive overview of Covered California. To find out more about the requirements and unique advantages of Covered California for Small Business, visit our carrier section. View additional FAQ topics.

Agent Certification

Are there any gross income or sales thresholds applied to small businesses in order to qualify for Covered California for Small Business?

No. Small businesses eligible to purchase health insurance through Covered California for Small Business are those that:

  1. Have 1 to 50 eligible employees. An eligible employee works an average of 30 hours per week based on a month of work. Employers may also choose to offer coverage to their part-time employees who work between 20 and 29 per week.
  2. Elect to offer, at a minimum, all full-time employees coverage in a Covered California Health Insurance Plan through Covered California for Small Business;
  3. Meet a minimum employee participation rate of 70%;
  4. Contribute a minimum of 50% of the employee-only premium amount of the employer’s selected anchor plan in the metal tier the employer selects; and
  5. Have the majority of and their employees employed in California.

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If Covered California for Small Business is not available in a county, would the small business lose the potential small business tax credit?

Covered California for Small Business is available in all counties, though the plans may vary in the different counties.

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Are 1099 workers eligible for Covered California for Small Business?

Seasonal workers, 1099 contract workers, part-timers working less than 20 hours per week, and temporary workers are NOT eligible to participate in Covered California for Small Business.

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Is an employer permitted to NOT offer coverage to dependents?

Yes, in Covered California for Small Business employers have the option of not offering dependent coverage.

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Is there premium assistance for EE’s in Covered California for Small Business?

No. Premium assistance is only available in the Covered California individual exchange.

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Can a small employer group enroll without a broker of record?

Employers can enroll directly with Covered California for Small Business if they are able to navigate through the application process on their own. However, it is best for employers to seek the assistance of an agent.

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I have two licensed staff who are not Certified with Covered California. How much can they say and do? Should they get Certified?

They can do all typical broker activities except the actual enrollment of either individuals or employer groups in Covered California.

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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.

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Is the exam taken online at your office/home or at a testing facility?

The agent certification exam is taken online at a time and place of your convenience.

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After passing the exam and completing all the paperwork, how long until we get notice of Certification?

Within 5-7 days of submitting the signed agent agreement and associated documentation (assumes correctly completed) and paying the endorsement fee, the next steps occur:

  1. Your status on CoveredCA.com will be updated to “Certified.” And you’ll receive an email confirming your status change.
  2. Your name and contact information is added to the Covered California website.
  3. Consumers and small businesses will be able to find your details by clicking “Find an Agent” on this page.
  4. You’ll be able to update and edit your Covered California public facing profile.
  5. Covered California will update the California Department of Insurance (CDI) website with your endorsement information. This fulfills a requirement by CDI and provides another place where consumers can verify that you’re certified.

More information on the Certification process can be found here.

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Covered California for Small Business is for small businesses with up to 100 employees, where do groups go that have over 100 employees? When did Covered California for Small Business expand to 100 employees?

If the small employer has more than 100 eligible employees, the small employer will be able to buy insurance through Covered California starting in October 2015 for coverage that begins in 2016.

Meanwhile, the employer with more than 100 eligible employees can continue to buy health coverage in the private marketplace.

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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.

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

Yes.

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Do agents have to be recertified with Covered California annually?

After careful consideration, and in an effort to support agent partners, Covered California has removed the annual requirement for agent re-certification.

The Covered California Certified Insurance Agent agreement previously required agents to participate in at least four hours of Covered California re-certification training each year in order to maintain certification status. The agent agreement will be updated soon to reflect this change.

Please note: Covered California is only removing the re-certification requirement. Licensed agents who are interested in selling products on behalf of Covered California must complete the initial training and certification process in order to become a Covered California Certified Insurance Agent.

Covered California is currently reviewing its entire training program and will be offering supplemental education through e-learning and other methods to help support enrollment efforts. Certified Insurance Agents are strongly encouraged to make use of these resources when they become available. Continued training will help to ensure agents have the latest updates on the individual and Covered California for Small Business marketplaces as well as Covered California’s policies and guidelines. More information on the supplemental education will be coming soon.

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Will Covered California for Small Business carriers provide prior carrier deductible credit?

Each carrier within Covered California for Small Business has its own policy. Refer to each carrier’s underwriting guidelines for more information.

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Are there tax advantages to the employer for participating in Covered California for Small Business?

The employer may be eligible for the small business health care tax credit, in addition to the tax advantages in offering any employer-sponsored health insurance to employees.

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Does the agent need to be appointed by each health insurance company?

Individual Marketplace – Certified Insurance Agents must be directly appointed by each of the health insurance companies in Covered California to receive commissions from the health insurance company.

Covered California for Small Business – The Certified Insurance Agent qualification is all that agents need to receive commissions from Covered California for Small Business.  Agents do not need to secure appointments with each of the carriers in Covered California for Small Business.

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What happens if half of an employer’s employees would be better off applying for individual coverage rather than group coverage, because they could be eligible for premium assistance and cost-sharing reductions?

Waiving coverage to enroll in the Individual Marketplace is not a valid waiver. Hence, 50% participation due to employees enrolling in the Individual Marketplace will make the employer ineligible for Covered California for Small Business since the participation requirement for Covered California for Small Business is 70%. However, the group can enroll during the special open enrollment period. In the small group market, a health insurance issuer may limit the availability of coverage to an annual enrollment period from November 15 till December 15 of each year if the employer is unable to meet employer contribution or group participation requirements.

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If a group has 60 full-time employees, but only 30 enroll for group coverage, is the group eligible for a Covered California for Small Business plan?

No, small businesses are eligible to purchase Covered California health insurance plans through Covered California for Small Business if they have 1 to 50 eligible employees. An eligible employee works an average of 30 hours per week over the course of a month. Employers may also choose to offer coverage to their part-time employees who work between 20 and 29 hours a week.

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Can you briefly outline the Certification requirements?

In order to obtain certification with Covered California, insurance agents must:

  1. Have an active California Accident and Health Agent license in good standing
  2. Provide proof of Errors and Omissions (E & O) insurance in the amount specified in the Certified Insurance Agent Agreement
  3. Complete Certified Insurance Agent training offered by Covered California
  4. Pass the Certification Exam by 80% or better
  5. Sign the Certified Insurance Agent Agreement
  6. Pay the $60 appointment fee

See here for more information on agent Certification:
https://www.claremontcompanies.com/covered-california/covered-california-agent-certification

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Using the Shop and Compare Tool requires information about household income. How does an employer know household income? If they ask the employee, is that a privacy issue?

The Shop and Compare Tool is available for the Individual Marketplace, not for Covered California for Small Business.

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Can commissions in the individual marketplace be set-up to pay an agency and then the agency pays agents down the line?

Since commissions will be paid by each health insurance company it will depend on the health insurance company’s policies and procedures.

In Covered California for Small Business, agents have to be certified independently, however, they will be given the option following certification to identify payment as either the individual agent or the agency.

Note: Certified Insurance Agents are permitted to split or share commissions provided the other agent is also a Certified Insurance Agent authorized to sell through Covered California.

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In Covered California for Small Business, how does the employee select coverage (plan)?

On the employee application, the employee will specify the name of the health plan selected.

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What are the turnaround times for the different steps in the Certification process?

Per Covered California, agents may expect the following turnaround times for important steps in the Certification process. (Please note that these are best estimates, and many times are much shorter.)

2-3 days – Time from attending instructor-led class to being credited with that attendance in Covered California’s Learning Management System (LMS).

5-7 days – Time from passing the exam until agent receives “congratulations and next steps” email.

5-7 days – Time from submitting agent agreement and associated paperwork (assumes correctly completed) and paying fee to receiving notice that agent is certified.

Under 30 days – Time for CE credits to be posted.

Click here for more information on Covered California Agent Registration, Training and Certification.

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What happens after the agent has completed the certification process?

Once the agent has completed the certification process, the agent’s name and contact information is added to the Covered California website.  Click “Find an Agent” on this page: https://www.coveredca.com/enrollment-assistance/

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Will the exam include questions on navigating through the portal?

Yes, there are questions related to the online modules on the CalHEERS system.

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Will employers be allowed to offer varying plans/benefits and/or premiums among their employees based on job description and/or tenure?

A plan cannot discriminate in favor of highly compensated individuals as to eligibility to participate; and the benefits under the plan cannot discriminate in favor of highly compensated individuals. Highly compensated individual is defined as (1) one of the 5 highest paid officers; (2) a shareholder who owns more than 10 percent in value of the stock of the employer; or (3) among the highest paid 25 percent of all employees.

Moreover, in Covered California for Small Business, employers will not be able to have different contribution levels within their selected metal tier based on employee classification.

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How will Covered California for Small Business underwrite start-ups (i.e. payroll records)?

See the list of required documents for the various business entities on page 1 of the Covered California for Small Business employer application:
https://www.coveredca.com/hbex/agents/PDFs/CC_shop-employer-application%20092513.pdf

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Is there a cost calculator for Covered California for Small Business like for individuals?

Not currently.

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What is the required employer contribution for Covered California for Small Business?

Employers must contribute a minimum of 50% of the employee-only premium amount of their selected anchor plan.

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If certified insurance agents are not allowed to share or split commission, does that mean Claremont or another GA cannot help with Covered California for Small Business programs?

Certified Insurance Agents are permitted to split or share commissions provided the other agent is also a Certified Insurance Agent authorized to sell through Covered California. GAs that have a contract with Covered California for Small Business are able to assist agents with Covered California for Small Business.  GAs that have a contract with Covered California for Small Business will be paid separately and directly by Covered California for Small Business.

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How many questions are on the exam?

75 multiple choice questions.

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Is there a time limit for the exam?

There is no time limit, however, the website cannot be inactive for 20 minutes.  If it is, it will time-out and it will count as one attempt at the exam.

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What is the passing score?

80%

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Why do agents have to pay the $60?

The $60 is a Department of Insurance endorsement fee.

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If an agent is currently appointed with a carrier that is also a Covered CA carrier, does the appointment automatically carry over?

Individual Marketplace – The appointment carries over.

Covered California for Small Business – Certified Insurance Agents must be appointed by Covered California to receive commissions.  Agents do not need to secure appointments with each of the carriers in Covered California for Small Business.  Agents will be appointed under the Covered California for Small Business Master Agent Agreement and agents will then have sub-appointments with all participating Covered California for Small Business carriers.

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What ID will be required of employees when purchasing a Covered California for Small Business plan?

Social Security Number or Tax Identification Number

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Can Certified Insurance Agents help employers and employees apply through Covered California for Small Business?

Yes.

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HHS/CMS has a certified agent process. How does this impact the Covered California certification?

HHS’ certified agent process is for the federally-facilitated exchanges.  California has opted to operate its own exchange.

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CCSB Eligibility & Enrollment

I’ve been told that Covered California for Small Business is an option only for employers eligible for the Small Business Health Care Tax Credit. Is this correct?

No, that’s incorrect. Covered California for Small Business is a health insurance marketplace that offers any California small business (1-100 employees) a choice of quality, affordable health insurance from multiple trusted carriers.

A wide range of California employers benefit from the many advantages offered by Covered California for Small Business. Discover the advantages here.

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If a group decides to cancel group coverage and get employees to sign-up for individual coverage, can a group start a carve-out plan for owners and key executives?

A plan cannot discriminate in favor of highly compensated individuals as to eligibility to participate; and the benefits under the plan cannot discriminate in favor of highly compensated individuals.  Highly compensated individual is defined as (1) one of the 5 highest paid officers; (2) a shareholder who owns more than 10 percent in value of the stock of the employer; or (3) among the highest paid 25 percent of all employees.

However, please be aware that on September 13, 2013, the IRS and the DOL issued guidance 2013-54 (“guidance”) on the application of certain ACA provisions on HRAs, reimbursement arrangements or employer payment plans, and health FSAs.  Due to the pouring in of questions regarding the guidance, the IRS issued a clarifying FAQ on May 13, 2014.  However, the guidance is complex and many questions still abound.

The guidance changes the landscape for certain employer-sponsored arrangements in that arrangements that facilitate the pre-tax payment or reimbursement of premiums for individual medical coverage for active employees are no longer permissible.  HRAs and other similar defined contribution arrangements for active employees are also impermissible unless they are “integrated” with an employer’s group health plan or the reimbursement under such arrangements are limited to retirees or certain excepted benefits.

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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.

 

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Can Covered California for Small Business groups make enrollment changes within the first 30 days after coverage becomes effective?

Per Section 6526 and pursuant to Health and Safety Code 1357.504 (d) and Insurance Code Section 10753.06.5 (d), once coverage is approved and effectuated, the employer can exercise the right to change coverage with the same carrier within the first 30 days. Other changes, such as requesting to change from one carrier to another, requesting to add dental, requesting to add members/dependents, are evaluated as an exception.

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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.


Coverage for Out-of-State (OOS) Employees


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).

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Are employees with individual subsidized coverage counted towards the Covered California for Small Business 70% participation requirement?

Enrollment in the Individual Marketplace is not a valid waiver

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Can Covered California for Small Business applications be submitted via email?

Employers can apply in the following ways:

  • Online at www.CoveredCA.com
  • Through a Covered California Certified Insurance Agent
  • By phone via the Covered California for Small Business service center
  • By U.S. Postal Mail
  • By Fax
  • In person

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Why use the Covered California for Small Business as opposed to going direct?

The Covered California for Small Business market offers the following products and services:

  1. Access to competing health insurance plans
  2. Access to multiple coverage options
  3. Access to tax credits
  4. Benefits administration
  5. Enrollment support
  6. Online account management
  7. Customer service

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Is the employer application discussed in slide 8, section 6 of the training binder only for the employer application or does it include all the employee applications too?

For the paper applications, the employer application form as well as the employees’ completed, signed applications are sent in. For online applications, the employer first submits the employer application including the employee roster then the employee submits his or her application.

See employer and employee paper applications:

http://www.coveredca.com/PDFs/paper_application/SHOP-Employer-Application.pdf

http://www.coveredca.com/PDFs/paper_application/SHOP-Employee-Application.pdf

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If a small business has three employees husband, wife, and daughter with a W-2, can they qualify for Covered California for Small Business?

In order to be eligible for the Covered California for Small Business, an employer must be a “small employer” as defined in state law.  (10 CCR 6522(a)(1)). A “small employer” is defined as an any person, firm, partnership that … employed at least one , but no more than 100 eligible employees, … and in which a bona fide employer-employee relationship exists. (See Health and Safety Code 1357.500(k) and Insurance Code 10753.14). With a group of one, or a group of several, but all are owners or partner, a bona fide employer-employee relationship does not exist.

Likewise, federal rules preclude this type of group from qualifying as a “small employer” eligible to participate in the Covered California for Small Business. Section 1304 of the Affordable Care Act defines “small employer” as an employer who employed “at least 1 employee on the first day of the plan year,” but no more than 100 employees on average in the preceding calendar year. (ACA § 1304(b)(1)( 2); 42 U.S.C. § 18024(b)(1)(2)). In the preamble to the final rules on this issue, the federal government explains that the regulations and the ACA have based the definitions of “employer,” “employee,” and “small employer” on long-standing definitions in section 2791 of the Public Health Service Act (PHS Act).  (77 Fed. Reg. 18399 (March 27, 2012)). Specifically, the definition of “employee” in the PHS Act is incorporated by reference to section 3(6) of the Employee Retirement Income Security Act (ERISA), which defines the term employee the same as it is defined under common law to mean “any individual employed by an employer.” (29 U.S.C. § 1002(6); See also Nationwide Mutual Insurance Co. v. Darden, 503 U.S. 318 (1992) (holding that the term “employee” as used in ERISA refers to common law principles)). Thus, to be eligible for Covered California for Small Business “the employer must employ at least one common law employee.” (77 Fed. Reg. 18399 (March 27, 2012)).

Therefore, under both state and federal law, a group must employ at least one employee and must have some sort of employer-employee relationship. In the case where there is only one individual, or several individuals who are owners or partners, irrespective of whether any of them is issued a W-2, an employer-employee relationship does not exist and is therefore not eligible for Covered California for Small Business coverage.

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Can a small business with several partners and no W-2 employees qualify for Covered California for Small Business?

In order to be eligible for the Covered California for Small Business, an employer must be a “small employer” as defined in state law.  (10 CCR 6522(a)(1)). A “small employer” is defined as an any person, firm, partnership that … employed at least one, but no more than 100 eligible employees, … and in which a bona fide employer-employee relationship exists. (See Health and Safety Code 1357.500(k) and Insurance Code 10753.14). With a group of one, or a group of several, but all are owners or partner, a bona fide employer-employee relationship does not exist.

Likewise, federal rules preclude this type of group from qualifying as a “small employer” eligible to participate in the Covered California for Small Business. Section 1304 of the Affordable Care Act defines “small employer” as an employer who employed “at least 1 employee on the first day of the plan year,” but no more than 100 employees on average in the preceding calendar year. (ACA § 1304(b)(1)( 2); 42 U.S.C. § 18024(b)(1)(2)). In the preamble to the final rules on this issue, the federal government explains that the regulations and the ACA have based the definitions of “employer,” “employee,” and “small employer” on long-standing definitions in section 2791 of the Public Health Service Act (PHS Act). (77 Fed. Reg. 18399 (March 27, 2012)). Specifically, the definition of “employee” in the PHS Act is incorporated by reference to section 3(6) of the Employee Retirement Income Security Act (ERISA), which defines the term employee the same as it is defined under common law to mean “any individual employed by an employer.” (29 U.S.C. § 1002(6); See also Nationwide Mutual Insurance Co. v. Darden, 503 U.S. 318 (1992) (holding that the term “employee” as used in ERISA refers to common law principles)). Thus, to be eligible for Covered California for Small Business “the employer must employ at least one common law employee.” (77 Fed. Reg. 18399 (March 27, 2012)).

Therefore, under both state and federal law, a group must employ at least one employee and must have some sort of employer-employee relationship. In the case where there is only one individual, or several individuals who are owners or partners, irrespective of whether any of them is issued a W-2, an employer-employee relationship does not exist and is therefore not eligible for Covered California for Small Business coverage.

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Can agents assist employers with the online application?

Yes.

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What Covered California for Small Business form should be used to make mid-year enrollment changes such as a new hire employee, marriage, birth or adoption?

Mid-year enrollment changes should be communicated using the Covered California for Small Business Change Request Form for Employees.

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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.

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What if an employee wants to pick a plan in a different metal tier than the employer has chosen?

Starting with coverage effective October 1st, employers may offer Covered California for Small Business plans from two adjacent metal tiers. The two tiers will not be available for existing groups until they come up for renewal. No exceptions for mid-year contract plan changes.

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Can an employer choose more than 1 tier?

Starting with coverage effective October 1st, employers may offer Covered California for Small Business plans from two adjacent metal tiers. The two tiers will not be available for existing groups until they come up for renewal. No exceptions for mid-year contract plan changes.

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Will multiple plan tiers be available in Covered California for Small Business?

Starting with coverage effective October 1st, employers may offer Covered California for Small Business plans from two adjacent metal tiers. The two tiers will not be available for existing groups until they come up for renewal. No exceptions for mid-year contract plan changes.

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Will Covered California for Small Business be administrating Cal Cobra coverage?

Yes, but it will be billed separately.

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What are valid waivers?

Valid waivers include enrollment in coverage through:

  • Another employer
  • An employee’s union
  • Medicaid
  • Medicare
  • The military

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Our office consists of 1 owner and 4 full time employees. 2 of us have coverage through our spouse’s union. Are the remaining 2 the only ones that have to be offered coverage?

The Affordable Care Act, does not require small employers to offer health care coverage. If the small employer chooses to offer coverage, in order to be eligible for SHOP the employer has to elect to offer, at a minimum, all full-time employees coverage in a Covered California Health Insurance Plan through the SHOP and meet a minimum employee participation rate of 70%. The employees who are covered through their spouse’s union would be counted as valid waivers.
See pages 4-5 in the Eligibility and Enrollment for the Small Business Health Options Program participant guide for the eligibility requirements for SHOP.

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How does an employer/agent provide supporting documents (ex. DE-9C, etc.) with an online application?

Documents may be submitted by fax, U.S. mail, or scanned and attached using secure email.

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If an employer has a majority of employees in California and goes through Covered California for Small Business for coverage, what happens to their out-of-state employees?

Covered California for Small Business will look first at an employee’s ZIP Code. If that ZIP Code is not a CA code they then look at the employer’s main business address for rating. As for networks, the employee should pick a plan that has an out-of-state network.

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Are there going to be paper applications?

Yes, please note that online applications have been delayed until Fall 2014.

Employer Application:
http://www.coveredca.com/PDFs/paper_application/SHOP-Employer-Application.pdf

Employee Application:
http://www.coveredca.com/PDFs/paper_application/SHOP-Employee-Application.pdf

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Can agents run quotes without creating an employer account?

Online enrollment and account management has been delayed until Fall 2014.

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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.

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Where can I find SBCs for the Covered California for Small Business plans?

SBCs for the Covered California for Small Business plans can be found here.

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Can an existing small group enroll in Covered California?

Yes, if the small business meets the eligibility criteria. See pages 4-5 in the Eligibility and Enrollment for the Covered California for Small Business participant guide.

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Will owner-only groups be eligible small employer groups outside of Covered California?

No.

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What documents will be required to be submitted?

See document checklist on page 1 of the employer application:

https://www.coveredca.com/PDFs/paper_application/SHOP-Employer-Application.pdf

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How does the employer defined contribution work in Covered California for Small Business?

The total employee premium for the lowest cost plan in the selected tier is paid by the employer as a percentage contribution. Let’s say that a 10 life group has a $2500 monthly employee premium for the lowest cost plan at the selected metallic level. The employer contribution is 50%. The employer responsibility would be $1250 or 50% of the total employee premium. As we have an age based rating methodology that premium would represent 50% of each employee premium at every age band. So a 65 year old would get more money that a 25 year old but they would each receive a contribution of 50%.

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Are part-time employees considered for participation requirements if not offered coverage?

No.

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Can employers choose to offer coverage to some 20-29 hour part-time employees and not others – or do they have to offer to all if they elect to cover any 20-29 hour part-time employees?

If employers choose to offer coverage to part-time employees that work between 20 and 29 hours a week, they must offer coverage to all those part-time employees.

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What if dependents want to pay for family coverage on an employee-only plan?

The dependents would not be eligible to join an employee-only group plan.

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What is the special open enrollment period?

In the small group market, for one month each year, a health insurance issuer must offer coverage to employers who do not meet contribution or participation requirements.  This special enrollment period (SEP) starts on November 15 and continues through December 15 for coverage effective January 1.

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Will the employer application require the State Employer Identification Number (SEIN)?

Yes.

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Are small employers who do not meet the 9.5% affordability requirement penalized/taxed?

The Affordable Care Act only requires employers that employed an average of at least 50 full-time (FT) and full-time equivalent (FTE) employees in the prior calendar year to offer Minimum Essential Coverage, that is Minimum Value and affordable, to substantially all of its FT employees and their dependents (does not include spouses).  Employers with less than 50 FT plus FTE employees will not be assessed a penalty for not meeting the affordability requirement.

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What is the participation requirement for Covered California for Small Business?

70%

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If a group grows to more than 100 employees mid-year, when do they lose eligibility for Covered California for Small Business?

By Federal Regulation, groups cannot be terminated or not allowed to re-enroll based upon the group growing to a size bigger than what was allowed at initial eligibility.

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Is there a group open enrollment period?

Small businesses have the option to enroll throughout the year according to their policy’s renewal date or whenever they choose.

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If an employer covers only employees, how does an employee get coverage for the remainder of the family?

There are a number of coverage options for the remainder of the family, which includes, but is not limited to the following:

  1. They can purchase coverage through Covered California’s individual and family market and possibly be eligible for premium assistance and cost-sharing reductions.
  2. They may be eligible for Medi-Cal.
  3. They can shop in the private individual and family market.

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Small Business Tax Credit

I’ve been told that Covered California for Small Business is an option only for employers eligible for the Small Business Health Care Tax Credit. Is this correct?

No, that’s incorrect. Covered California for Small Business is a health insurance marketplace that offers any California small business (1-100 employees) a choice of quality, affordable health insurance from multiple trusted carriers.

A wide range of California employers benefit from the many advantages offered by Covered California for Small Business. Discover the advantages here.

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What if employees work only a few months?

Seasonal workers who work fewer than 120 days during the tax year are not considered employees in determining FTEs and average annual wages.  However, premiums paid on their behalf are counted in determining the amount of the credit.

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What time period is used to calculate wages?

The taxable year.

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What is the Marketplace Identifier employers should use on IRS Form 8941 when claiming the tax credit?

Assuming they purchased coverage through Covered California for Small Business (CCSB), the CCSB market identifier is: 0CA (the first character is a zero).

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Are employer premiums paid toward dependent coverage included in the calculation for the small business tax credit? Is the employer required to pay at least 50% of dependent coverage to be eligible to claim the credit?

An employer may include amounts paid toward dependent coverage when determining employer premiums paid for purposes of the small business tax credit. To get the credit, an employer is not required to pay for all or even a portion of dependent coverage, but to the extent the employer pays these amounts, they may be included in employer premiums paid when calculating the credit.  Additionally, the employer will not fail to satisfy the uniform percentage requirement by contributing different amounts toward dependent coverage under I.R.C. § 45R.

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Will Covered California help determine eligibility for the federal tax credit?

Covered California has a small business tax credit calculator on their website: https://coveredcaagent.pinnacletpa.com/smallbusiness_tcc/. Claremont also has a health care tax credit solution on our website: https://www.claremontcompanies.com/tax-credit. Since this determination can be complicated, small businesses should always contact their tax professional for this determination and for other detailed tax information related to their specific situation in this regard.

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Will the small business health care tax credit no longer be available in 2016?

Tax credits are available for a total of two consecutive years beginning when the small business claims the tax credit. There is no expiration date for the tax credit provision itself.

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What is an FTE?

An FTE is a full-time equivalent employee. For purposes of the tax credit, a full-time employee is one that works on average 40 hours per week or 2,080 hours per year. So for example two 20-hour/week employees = 1 FTE. To calculate the number of FTE’s, add up all hours worked (max hours/employee is 2,080, even if they worked OT) and divide by 2,080. If the result is a fraction, then round down to the nearest whole number.

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Not all my employees are enrolled in the medical plan, do I count just my enrolled employees?

All employees, past and current that worked during the year should be included in the calculation.

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If a non-profit pays no taxes, how does it receive a tax credit?

The credit for tax-exempt organizations is actually a refund on quarterly payments the nonprofit has made to the IRS for income tax withholdings or Medicare withholdings from employee wages. The tax credit can be claimed against three of the payroll taxes that non-profits regularly send into the IRS: the employer and employee share (combined total of 2.9%) of Medicare withholding, and the federal income taxes withheld by the employer on behalf of the employee. Employees will continue to get credit for their withheld income tax payments. 

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My client owns a number of businesses, they all file separate taxes. Can they each qualify for the tax credit?

The “controlled group” concept applies when calculating FTE’s and average wages. Generally, if the same five or fewer individuals own 80% or more of the companies, then the FTE’s and average wages must be aggregated.

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Are Seasonal Workers included in the calculation?

Interesting guidelines from the IRS on Seasonal Workers. Provided the worker is employed less than 120 days, they are not considered employees for purposes of the tax credit and don’t need to be included in the FTE and average wage calculations. However, if the employer paid for their healthcare coverage while they were employed, the employer can add premiums paid for their coverage to the total premiums paid when calculating the tax credit.

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Is whether or not a group took the tax credit in past years going to have any bearing on their estimate for this year? 

Whether they took the tax credit in past years will NOT impact the amount or ability to take the tax credit this year. If they took the tax credit last year (2013), they may not realize that to take the credit again in 2014, they will HAVE to be in a SHOP plan. That was not a requirement in 2013, so this is a change they need to be aware of.

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Are owners and/or partners exempt from the $50K income average?

Yes. Employees do not include independent contractors (including sole proprietors), partners in a partnership, shareholders owning more than 2% of an S-corp, and any owners of more than 5% of other businesses. Employees also do not include family members of the owners and partners. Family members include a child (or descendent of a child); a sibling or step-sibling; a parent (or ancestor of a parent); a step-parent; a niece or nephew; an aunt or uncle; and in-laws. A spouse of any of these family members is also considered a family member.

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Under the ACA, how many years will the tax credit be available?

Two-consecutive taxable years beginning in 2014 or later, for which the eligible small employer files an income tax return with an attached Form 8941. If the small business took the tax credit in the 2013 tax year or earlier, that does not count as part of the two-consecutive tax years.

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If the employer takes the credit in tax year 2014, can they skip 2015 and take the credit again in 2016 or later?

No, the tax credit must be taken in two-consecutive taxable years. If the employer takes the credit in 2014, and does not take the credit again in 2015, they lose the ability to take the credit again in future years.

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Published statistics indicate hundreds of thousands of California small employers being eligible for the small business health care tax credit. This is not my experience. Can you comment on this?

There are over half a million small employers in California. A recent report by the Lewin Group and published by The Small Business Majority found that:

  • More than 375,000 small businesses in California (70 percent of California businesses with fewer than 25 workers) are eligible for tax credits to help with the cost of health coverage for their workers for the 2011 tax year
  • More than two in five (42 percent of) small businesses that are eligible for this tax credit are eligible for the maximum tax credit when they file their 2011 taxes
  • More than 2.4 million Californians are employed by a small business that is eligible for a tax credit for the 2011 tax year
  • The total value of the tax credits that are available to eligible small businesses for 2011 is more than $1.8 billion, an average of $752 per worker

It’s worth bearing in mind that many of these small businesses do not currently offer health insurance to their employees. While the tax credit may not be the main reason for an employer to start offering coverage, we believe it’s a strong message for brokers to communicate to their employer prospects along with all the other reasons why employers should start offering coverage.

Lastly, these are statewide statistics. Agents with a client base in relatively affluent, higher-wage areas of the state will experience fewer employers that are eligible for the credit.

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Why are small businesses not able to qualify for the small business tax credit if they have group coverage outside the exchange?

Beginning in 2014, eligible small businesses can secure the tax credit only if they purchase coverage for their employees through Covered California for Small Business. The small business health care tax credit is a provision of the Affordable Care Act. This requirement is part of the legislation.

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In the small business tax credit example on slide 49 of tab 1 in the training manual, why is the tax credit 12% in 2013 and 17% in 2014 for the restaurant with 40 part-time employees?

The maximum tax credit in 2013 is 35% and the maximum tax credit in 2014 is 50%. Employers with 10 or fewer full-time equivalents (FTEs) with average wages of $25,000 or less are eligible for the maximum tax credit.  The tax credit is subject to a reduction if the employer’s FTEs exceed 10 or average annual FTE wages exceed $25,000.

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What is the estimated number of businesses that qualify for the small business tax credit?

More than 375,000 small businesses in California (70.1 percent of California businesses with fewer than 25 workers) are eligible for the small business health care tax credit.

See: http://www.smallbusinessmajority.org/small-business-research/downloads/050912_CA_Small_Business_Healthcare_Tax_Credit.pdf

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Must a small business be enrolled in Covered California for Small Business for all of 2014 to qualify for tax credit? Is credit prorated if enrolled for half the year?

No, a small business need not be enrolled in Covered California for Small Business for all of 2014 to qualify for the tax credit if the following conditions are met:

(i) the employer offers coverage in 2014 that begins on a date other than the first day of its taxable year;

(ii) the employer offers coverage during the period before the first day of the plan year beginning in 2014 that would have qualified the employer for the credit; and

(iii) the employer begins offering coverage through Covered California for Small Business as of the first day of its plan year that begins in 2014.

If these conditions are met the employer will be treated as having offered coverage through Covered California for Small Business for its entire 2014 taxable year. Thus, the credit will be calculated at the 50% rate for the entire 2014 taxable year and the 2014 taxable year will be the start of the two-consecutive-taxable year credit period.

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Will small business employers that currently provide health insurance be able to get tax credits?

Yes, if the small business meets the eligibility requirements. See http://www.irs.gov/pub/irs-utl/3_simple_steps.pdf

For tax years 2010 through 2013, there is a sliding-scale credit of up to 35% of the employer’s eligible premium expenses. For tax-exempt employers, the maximum amount of tax credit is 25% of eligible premium expenses. Beginning in 2014, the maximum amount of tax credit increases to 50% of premium expenses as long as coverage is purchased from Covered California. For tax-exempt employers, the maximum amount of tax credits increases to 35% in 2014.

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How will the small business tax credit work?

  1. Determining Eligibility:  See http://www.irs.gov/pub/irs-utl/3_simple_steps.pdf
    Note:  Beginning in 2014, eligible small businesses can secure the tax credit only if they purchase coverage for their employees through SHOP.
  2. Calculating the Credit:  The maximum tax credit is 50% (beginning in 2014) of the eligible small employer’s premium payments made on behalf of its employees.  For tax-exempt eligible small employers, the maximum tax credit is 35% (beginning in 2014).  Employers with 10 or fewer full-time equivalents (FTEs) with average wages of $25,000 or less are eligible for the maximum tax credit.  The tax credit is subject to a reduction if the employer’s FTEs exceed 10 or average annual FTE wages exceed $25,000.  Tax credits are available for a total of two consecutive years.
    Note:  The tax credits are subject to adjustments and limitations.  Please consult with a tax/financial adviser.

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How is the tax credit applied to owner employees?

For purposes of the small business tax credit, the following are excluded from the definition of employee:

  1. The owner of a sole proprietorship
  2. A 5% or more partner in a partnership
  3. A 5% or more shareholder of a C-corporation
  4. A 2% or more shareowner of an S-corporation
  5. Any dependent of the above
  6. Any family member of the above

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Individual Family Eligibility & Enrollment

If an individual enrolls in COBRA, can the individual switch to Covered California?

If the individual enrolls in COBRA coverage and the special-enrollment period lapses, the individual cannot cancel the COBRA coverage and enroll in a Covered California health plan until 1) the COBRA coverage is exhausted, 2)  the individual has a different qualifying life event for special enrollment, or 3) the next annual open-enrollment period.

If the individual stops paying the COBRA premium and loses coverage (or if the employer has agreed to pay for a limited time and the individual does not continue the payments), the individual will not be eligible for special enrollment through Covered California. The individual will only qualify for special enrollment if:

  1. Someone else responsible for sending the COBRA premium payments (for example, the former employer) fails to do so on a timely basis.
  2. The individual moves out of the plan coverage area, and there is no COBRA continuation coverage available.
  3. The individual reaches the plan’s lifetime limit for benefits.

If none of these reasons apply, the individual will have to wait until the next Covered California open-enrollment period to cancel the COBRA plan and sign up for a Covered California health insurance plan, unless there is another qualifying life event for special enrollment. It’s also important to know that if the individual decides to drop or forgo COBRA and enroll in a Covered California plan, the individual cannot go back to COBRA.

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If a couple has no income, can they qualify for Covered California?

If the couple’s household income for the taxable year is below 138% of the federal poverty level, which it probably will be if they have no income, they may be eligible for Medi-Cal if they also meet the other eligibility requirements.

See pages 8-12 in the Eligibility for Individuals and Families participant guide.

If the couple is eligible for Medi-Cal they will not be able to receive premium assistance or a cost-sharing reduction through Covered California. However, they can buy a Covered California plan at full cost.

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Can members of the same family be on different plans and metal tiers?

Yes, however, currently the system will only allow one member of the family to get the premium assistance in advance. The other members of the family would have to receive the premium assistance at the end of the year when filing taxes.

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An employee wants a different metal tier than is available to him through his employer’s Covered California for Small Business plan. Can he opt out and buy an individual Covered California plan?

Yes, the employee can decline his employer’s coverage and purchase a Covered California individual plan. Agents should bear in mind:

  • the employee will not be eligible for subsidies if he is eligible for his employer’s plan and it is of minimum value and is affordable
  • employees that decline coverage to go to the individual exchange count against the employer’s participation requirement for Covered California for Small Business coverage.

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How can clients find out the status of their individual applications?

See below a link to a Covered California Application Status FAQ:
https://www.coveredca.com/FAQs/FAQ-PDFs/Application_Status_FAQ.pdf

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Will Covered CA paper applications be available in English & Spanish?

Yes.

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Can an individual change the plan they are enrolled in mid-year?

Plan changes can only be made during open enrollment, or during special enrollment periods after certain qualifying events.

For a list of qualifying events see page 6 of the module: “Eligibility for Individuals and Families” participant guide.

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What does lawfully present mean?

See page 12/13 of the Eligibility for Individuals and Families  participant guide:

See also page 27 of the individuals and families application has a list of acceptable immigration statuses.

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If eligibility is based on total household income how can a child be on Medi-Cal and a parent on a Covered California health plan?

There are different Medi-Cal income eligibility thresholds for different populations.  See the chart on page 11 of the Eligibility for Individuals and Families participant guide.

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My son is 24 years old and my daughter is 21 years old. They are both in college. Can I buy a Covered California family health plan?

Yes, if you meet the eligibility requirements.  See pages 12-13 in the Eligibility for Individuals and Families participant guide.

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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

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My clients with cancelled individual plans have questions about the recently announced eligibility for catastrophic plans. What can I tell them?

See below a link to a recent Covered California FAQ on eligibility for catastrophic (aka minimum coverage) plans.
https://www.coveredca.com/FAQs/FAQ-PDFs/Exemptions_and_Min_Cov_FAQ.pdf

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My clients enrolled in Covered California individual plans have questions about access to care starting Jan 1. What can I tell them?

Covered California FAQs.

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What is considered loss of minimum essential coverage?

See the table on page 8 of the Introduction to the Affordable Care Act participant guide for examples of minimum essential coverage.

Loss of any of these coverage options would be considered loss of minimum essential coverage.

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If an insured signs up after 1/1 is the insurance retroactive?

See enrollment and effective dates in the tables on pages 5-7 of the Eligibility for Individuals and Families participant guide.

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On Covered CA it states a person may not get GI if the person misses the October-March enrollment period, please explain.

Covered California applicants should apply during open enrollment, which is the period of time that usually happens once a year when consumers may select a health plan and enroll. However, certain qualifying events allow consumers to apply for coverage during special enrollment periods. For a list of qualifying events see page 6 of the Eligibility for Individuals and Families participant guide.

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What happens to someone who has a qualifying event outside of the special enrollment period, will he/she get coverage November 1st or December 1st?

See the table with coverage effective dates for qualifying events on page 6 of the Eligibility for Individuals and Families participant guide.

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Are undocumented immigrants who file taxes eligible for Covered California?

No, not unless they are a U.S. citizen, national or lawfully present.

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Are out-of-state students eligible to enroll in Covered California?

Out-of-state students are eligible if they are a resident of California; a U.S. citizen, national or lawfully present in the U.S.; and not incarcerated.

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Will exhausting COBRA be considered a qualifying event to enroll under a special enrollment period?

Individuals that lose Minimum Essential Coverage, including COBRA coverage, will qualify for a special enrollment period.

 

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If the parents stay overseas and the children live in California, how can the parents apply for Covered California?

In order to enroll in a Covered California plan, the individual must reside in California.

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Does moving into the State qualify as a qualifying event?

Yes.

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Can individuals enroll directly online without a Certified Insurance Agent?

Yes.

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What if an individual does not have a SSN?

If the individual is not a U.S. citizen or U.S. national, the application asks whether the individual has satisfactory immigration status.  The application also asks for immigration document information including document type, ID number (in most cases this will be the Alien Registration Number), country of issuance, expiration date, and name as it appears on the document.

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From the date of the qualifying event, e.g. child birth, how long does the policy holder have to notify Covered California?

Consumers have 60 calendar days from the date of the qualifying event to take advantage of the special enrollment period.

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If an individual has an accident and did not elect insurance during the open enrollment period, will there be an “emergency” late enrollment allowed even if an added penalty or cost is added to the individual premium?

No.

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Why would an individual enroll in the exchange if their income is greater than 400% of the FPL and thus the individual would be paying the full cost?

Covered California’s individual market offers access to a variety of health insurance plans with standardized plan designs that could meet the consumer’s needs and makes shopping for coverage more convenient.

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Agent Concerns

I’ve been told that Covered California for Small Business is an option only for employers eligible for the Small Business Health Care Tax Credit. Is this correct?

No, that’s incorrect. Covered California for Small Business is a health insurance marketplace that offers any California small business (1-100 employees) a choice of quality, affordable health insurance from multiple trusted carriers.

A wide range of California employers benefit from the many advantages offered by Covered California for Small Business. Discover the advantages here.

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How does an employer make an Agent-of-Record change in Covered California for Small Business?

The employer group must write a letter to Covered California and state who their current agent is and who they want their new agent to be. The letter should be dated and signed by an employee of the group who is authorized to make the decision. The letter should be mailed to:

Covered California
P.O. Box 7010
Newport Beach, CA 92658

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Can an agent’s staff member get certified as an enroller if they are not licensed so they can assist us with sales?

No.

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Can enrollment counselors refer leads directly to CIAs?

Certified enrollment counselors can refer business to certified insurance agents, but certified insurance agents cannot share commissions with the certified enrollment counselors.

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If customer service representatives assist with employee enrollments and changes do they need to be a Certified Insurance Agent?

Anyone using the CALHEERs system to enroll and maintain groups will need to be a Certified Insurance Agent.

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Can agents use translators that are not Certified Insurance Agents?

If the translator is using the CALHEERs system to enroll and maintain groups, the translator will need to be a Certified Insurance Agent.

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Will there be an agent link to the portal so agents get credit for the sale?

There is no current ability to link an agent’s website with Covered California’s website.  However, agents can create a profile on the Covered California website and there will be a field on the enrollment form that allows consumers to select/designate their agent.

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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

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I can’t access my Covered California agent portal. Help!

A number of agents have reported that they can’t access their agent portal. Many of them, it turns out, created two accounts for some reason. There can only be one “certified” account per agent/license #. These agents have been trying to access their clients through a non-certified account. Here’s what to do to check if this is the problem that’s impacting you:

Determine if the account is “certified” by looking at the Certification Status screen. See the screenshot in the link here:
https://www.claremontcompanies.com/wp-content/uploads/2014/01/CoveredCA-Agent-Certification-Status-Screenshot.png

If Certification Status indicates “Certified,” then that’s the account you should use and to avoid confusion you should call the service center (1-877-453-9198) and have the other account deleted.

If Certification Status indicates “Eligible”, as in the screen shot, then that account is not valid, but you shouldn’t delete this “Eligible” account until you have confirmed you have a “certified” account.

If you don’t know the username and password for an account, you will need to call the service center to get the username and get a password reset.

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Can I update my Covered California agent profile to indicate I only serve employers (i.e. not individuals?)

Yes. To update your profile, simply select ‘Employers’, and de-select ‘Individuals/ Families’ in the ‘Clients served’ section.

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Who should the agent contact to get pre-approval for marketing materials?

Review and approval of advertising materials should be submitted to Covered California at agents@covered.ca.gov.

Agents should allow at least 10 business days from the date of the request for Covered California to review any materials submitted. When submitting required materials for approval, indicate the following in the subject line: Advertising Approval Request – Agent name and material type. When submitting revised material, indicate so in the body of the email and include the original submission date of the material. Do not bundle multiple materials in the same submission email. Send a separate email for each material. The only exception is translations. Translations may be sent in one email along with the corresponding English version if available.

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On slide 17 of the Compliance Standards section of the training manual, at what point does advising become coaching?

What slide 17 of the Compliance Standards section of the training manual is explaining is that agents are not allowed to coach the consumer to provide inaccurate information on the application regarding income, residency, immigration status and other eligibility rules.

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What is the broker of record (BOR) process in Covered California for Small Business?

Covered California uses the term agent of record (AOR). A new agent of record is assigned when Covered California receives a notice in writing from the employer designating the new agent of record. Notices should be sent to Agents@covered.ca.gov.

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How is the public going to find their closest agent?

Consumers can search for agents according to consumer preferences, e.g. location, language.

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What is the status of the Navigator program?

A request for applications was released on June 30, 2014.

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Can we use the Covered California logo on our business cards?

Covered California has developed a Certified Insurance Agent logo to designate insurance agents who have met the requirements established by Covered California.  The logo is available to Certified Insurance Agents to use on their websites, business cards, letterhead and other communications materials.

See agent tools: http://hbex.coveredca.com/agents/tools

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Can Certified Insurance Agents take a paper application, then process it online for our clients?

Online applications have been delayed until Fall 2014.

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Do certified enrollment counselors have E&O coverage?

No.

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What is the impact of the ACA on the San Francisco Health Care Security Ordinance (SF HCSO)

The City and County of San Francisco recently published FAQs on the HCSO and the Affordable Care Act. Click here:

http://sfgsa.org/index.aspx?page=6306

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Can a Certified Insurance Agent conduct seminars/workshops to provide Covered CA information to groups of people or individuals without becoming a certified educator?

Yes.

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Why would consumers need an agent if they can go online and sign-up?

Certified Insurance Agents bring a depth of experience to consumers by:

  • Serving as trusted licensed advisors
  • Maintaining deep customer relationships
  • Providing valued service (not just enrollment but ongoing support)
  • Offering solutions within and outside of Covered California

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I share a house with other housemates and I operate my business in my home office. I keep my records in my bedroom. What kind of locking/security measures are required?

It is best to check with your Errors and Omissions provider for guidance.

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Are there Certified Enrollment Counselors in the private individual marketplace or only in Covered California’s Individual Marketplace?

Certified Enrollment Counselors only assist consumers in Covered California’s Individual Marketplace.

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What is CalHEERS?

CalHEERS is the California Healthcare Eligibility, Enrollment and Retention System. It is a web-based system that streamlines the eligibility and enrollment process for all products and programs available through Covered California.

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Can an agent take the Covered California 8-hour certification class only and receive CE credit?

Yes. The agent will get CE credit after having taken the 8-hour class. The agent does not need to complete any other steps towards certification in order to receive CE credit for having taken the 8-hour class. The agent will need to follow the usual process: create an account with Covered California and then log into the Learning Management System to sign up for a class.

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How much information will Certified Enrollment Counselors need and have access to?

Certified Enrollment Counselors will have information about consumers, health insurance, affordability programs, and Covered California health plans in order to provide in-person assistance to consumers and successfully enroll them in coverage.

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Will agents be able to make changes to their Covered California account?

If agents would like to make changes to their Covered California account (the one first established when registering for training), they will be able to so do once all steps in their certification process have been completed.  At that time they will be able to modify their agent profile and payment information (to direct payments to their agency rather than themselves).

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As a Certified Insurance Agent, what should we do if we find that Certified Enrollment Counselors are making plan recommendations?

You should report it to Covered California.

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How can Covered CA give rate information without being licensed?

Assuming the question pertains to Certified Enrollment Counselors, Certified Enrollment Counselors have been trained and certified to describe available health care options and guide the enrollment process. Certified Enrollment Counselors, however, cannot recommend specific health insurance companies.

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Broker of Record or Agent of Record?

Covered California uses the term “agent” rather than “broker.”

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Is there a reciprocal agent certification agreement with out-of-state Exchanges?

Currently there is no reciprocal agent certification agreement with out-of-state Exchanges.

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Are there bilingual marketing materials available now?

Yes, marketing materials are available now in English, Spanish, Chinese, and Vietnamese.

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What is the role of your company (Claremont) to an agent like me?

As a General Agent, we provide product information regarding our carriers; assist with running proposals; provide market information; and assist with enrollment, post-sales support, and claims issues.

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Can individual/family plan transfer from one agent to another using agent of record?

Yes.

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How are Certified Enrollment Counselors paid?

Certified Enrollment Counselors have to be affiliated with a Certified Enrollment Entity and the Certified Enrollment Entity is paid $58 for each initial application during open or special enrollment; $58 for each re-enrollment application; and $25 for each annual renewal application.

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If an individual applies for a plan through me on October 17th and on December 10th some other agent talks the individual into another plan, who would be the agent of record?

The first agent will remain the agent-of-record until Covered California receives a notice in writing designating a new agent-of-record.

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My sister lives in Hawaii and would like to purchase health insurance from me starting January 1st, 2014. Since all coverage will be purchased online, can she fill out an online application and I receive the credit for this sale as her representative?

You would have to abide by the regulatory, Marketplace, and carrier requirements of that state.

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The House is talking about defunding ObamaCare and postponing health care reform. Will this affect Covered California or are we moving ahead regardless of what the House decides?

The funding for the implementation of Covered California is already in place.  Hence, the defunding of the ACA has no short-term impact on California’s implementation.

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Is Covered California ready to take appeals?

Yes.

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Do agents assist with annual re-certifications or is that done by Covered California?

The role of the agent includes promoting and supporting retention efforts, which includes coverage renewals, eligibility redeterminations, etc.

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Premium Assistance & Cost Sharing Reductions

What is counted in household income?

Household income is the sum of a taxpayer’s modified adjusted gross income (MAGI) plus the aggregate MAGI of all the individuals for whom a taxpayer properly claims a deduction for personal exemption and are required to file a tax return.

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Are individuals enrolled in retiree coverage eligible for the premium tax credit?

Individuals enrolled in an employer-sponsored plan, including retiree coverage, are not eligible for the premium tax credit, even if the employer plan is unaffordable or fails to provide minimum value. The individual may be eligible for a premium tax credit for another family member who enrolls in Marketplace coverage and is not enrolled in the employer plan

The individual may be eligible for the premium tax credit if the individual declines the coverage from a former employer, such as COBRA or retiree coverage, even if it is affordable and provides minimum value.

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Can an individual get the premium tax credit subsidy if the individual is eligible for COBRA?

If the individual declines the COBRA coverage, even if it is affordable and provides minimum value, the individual may be eligible for the premium tax credit.

 

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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.

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What is the limit on repayment of excess premium assistance?

If an individual’s income changes, any excess amount that was overpaid in premium assistance would have to be repaid to the federal government as a tax payment. However, there are limits on the excess amounts to repaid and is as follows:

If Household Income Is: The Dollar Limit for Single Filers Is: The Dollar Limit for Joint Filers Is:
Less than 200% of the FPL $300 $600
At Least 200% of the FPL but less than 300% of the FPL $750 $1,500
At Least 300% of the FPL but less than 400% of the FPL $1,250 $2,500

 

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If cost-sharing is only available for silver plans, what’s the advantage in buying the other plans in the Exchange?

Plans in the other metal levels may better suit the consumer’s needs.  For instance, gold and platinum plans will have richer benefits, but bronze plans have lower premiums.  Moreover, premium assistance is available in the other metal tiers.  Finally, not everyone will qualify for cost-sharing reductions.

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Why not buy bronze at all times if low income?

Cost-sharing subsidies are only available to individuals enrolled in silver plans.  Moreover, premium assistance is available in the other metal tiers.  Finally, plans in the other metal levels may better suit the consumer’s needs.

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If the employer provides health insurance to the employee and the employee falls within the 138%-250% of the FPL, does the employee qualify for cost-sharing reductions?

An individual would not be eligible for the cost-sharing reductions if the employer provides minimum essential coverage that is affordable and of minimum value.  Affordable means the employee’s portion of the premium, for employee-only coverage, is 9.5% or less of the employee’s income.  Minimum value means the plan has at least a 60% actuarial value, i.e. for an average population, it is expected to pay at least 60% of allowed costs.

It is also important to note that the cost-sharing reductions are only available in the silver tier of Covered California’s Individual Marketplace.

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If an individual has a domestic partner filing a separate tax return, can the individual just report his/her own income to qualify for a premium subsidy if they live with a domestic partner who earns a higher income and their household income combined would be too high to qualify for a premium subsidy?

Household income is the sum of a taxpayer’s modified adjusted gross income (MAGI) plus the aggregate MAGI of all the individuals for whom a taxpayer properly claims a deduction for personal exemption and are required to file a tax return. Hence, if the taxpayer does not claim a deduction for personal exemption for another individual, only the taxpayer’s income will be considered for eligibility for premium assistance.
See example on page 15 in the Eligibility for Individuals and Families participant guide.

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Is there a resource to learn how the premium tax credits are calculated?

See the following:
http://www.fas.org/sgp/crs/misc/R41137.pdf
http://www.cbpp.org/files/QA-on-Premium-Credits.pdf

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Does unemployment count as income?

Unemployment compensation is included in the MAGI calculation.
See: http://laborcenter.berkeley.edu/healthcare/MAGI_summary13.pdf

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What if someone shares custody of the children & changes the dependents claimed annually, how is the household size determined (for instance, 2 children are claimed in odd years and 1 child is claimed in even years)?

A household includes individuals for whom a taxpayer claims a deduction for a personal exemption. Hence, the household size would depend on how many individuals are claimed. In this situation, it would be a household size of 3 in the odd years and a household size of 2 in the even years.
See the following link for a more detailed explanation and examples:
http://www.cbpp.org/files/Household-Definitions-Webinar-7Aug13.pdf

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What is the minimum premium that qualifies for a subsidy and how does it effect the amount of reduction? From section 5, slide 33 of 59

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.

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My daughter worked full time until last week returning to a post baccalaureate program full time. Is she eligible for a subsidized health plan because her income will be in nil in 2014?

If your daughter is a dependent on your tax return, then your household income will be used to determine her eligibility for subsidy. If she files her own taxes, her own income will be used to determine her eligibility for subsidy. Subsidies are based on current income.

Looking for a primer on how Covered California works for individuals and families, including subsidy eligibility?. Click here for an informative webinar recently hosted by Covered California.

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Can parents purchase Covered California plans for their children without purchasing plans for themselves? Can the children be eligible for subsidies?

Parents can purchase Covered California plans for their children without purchasing plans for themselves. The child’s eligibility for premium assistance is determined by the household income.

Covered California hosted an agent webinar that includes a primer on how subsidy eligibility works. More information is available here:
https://www.claremontcompanies.com/wp-content/uploads/2013/11/CoveredCA-CustomerRolloverWebinar_11_08_13.pdf

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Is there a table which breaks out income levels for subsidies instead of using the Covered California calculator?

Yes. You can find a table of eligibility by FPL here:

https://www.claremontcompanies.com/wp-content/uploads/2013/10/Job-Aid_Program-Eligibility-by-FPL_8.13.17_FINAL.pdf

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Can the wife qualify for premium assistance if the husband earns $100k but is on Medicare and her income is $24k?

Firstly, Covered California recommends that individuals with mixed eligibility situations such as this use the online calculator at www.coveredca.com.

The husband is ineligible for Covered California if he is on Medicare.

In order for either a husband or wife to be eligible for subsidies, they must file taxes jointly. The wife’s eligibility for subsidies will be determined by the household income (MAGI).

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“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.

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

No.

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Please explain cost sharing reductions.

Cost sharing reductions (CSR) help people with their out-of-pocket costs such as deductibles, coinsurance and copayments.  It is only available to people who enroll in in a silver plan.  The issuers provide the extra help with out-of-pocket costs by covering more of the costs of covered benefits, hence increasing the actuarial value of a silver plan.  As a result, the individual pays lower deductibles, coinsurance, and/or copayments.

There are three levels of savings available to people who qualify for a CSR.  The level of savings is based on the family’s income.  See table on page 18 in the Eligibility for Individuals and Families participant guide.

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What is counted as income?

See the table on pages 7-8 in the following link:  http://www.fas.org/sgp/crs/misc/R41997.pdf Also see Attachment E on p. 7 of Covered California’s individual application:  http://www.coveredca.com/PDFs/paper_application/CA-SingleStreamApp_92MAX.pdf

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Does someone with income below 138% always qualify for Medi-Cal?

If the individual meets all the eligibility requirements. See pages 8-12 in the Eligibility for Individuals and Families participant guide.

If so, why are they included in Covered California premium assistance tables?

The tables apply to states that did not opt to expand Medicaid, hence Medicaid coverage is limited to those up to 100% of the federal poverty line.

Note: To qualify for Medi-Cal, an individual must meet both financial and non-financial criteria, such as citizenship and immigration requirements. For example, most individuals who are not citizens but are lawfully present in the United States are not eligible for Medicaid for the first five years that they are in the United States. Hence, the individual may be eligible for premium assistance and cost-sharing reductions.

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Is there a minimum payment after subsidy?

In certain instances, the credit amount may cover the entire premium and the taxpayer pays $1 towards the premium.  In other instances, the taxpayer may be required to pay part or all of the premium.  The amount of the tax credit will vary from person to person depending on the household income of the taxpayer (and dependents), the premium for the exchange plan in which the taxpayer (and dependents) is (are) enrolled, and other factors.

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My daughter is 25 years old and neither mom nor dad claim her. Can she get a plan that is subsidized?

If she meets the eligibility requirements.  See pages 12-14 in the Eligibility for Individuals and Families participant guide.

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If a person is exempt from the individual mandate, but wants to enroll in an individual Covered California plan, can the person still receive a premium subsidy?

If the person meets the eligibility requirements.  See pages 12-14 in the Eligibility for Individuals and Families participant guide.

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If an employer offers affordable and minimum value coverage to employees but does not contribute to the dependents’ premium (including the spouse), can the dependents still qualify for premium assistance and cost sharing reductions?

When dependent coverage is “offered” in an employer-sponsored plan (regardless of employer contribution to the dependent coverage) subsidy eligibility will be dependent on the affordability of the employee-only share of premium costs and if those costs exceed 9.5% of the employee’s household income.  Costs for dependent coverage are not part of the affordability calculation with respect to employer-sponsored coverage.  So if the employer’s offer of coverage is affordable according to this measure, neither the employee nor the dependents will be subsidy eligible.

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If someone has a grandfathered plan, can they cancel that plan to get premium assistance with Covered CA?

Yes, an individual can cancel their Grandfathered plan and enroll in Covered California. Subsidy eligibility will be determined by the regular criteria, and not related to any previous enrollment in an (individual) Grandfathered plan.

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If an employee is eligible for an employer-sponsored plan, but declines coverage, can the employee and family enroll in a Covered California plan? Can they receive subsidies?

The employee and family can enroll in a Covered California plan at full cost. If the employer-sponsored coverage is of minimum value, and is affordable to the employee, then the employee will not be eligible for subsidies. If the dependents are eligible for the employer coverage, and the coverage is of minimum value, and is affordable to the employee, then the dependents will not be eligible for subsidies.

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If an over-age dependent (age 30) is unemployed and living with mom and dad, are mom and dad earnings considered in determining medical/premium & cost sharing subsidies?

If this individual’s parents claim him/her as a tax dependent, then his/her subsidy eligibility will be determined by his/her parent’s household income. If s/he is not claimed as a tax dependent, his/her subsidy eligibility will be determined by his/her own income.

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Who is included in a taxpayer’s family, i.e. household size?

A taxpayer’s family (household size) includes individuals for whom a taxpayer claims a deduction for a personal exemption (see IRS code:  http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleA-chap1-subchapB-partV-sec151.pdf).  This may include the taxpayer, the taxpayer’s spouse, and dependents.  Dependents include a qualifying child, or a qualifying relative.  A qualifying relative is someone (1) who bears a relationship to the taxpayer, such as a father and/or mother; (2) whose gross income for the calendar year in which the taxable year begins is less than the exemption amount; (3) whom the taxpayer provides over one-half of the individual’s support for the calendar year in which the taxable year begins; and (4) who is not a qualifying child of the taxpayer or any other taxpayer.  (See IRS code: http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleA-chap1-subchapB-partV-sec152.pdf)

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Can individuals that are lawfully present apply for premium assistance and cost-sharing reductions?

Yes.

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Who ensures that individuals taking the premium tax credits in advance pay it back if they are no longer eligible?

The IRS ensures that any excess amount that was overpaid in premium credits are repaid to the IRS as a tax payment.

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How are cost-sharing reductions administered?

Consumers who get cost-sharing reductions will pay less out-of-pocket when they use health care services.

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If all members are not in need of health insurance, will that affect the household number qualification for subsidy?

Households include individuals for whom a taxpayer claims a deduction for a personal exemption even if those individuals are not in need of health insurance.

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Are assets included in the income calculation?

No.

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Will the premium assistance and/or cost-sharing reductions go away or phase out after some period of time?

No.

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What is Modified Adjusted Gross Income (MAGI)?

Gross income is total income minus certain exclusions (e.g. public assistance payments, employer contributions to health insurance payments). From gross income, adjusted gross income (AGI) is calculated to reflect a number of deductions, including trade and business deductions, losses from sale of property, and alimony payments. MAGI is defined as AGI plus certain foreign earned income and tax-exempt interest. For premium assistance purposes, the definition of MAGI will include non-taxable Social Security benefits.

See: http://laborcenter.berkeley.edu/healthcare/MAGI_summary13.pdf

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Please elaborate on the premium assistance. Do consumers pay the full premium and receive a monthly check or do consumers pay a lower premium each month?

Covered California uses the consumer-friendly term “premium assistance” in referring to the Advance Payment of the Premium Tax Credit (APTC).

Consumers who are eligible for premium assistance can choose when and how
they want to apply their premium assistance amount.

Consumers have the following options:

  1. Taking the premium assistance in advance to lower the cost of monthly premiums;
  2. Applying the premium assistance at the end of the year when filing taxes; or
  3. Using some of the premium assistance in advance and receiving the balance at tax time.

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Is income based on gross or net income?

Income is based on Modified Adjusted Gross Income (MAGI).

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What happens if one does not report changes in a timely manner?

It depends on the change.  For example, if the individual’s income changes, the individual may no longer be eligible for premium assistance.  There will be reconciliation at the end of the year and the consumer may be required to pay back advance premium assistance.  Another example is if the individual does not report a special enrollment qualifying event, the individual may not be able to take advantage of the special enrollment period.

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Are tax credits or premium assistance shared by the state and federal government? Who essentially ends up paying for the assistance?

Premium assistance or tax credits are paid by the federal government from penalties and taxes that are part of the ACA.

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What would be an example of change in health coverage that needs to be self-reported to Covered California within 30 calendar days?

Change in employer-sponsored coverage – for example, the individual’s employer now offers minimum essential coverage that is affordable and of minimum value.

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What happens when a single parent with 2 children – children are covered by the other parent? How do we determine the single parent’s assistance?

Covered California’s individual marketplace application requires the applicant to include in the application children who live with them as well anyone on their federal income tax return. However, there is a section that asks whether the other individuals on the application aside from the primary applicant are also applying for health insurance. Moreover, there is a section on the application that asks whether the person claiming the dependents is a parent without custody.

As for the determination of the taxpayer’s family, a taxpayer’s family includes individuals for whom a taxpayer claims a deduction for a personal exemption (see IRS code: http://www.gpo.gov/fdsys/pkg/USCODE-2011-title26/pdf/USCODE-2011-title26-subtitleA-chap1-subchapB-partV-sec151.pdf).

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Is income based on individual income or household income?

Household income is used for determining eligibility for premium assistance and cost-sharing reductions.

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If an individual does not pay taxes does that mean they are not eligible for subsidies?

Applicants seeking premium assistance must intend to file taxes or be claimed as a tax dependent in the coverage year. However, if an individual’s household income is less than the applicable filing threshold, their income may be below 138% of the federal poverty line and therefore may be eligible for Medi-Cal.

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What if my income changes after I apply?

If information that you put on your application changes during the year, you must report it. Changes in things like address, family size and income can affect whether you qualify for Medi-Cal or qualify to get help paying for your health insurance through Covered California.

If you have Medi-Cal, you must report changes to your local county office within 10 days of the change. If you have health insurance through Covered California, you must report changes within 30 days.

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Can married couples that file taxes separately apply for premium assistance together?

Married couples must file jointly for the benefit year in which they are applying for coverage in order to apply the premium assistance amount as a credit to their taxes.

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Can an individual employee apply for the cost-sharing reduction under group coverage?

No, premium assistance and cost-sharing reductions are only offered through Covered California’s individual market.

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Can an applicant take advantage of both cost-sharing reductions and premium assistance?

Premium assistance and cost-sharing reductions are available to individuals whose household income is between 138% and 250% of the federal poverty line (FPL).  Only premium assistance is available to individuals whose household income is between 250% and 400% of the federal poverty line (FPL).

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Which tax year will the Marketplace use to determine household income?

The taxpayer’s actual household income for the taxable year will be used.  Marketplaces will use data from tax filings and Social Security data to verify household income information provided on the application, and in many cases, will also use current wage information that is available electronically.  If the data submitted as part of the application cannot be verified using IRS and SSA data, then the information is compared with wage information from employers provided by Equifax.  If Equifax does not substantiate the information on the application, the Marketplace will request an explanation or additional documentation to substantiate the applicant’s household income.

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What is the timeline for Covered CA to determine eligibility for premium assistance and cost sharing? Do they know immediately after entering information on the website?

The application processing times are as follows:

  • Online and telephone applications that do not require resolution of any inconsistencies – Real-time, within minutes.
  • Complete paper applications received by mail or fax and do not require resolution of any inconsistencies – 10 calendar days.

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Can an individual who qualifies for a cost-sharing subsidy move up to ‘gold’ or ‘platinum’ without losing the subsidy?

No, cost-sharing subsidies are only available to individuals enrolled in silver plans.

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Will federal subsidies be available for those in the 100% to 400% FPL who purchase policies that are ACA compliant in the private marketplace?

No, premium assistance and cost-sharing reductions are only available through Covered California.

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Will there be a tax penalty if a consumer applied for premium assistance and ended up with more income than expected? Just like if you underpay tax you are to pay a penalty and tax.

There will be reconciliation at the end of the year and the consumer may be required to pay back advance premium assistance.  Hence, it is important to report any income changes to Covered California.

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Plans

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.

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Are all the plans within a metal tier priced the same?

No.

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Is pediatric dental an essential health benefit?

Yes.

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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.


Coverage for Out-of-State (OOS) Employees


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).

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Cadillac Plan Tax penalties?

The “Cadillac Tax” is an excise tax on high-cost health plans. Starting in 2020 an excise tax of 40% will be assessed on the cost of coverage for health plans that exceed a certain annual limit ($10,200 for individual coverage and $27,500 for self and spouse or family coverage).

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Will there be more carriers later on?

Other carriers are welcome to bid to be in the Exchange in 2016.

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Is pediatric vision embedded in Covered California plans?

Yes.

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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.

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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.

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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.

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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.

Health Insurance Plan Selected Pediatric Dental Coverage
Embedded into Health Insurance Plan
Anthem Blue Cross of California Anthem Blue Cross
Blue Shield of California Blue Shield of California
Chinese Community Health Plan Delta Dental of California
Health Net Dental Benefit Providers
Kaiser Permanente Delta Dental of California
L.A. Care Health Plan Liberty Dental Plan
Molina Healthcare California Dental Network
Sharp Health Plan Access Dental Plan
Valley Health Plan Liberty Dental Plan
Western Health Advantage Premier Access

 

 

Family dental plans are offered from the companies listed below.

Optional Family Dental Plans
Access Dental Plan
Anthem Blue Cross
Blue Shield of California
Delta Dental of California
Dental Health Services
Premier Access

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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.

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Are provider networks driven by metal levels?

No. The metal tiers (Platinum, Gold, Silver, Bronze) are determined by the Actuarial Value of the plan, which is independent of the provider network.

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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.

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Do all counties in California have Covered California plans?

Covered California (individual exchange and Covered California for Small Business) is available in all counties. Not every plan is available in each county.

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Are carriers also applying the “non spouse W-2s” husband and wife rule outside the exchange? What about 1099s?

Yes, carriers are all applying similar small group definition rules regarding both “non spouse W-2s” (sometimes referred to as “common law employee”) and 1099s. Check with the individual carriers for their exact rules.

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When can you enroll outside of the Marketplace?

A health insurance issuer in the group market must allow an employer to purchase health insurance coverage for a group health plan at any point during the year.
A health insurance issuer in the individual market must allow an individual to purchase health insurance coverage during the initial open enrollment period of Oct. 1, 2013 – March 31, 2014. SB 20, which was signed by the Governor on June 16, 2014-

  • Requires health plans and insurers in the individual market to provide an annual enrollment period of November 15, 2014, through February 15, 2015, for the policy year beginning on January 1, 2015, only.
  • Requires health plans and insurers in the individual market provide the current annual enrollment period of October 15 through December 7 for policy years beginning on or after January 1, 2016.

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What are the eligibility requirements for catastrophic plans?

To be eligible for a catastrophic plan/ minimum coverage plan, the individual must both:

AND

  • Meet the eligibility requirements to purchase a Covered California plan. See pages 12-13 in the Eligibility for Individuals and Families participant guide.

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How can I identify if my client is enrolled in a grandfathered plan?

Carriers are required to notify consumers with these policies that they have a grandfathered plan and disclose if they are grandfathered in all materials describing plan benefits.

If in doubt, contact the carrier.

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Can formularies vary within a company, i.e., can a BSC plan platinum formulary be different than a BSC bronze plan formulary?

Yes.

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How will consumers know about the provider networks in Covered California plans?

The health plans that are part of Covered California have online directories available on their websites.  These directories will list the doctors and hospitals that are part of the health plan’s network.

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Is pediatric dental included in the plans in Covered California?

Insurers signed contracts to offer pediatric dental coverage in 2014 in both the Exchange’s individual and small-group employer markets. The contracts offer stand-alone plans for children’s dental coverage in the first year. Because of technical constraints, Covered California is unable to offer bundled pediatric dental plans in 2014. However, Covered California pledged to work toward embedding pediatric dental coverage in its 2015 portfolio of comprehensive medical insurance products in the individual exchange. Only stand-alone pediatric dental will be offered in Covered California for Small Business in 2015.

 

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Is open enrollment for all health plans in Covered California and outside Covered California/private coverage?

The following open enrollment periods apply to health plans and insurers in the individual market:

The first open enrollment period will begin on Oct. 1, 2013 and will end on March 31, 2014.

SB 20, which was signed by the Governor on June 16, 2014-

  • Requires health plans and insurers in the individual market to  provide an annual enrollment period of November 15, 2014,  through February 15, 2015, for the policy year beginning on  January 1, 2015, only.
  • Requires health plans and insurers in the individual market provide the current annual enrollment period of October 15  through December 7 for policy years beginning on or after  January 1, 2016.

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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.

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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

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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.

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Which carriers are participating in Covered California?

Individual and Family Market:

Anthem
Blue Shield
Chinese Community Health Plan
Contra Costa Health Plan
Health Net
Kaiser
L.A. Care Health Plan
Molina Health Care
Sharp
Valley Health Plan
Western Health Advantage

Covered California for Small Business:

Blue Shield
Chinese Community Health Plan
Health Net
Kaiser
Sharp
Western Health Advantage

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If a carrier drops a plan for a group and offers an alternative can the company still invoke the grandfather clause?

No. Grandfathered plans are those that were in existence on March 23, 2010 and haven’t been changed in ways that substantially cut benefits or increased costs.

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Can minimum coverage plans/ catastrophic plans be sold to people over 30?

Minimum coverage plans/catastrophic plans can be offered to people under age 30 and to those without affordable coverage options or those eligible for a hardship exemption.

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Are carriers going to use the same network in Covered CA as their off-exchange plans, or are they going to offer limited or narrow provider networks?

Networks may be different inside Covered California.  However, any plans in Covered California that are also offered outside of Covered California must have the same benefits and premiums. Check with the individual carriers for their provider networks.

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Are there any HSA plans for individuals available in Covered California?

There are HSA-qualified high deductible health plans (HDHPs) available in Covered California’s individual exchange. For example, the Blue Shield of California Bronze 60 HSA Plan.

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Can people still buy direct or will pricing be better with Covered CA?

Any plans in Covered California that are also offered by the carrier outside of Covered California have to have the same benefits and premium rates.

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Do people on dialysis qualify for a Covered California plan now?

Health plans are banned from imposing pre-existing condition exclusion on children under age 19. In 2014, the ban on excluding coverage of pre-existing conditions is extended to adults as part of a broader set of 2014 insurance reforms.

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Are there Evidence of Coverage (EOC) documents on Covered California?

Not yet.

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Can carriers offer plans off the Exchange? If so, can the plan design vary from the standardized plans?

Yes. Any plans in Covered California that are also offered outside of Covered California have to have the same benefits and premiums.

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Must grandfathered plans provide the full suite of mandated preventive benefits at no cost?

Preventive health benefits with no cost-sharing does not apply to grandfathered plans.

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For what age is the pediatric dental and vision?

Under age 19.

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Is Covered California the only place to register for new health insurance? If not, what is the other place?

No, the private market is also an option.

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Will groups be able to change carriers out of open enrollment outside of the Exchange?

In the small group market outside the exchange, employers can cancel coverage at any time and also apply for coverage with another carrier at any time.

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Where do plans outside of Covered California fit in?

Plans outside of Covered California are part of the range of options available to consumers.

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Where does a consumer check for drug formularies?

The health plans that are part of Covered California will have online drug formularies available on their websites.

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What is the AV of catastrophic plans?

Catastrophic plans can have actuarial values less than 60%.

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If an individual has already bought an individual and family high-deductible plan that does not have the essential health benefits, does the individual have to change to a Covered CA plan?

It is our understanding that all individual and family non-grandfathered plans in the private market will be replaced by the carriers with ACA-compliant plans.

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What is the out-of-pocket max?

The maximum out-of-pocket limit allowed by regulation for health plans (inside and outside of the Exchange) is $6,350 for individuals and $12,700 for a family. Plans may have lower out-of-pocket limits.

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How are premium rates based on family composition calculated?

Each family member will be charged based on the premium of their age.  However, health plans can only charge for the three eldest children under 21.  All children age 21 and older are charged premiums based on their age.

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What is the difference between individual and Covered California for Small Business plans?

Covered California Health Plans in the Individual Marketplace.

Information on Covered California for Small Business plans can be obtained through PRISM, Claremont’s proprietary quoting system for brokers.

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Will out-of-pocket maximums include copayments for Rx?

Yes.

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For a catastrophic plan, what constitutes not having affordable coverage for those over 30?

If the individual’s required contribution for coverage for the month exceeds 8% of the individual’s household income, then the individual cannot afford coverage.

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If you sign up and change your mind as to company or benefit can you change?

Yearly open enrollments allow for these types of changes.

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What is included in out-of-pocket costs?

Out-of-pocket cost, also called cost-sharing, refers to the amount the consumer pays for covered services at the time they use them. It usually includes:
• Coinsurance (e.g. 20%)
• Co-payments, or similar charges ( e.g. $45/doctor visit)
• Deductibles
Out-of-pocket costs generally do not include:
• Monthly premiums
• Balance billing amounts for out-of-network doctors and hospitals
• The cost of non-covered services or not medically necessary services

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Is there a catastrophic plan in Covered California for Small Business?

No, catastrophic plans are only offered through the Individual Marketplace.

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What is Essential Community Provider Requirements (Tab 4, slide 19 of 41, in the training binder)?

A Qualified Health Plan (QHP) issuer must have a sufficient number and geographic distribution of essential community providers, where available. Essential community providers are providers that serve predominantly low-income, medically underserved individuals in the QHP’s service area.

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How many plan options are available within the Marketplace?

There are 33 plans in Covered California for Small Business.

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What are the rates in Covered California for employees 65 and older?

There is a single age band for adults ages 64 and older.  Moreover, rates shall not vary by more than 3 to 1.  Rates, however, vary by plan, hence it is best to obtain a quote.

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How can plans with different co-pays be in the same metal level?

Cost-sharing structures could vary from one plan to another, but still achieve the same actuarial value.  For example, one plan may have a higher deductible than another, compensating by having a lower coinsurance percentage once the deductible is met in order to achieve the same actuarial value.

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Are there limited visits for speech, physical therapies?

Health plans can no longer impose annual or lifetime dollar limits on essential health benefits.  The list of essential health benefits includes rehabilitative and habilitative services and devises.  These include physical, occupational, and other therapies and treatments to help people regain function after an accident or illness (“rehabilitative” services), or to help them maintain (rather than regain) their ability to function on a daily basis (“habilitative” services).

As for limits on visits, there are no limits on Department of Managed Health Care plans, but there can be limits on Department of Insurance plans.

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Regarding individuals, you say rates can only change once a year. What if member has a birthday during the year or there is a carrier rate change?

Rate changes, including carrier rate changes and rate changes due to a birthday, will occur on renewal.

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Can you discuss/address the difference between AV and minimum value?

Actuarial value (AV) is the percentage of costs a health plan will cover for a standard population.

Minimum value means the total allowed costs of benefits provided under the plan is no less than 60%.  Basically, the plan has to have a 60% AV.

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Is the premium rate based on the individual’s age at the time of application or approval?

The premium rate is based on the individual’s age as of the effective date.

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Who determines the pricing regions?

The California legislature in coordination with California regulators.

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Payments

Will EFT be available during enrollment?

Individual and Family – All payments should be made payable to the selected health plan. Covered California health plans accept payments via personal check, money order, or re-loadable credit, debit and prepaid cards that contain a Visa, Mastercard or American Express symbol. Some Covered California health plans are planning to include other payment options including cash, delivered in-person to a designated payment facility, or Electronic Funds Transfer (EFT)/Automated Clearing House (ACH) transactions. See the chart on page 13 in the Covered California Plan Options participant guide.

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Which carriers will accept EFT?

See the chart on page 13 in the Covered California Plan Options participant guide.

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If the applicant submits the application on the 10th and the insurer receives the check for the first month’s premium on the 20th, what is the effective date of the plan?

In order for coverage to start, payment must be received in full by the Covered California health plan that the consumer selects.  Hence, if the consumer remits payment between the 16th and the last day of the month, the effective date is the first day of the second following month.

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What are Automated Clearing House (ACH) transactions?

It’s a mechanism by which banks are able to transfer money directly from one account to another, i.e. it’s a direct withdrawal from a checking account.

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For families who choose different plans in the Individual Marketplace for each member of the family, will multiple payments have to be paid?

Yes.

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To whom will Covered California for Small Business premiums be payable?

Covered California for Small Business premiums will be payable to Covered California. Covered California will invoice and collect both initial and monthly premiums from employers and provide payment to the appropriate health plans on behalf of the small business.

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For open enrollment 10/1/13-3/31/14, if someone registers for 1/1/14 start do they have to pay immediately?

In order for coverage to start, payment must be received in full by the Covered California health plan that the consumer selects.

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Notice of Coverage Options Available Through The Marketplace

Agent Appointments & Commissions

If the applicant forgets to include our agent information when submitting the online application, is there a process for the agent to show proof that we assisted applicant?

Yes, the applicant can send a letter to Covered California designating their agent.

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What is the commission on Covered California for Small Business plans?

Covered California for Small Business commissions are paid by Covered California. See commission schedule: https://www.claremontcompanies.com/wp-content/uploads/2015/12/CCSB-2016-Agent-Commission.pdf

Certified Insurance Agents must be appointed by Covered California to receive commissions. Agents do not need to secure appointments with each of the carriers in Covered California for Small Business. Agents will be appointed under the Covered California for Small Business Master Agent Agreement and agents will then have sub-appointments with all participating Covered California for Small Business carriers. The Certified Insurance Agent Agreement includes full vesting language with familiar terms. Agents can be assured that business sold during the year is secured under the agreed-upon commission rate.

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Are agents compensated for renewals?

Individual Marketplace – Commissions are set by each carrier in the exchange.

Covered California for Small Business – Yes.

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Will agents be compensated for Medi-Cal enrollments?

Certified Insurance Agents (CIAs) receive $58 for each approved Medi-Cal application when:

  • Medi-Cal applicants are newly eligible for coverage pursuant to the federal Patient Protection and Affordable Care Act, or
  • Applicants have not been enrolled in the Medi-Cal program during the previous 12 months prior to making the application
  • Each application may be for several individuals

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How will commission splitting be handled?

Certified Insurance Agents are permitted to split or share commissions provided the other agent is also a Certified Insurance Agent authorized to sell through Covered California. The Covered California for Small Business system does not automatically allow for commission splits but agents can make their own split arrangements until such a feature is made available in Covered California for Small Business. In the individual marketplace, since commissions will be paid by each health insurance company how commissions will be split will depend on the health insurance company’s policies and procedures.

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Does each person/agent within a company need to be appointed with a carrier or can appointments continue with the company/agency?

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Does each person/agent within a company need to be appointed with a carrier or can appointments continue with the company/agency?

Individual Marketplace – Since commissions will be paid by each health insurance company it would depend on the health insurance company’s policies and procedures. However, each agent must be certified with Covered California to transact business with Covered California.

Covered California for Small Business – Each agent must be certified with Covered California to be appointed by Covered California. Agents do not need to secure appointments with each of the carriers in Covered California for Small Business. Agents will be appointed under the Covered California for Small Business Master Agent Agreement and agents will then have sub-appointments with all participating Covered California for Small Business carriers.

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What is the commission on Covered CA individual plans?

Commissions are paid by each health insurance company according to the Agent’s active commission schedule at the time of enrollment.  Certified Insurance Agents must be directly appointed by each of the health insurance companies in Covered California to receive commissions from the health insurance company.  The commission rate is the same rate as non-exchange business.  

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Are commissions based on pre-subsidy/credit premium?

Commissions are based on the gross premium and not the net premium.

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If the enrollment is online or mail how will Covered CA know I’m the agent for the commission payment?

There will be a field in the application to designate the agent.

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Agent Agreement

Standard Agreement (Std 213) Section 1 – What do I list as the “Contractor’s Name”, my own name or my agency’s?

Use the certified agent’s name, NOT the agency name.

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Standard Agreement (Std 213) Contractor Section – Do I use my information or the agency’s?

Use the certified agent’s name and signature and it is OK to use the agency’s address.

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Exhibit D – P.1 Business Associate Agreement Do I list the agency name or my name in the second blank?

Use the certified agent’s name.

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Exhibit G – P.1 Darfur Contracting Act Certification Form. Do I list the agency’s FEIN or do I list my own SSN?

List the agency’s FEIN.

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Payee Data Record (Std 204). Section 3 – Do I enter the agency’s FEIN? I want all payments to go to the agency, not me.

If the agency is to be paid, put the agency’s FEIN.

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Payee Data Record (Std 204). Section 5 – Do I put my information and signature here, or can the owner of the agency put his information and signature?

If the agency is to be paid, the agency should fill out the form and the agency’s authorized payee representative should sign it.

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Agent contract: Do we need to maintain a min. book of business in Covered California for Small Business to keep contract?

No.

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Exhibit A – P.1 Scope of Work Do I enter the agency’s FEIN or do I put my own SSN. I don’t want to put my own SSN if payments will go to me.

For those agents who want their commissions to go to an agency, they should put the agency’s FEIN.

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Has the agent contract been approved or is it still in draft?

The agent agreement has been approved.

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My agency’s E&O policy doesn’t list the agents. It’s written in the name of the agency. During training class, I was told that this would be acceptable to submit, however on the Agent Certification Checklist it says the following: “Errors & omissions declaration page demonstrating minimum required coverage levels in the Agent’s name.

It is acceptable to submit the declarations page from the agency’s policy as evidence of the agent’s coverage, provided that the agency’s policy does actually cover the agent.

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Will the E&O policy need to be in the agent’s name or the agency’s name?

It is acceptable to submit the declarations page from the agency’s policy as evidence of the agent’s coverage, provided that the agency’s policy does actually cover the agent.

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The answers provided are a best interpretation of the information available as of the date posted. The answers are for informational purposes and should not be construed as tax or legal advice.