Frequently Asked Questions

What to do if your premium estimate is higher than you expected?

There are two ways to answer this question. First which premium are we talking about, and second, is the estimate too high according to federal standards.

If the premium we are talking about is one that your employer offers you, but does not cover your spouse and/or dependents, and the resulting premium is greater than 9.1% of your total income, then your family can go on CoveredCA and receive tax credits (this is called the family glitch). You would take your employer’s coverage, but you could save money on your family by enrolling them in CoveredCA. Too high by Federal Standards is 9.1% beginning in 2023.
If the premium we are talking about is the one generated form your quote from CoveredCA, then the only way to lower that premium is to adjust the numbers used in the quote. If, for example, you decided to not claim one of your kids as a dependent, that will raise your premium because now your household size has beocme smaller. If you talk it over and decide to claim your child as a dependent, then the premium will adjust to be a little lower. Of course, you could always adjust your income esimate to be lower, but you run the risk of being too low and having to deal with subsidy repayment back to the government if you earn signficantly higher. The standard for Covered California is typically to take the lowest priced Silver plan and make it 9.1% of your income.

What if my insurance through my employer or spouse’s employer seems way too high?

It is rare that employer’s do not offer affordable coverage as their are penalties for doing so. Having said that, 5 million people were enrolled in what is now called “the family glitch” where coverage was affordable for the employee, but not their spouse/dependents. Here is a quick way to determine if your employer’s offer of insurance is affordable. First, the affordability determination only applies to plans that offer “minimum value” coverage (60% of health care costs). Second, your total premium, including your spouse and dependents, would have to total more than 9.12% of your monthly income. If you decide that your situation meets the test, and your coverage is affordable for you, and not for your family, then you would need to disenroll your family from your employer’s sponsored coverage BEFORE you enroll them in CoveredCA.

What if I do not want my kids on Medi-Cal?

Often when you run a quote, it will show that the parents qualify for CoveredCA, but the kids qualify for Medi-Cal. This is common, even for upper earning middle class families, because the threshold for eligibility is quite high. A family of 4, for example, would have to earn greater than 80k a year in order to keep their kids off of Medi-Cal. There are a few approaches you can take. First, if you elect Kaiser, and want to keep the family on Kaiser, then you can sign your kids up for Medi-Cal with Kaiser. The parents would be on Kaiser through CoveredCA, and the kids would be on Kaiser through Medi-Cal (and have it paid for). That is one option. Another option is to simply estimate your income above the Medi-Cal threshold. It is merely an estimate, and because nobody knows for sure how much moeny they may earn in a given year, you have the freedom to estimate higher than the eligibility for Medi-Cal (This may not be a lasting solution, but a good start). Third, another way to keep kids off of Medi-Cal is to pay full price unsubsidized coverage. This option is not as scary as it seems because private health insurance for kids is significantly cheaper than for older adults. For some, it is simply worth it.

Which plan will work best for me?

The best way to choose a plan is to first determine how much you regularly use it. Some people, for the last 7-10 years, have only went to the doctor for their annual check-ups. They probably do not need a Platinum plan. Some people know that they are going to have expensive surgery this year. They may want to go on a Platinumk plan! The first question to ask is to try and predict how much you will go to the doctors, specialists, testing facilities and hospitals. If it’s infrequent, you can probably get away with a Silver or Bronze. The second question to ask is “what premium range you can afford?” Obviously, this is a crucial question. if the range is $400-$500, which fits a Silver, and a Gold is $800-900, then we’ll look more closely at a Silver. The third question to ask is “what type of Physician Network would I like to use?” Do you like to self-refer and find your own doctors? Then you would probably want a PPO. Do you want the thinking of it done for you? An HMO will coordinate your care in a narrower network. Determining your Frequency of Use, Premium Range, and Physician Network, will all help you figure out the best plan for you.

Will my newborn baby be covered on my CoveredCA insurance?

All infants and newborns are covered under their mother’s insurnace for the first 30 days. If the mother is not covered, then the baby is not covered. After Day 31, the baby is no longer covered. Remember, however, that insurance coverage typically begins the first day of the next month, so even if your baby is born in the middle of the month, if you go the full 30 days and wait until the middle of the next month to enroll your baby, there will be a half a month where your baby is uncovered and you will have to pay out of pocket. For example, say you give birth on November 11th. Your coverage would go until December 11th. If you wait to sign your baby up on or after December 1st, that coverage will not take effect until January 1st, leaving December 12-31 as uncovered days for your baby. If a mother has Medi-CAL, then the baby is covered for the first year.

Does CoveredCA offer dental and vision Insurance?

Yes it does. The dental can be done simultaneously witht he Medical insurance. Vision can be obtained via CoveredCA directly thorugh the Vision carrier. CoveredCA offers EyeMed, VSP, and Superior Vision.

What if I live in two different residences in different counties?

In general, you’d probably want to stick with a PPO plan so that you can self-refer to a doctor and have an in-network provider list to work from between the different counties in California. This may become especially necessary if you travel between two states. While it’s not uncommon simply enroll in two different plans, it is always worth investigating what kind of coverage your primary offers in other areas.

I already have CoveredCA, I just need to access information on my application.

No worries. We can help. Click this link at mycalhealth.com, and we’ll walk you thorugh it! You can also log-in to your CoveredCA account. If you do not know the log-in then call us direct at 661-432-1474 and let the recpetionist know that you would like to gte your tax info off of CoveredCA and they can assist you with that. If you do know your CoveredCA account info, then after you log in, click the GET HELP link on the top of the page, then click FIND LOCAL HELP, and then click FIND CERTIFIED INSURANCE AGENT. Search for “Duncan Harris” and after you find him, click “designate.” After you hit the CONTINUE button, check the appropriate boxes with and a signature. Simply email us at info@mycalhealth.com (this tells us that we have a delegation request from you), and let us know what you are looking for. We’d be happy to help.

I already have CoveredCA, I just need my tax forms.

How CoveredCA works and why it’s the best in 500 words!

Covered California is like a big store for Health Insurance in California. It makes the process of getting health insurance as easy as it gets in this day and age! First, you can get a quote using your zip code, estimated income, tax household size, number of people needing coverage, and their ages. The quote will also show you what tax credits you may qualify for (this may significantly lower your premium). After the quote, we do the application. We have a 10 question online application tool, plus tips in how to apply. After your applicaiton is accepted you choose a plan (typically the one you liked off of your quote). We enroll you (and can even help you make your first payment if you don’t want to wait)! Both your agent (us) AND CoveredCA helps represent you to the health insurance company in regards to your application, premium, and effective dates. Plus, we will look over your application for common errors. You don’t pay any fees for this service. It is already built into the rates. In other words, you pay for a health agent whether you use one or not, (SO YOU MIGHT AS WELL USE US)!

I just lost my employer coverage, how soon can I get CoveredCA?

Right away. If you can no longer work or are leaving the workforce, you may qualify for Medi-CAL. If you plan to get another job, then we will sign you up with CoveredCA for however long it takes to get back on employer sponsored health insurance again. If you know you are going to lose coverage, call us right away so that there is no lapse in coverage. If you think you’ll lose coverage April 1st, call us by March 31st and we can get you covered April 1st. If you lose coverage April 1st, but call us on April 1st, you will have to wait until May 1st to begin your new CoveredCA plan. CoveredCA plans typically always start the first day of the month after you apply.

How long do I have to wait for pre-existing conditions?

Not one second. Pre-existing conditions cannot prevent you from obtaining health insurance in California. There are also no longer any “waiting periods.” In days gone by, if you had a pre-existing condition, and you did not have health coverage in the previous 6 months, then the carrier may not pay for that pre-existing condition for 6 months. It is now a moot point since California law prohibits exclusions based on pre-existing conditions; hence no waiting periods either.

I have heard about the family glitch… what is that?

For the past few years, about 5 million families were offered health insurance through their employer which was affordable for the employer, but unaffordable for the “family” (spouse and dependents). A recent law change now allows the spouses and dependents of employees to test and determine whether their coverage is affordable. The test is this – based off of the employer’s most minimal plan which pays at least 60% of health care costs, does the premium amount exceed 9.12% of the family’s income. Say you make $100,000 a year, but your employer has you paying $2,000 a year on a 60% plan for just your health insurance costs, but it jumps up to $10,000 a year for your family. Because the total family cost exceeds $9,120, you can disenroll your family from your employer sponsored coverage and sign them up for CoveredCA WITH FEDERAL SUBSIDIES. The employee would still have to take the $2,000 a year plan, since that is affordable. If this sounds confusing, remember we have links to affordability tools and tests which can help you determine if this is an option for you.

I have kids older than 18 at home that I claim as dependents (or not), can I keep them on my health insurance?

If the parents’ insurance offers dependent coverage (an obvious consideration) then they can remain on the parents’ coverage until their 26th birthday. The Affordable Care Act requires plans and issuers that offer dependent child coverage to make the coverage available until a child reaches the age of 26. Both married and unmarried, in school or out of school, children qualify for this coverage. Your child can also be a parent themselves! It also does not matter how they file their taxes (whether they are dependents or not).

What is a Bronze HSA plan and why would somebody choose that?

A Bronze HSA is a special Bronze plan that offers no first dollar benefits (such as doctors visits and urgent care), but instead uses a specialized health savings account which can pay for those services. When enrolled in a Bronze HSA plan, you can make contributions to your account which lower you taxable income and can be used to pay for out of pocket medical, dental, and vision expenses. Medicare premiums can also be paid from an HSA. The reason why someone might enroll in a Bronze HSA is that they would be able to make contributions to an HSA which reduces their taxable income. People who choose Bronze HSA plans are only planning to use their health plan for major medical expenses while covering the minor health care expenses either through a personal account or the health savings account. These plans are typically for high income earners who are comfortable self insuring a portion of their health care costs, while having protection against catastrophic health care needs, as well as desiring the tax benefits of opening up a health savings account.

What is the difference between a deductible, a co-pay, and co-insurance?

A deductible is a set amount of money a subscriber will have to pay BEFORE certain services are covered. Not all services, such as a doctor’s visit, are subject to paying the deductible first. A co-pay is a fixed fee that is set for certain services. Co-pays generally DO NOT count toward your deductible. Once you have satisfied your deductible and your insurance carrier begins paying benefits you will still have co-pays for certain services as outlined in your summary of benefits. Once you have satisfied your out of pocket maximum (which is a set limit you pay and then the insurance carrier covers all billed costs after that limit), you will no longer have copays. Co-insurance is a VARIABLE amount usually assigned a percentage (as in 20 or 30%) which is your percentage portion of the health bill that you are responsible to pay. Deductibles typically do count toward your out of pocket maximum limit as do the various co-pays and coinsurance payments.

I do not like my health plan, when and how can I change it?

Typically, “open” enrollment occurs once a year from November 1st to January 31st. At that point you can either renew your current plan or change your plan. It is also helpful to update any of your contact or financial information as well. For the time period between February 1st and October 31st you will need what’s called a “Qualifying Life Events,” or QLE, in order to sign up or change your health plan.

Here is a list of the Qualifying Life Events as outlined by the California Department of Insurance:

Gaining a dependent or becoming a dependent through birth or adoption
Getting married
Applicant or dependent lost minimum essential coverage due to termination or change in employment status
Cessation of an employer’s contribution toward an employee or dependents coverage
Death of the person through whom the applicant was covered
Entitlement of benefits of the subscriber under Title XVIII of the Social Security Act (Medicare), resulting loss of coverage to the dependents
Dependent child’s loss of dependent status under the applicable requirements of a group plan, such as reaching age 26
Loss of minimum essential coverage excluding the loss of termination due to failure to pay premiums or situations allowing rescission
Gains a dependent or becomes a dependent through marriage or partnership
Dependent is mandated to be covered pursuant to a valid state or federal court order
Legal separation or divorce through whom the applicant was covered as a dependent
Loss of coverage under the Access for Infants and Mother’s Program and Medicaid share of cost program
Loss of HMO coverage benefits as the individual no longer lives or works in the HMO service area
Applicant became a permanent resident of California during a month outside of open enrollment period
Applicant returns from active military duty
Applicant is released from incarceration

Additionally, we are currently still under the Public Health Emergency form the Covid-19 epidemic which would allow you to enroll without any of the above factors. The Public Health Emergency acts just like the open enrollment since it is not dependent on any of the above criteria to enroll.

Do I need to have legal status to be in the US in order to get CoveredCA?

In general, you do have to have legal status to be in the United States in order to enroll in CoveredCA. Those without legal status and who are not lawfully present do not qualify for a health plan through Covered California; however, they may qualify for coverage through Medi-Cal if they are younger than 26 or are 50 or older. They may also qualify if they are a DACA recipient or if they are currently pregnant or were recently pregnant. Immigrants who are not lawfully present can also buy private health insurance on their own outside of Covered California. Additionally, some counties offer other health care options for immigrants who are not lawfully present.

What happens if I estimate my income lower to get more premium assistance?

The Federal Assistance toward your premium is based on your tax returns. In general, whatever your Adjusted Gross Income is, combined with the number of people in your tax household, is going to determine how much federal subsidy you qualify for. If you estimate low and actually claim a higher income on your taxes, you will most likely have to repay the difference back to the IRS when you go to file your taxes.

What happens if I estimate my income higher to get more less premium assistance?

The Federal Assistance toward your premium is based on your tax returns. In general, whatever your Adjusted Gross Income is, combined with the number of people in your tax household, is going to determine how much federal subsidy you qualify for. Some people may estimate higher income than they actually claim on their tax return. In that event, the IRS will issue you a larger refund to cover the difference you should have received because you actually had lower income. Estimate high and claim lower – you get money back. Estimate low and claim higher – you may have to repay.

What identification do I need to apply for CoveredCA?

To apply for CoveredCA you will need ONE or TWO of the following:

(Only need 1) Driver’s license issued by a state or territory showing either a photograph of the individual and/or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.
School identification card that includes a photograph.
Voter Registration Card.
U.S. Military card, draft record or Military dependent’s identification card.
Identification card issued by the federal, state, or local government that contains a photograph.
U.S. or foreign passport, U.S. passport card (expired passport may be used) or identification card issued by a foreign embassy or consulate that contains a photograph.
Certificate of Naturalization (Form N-550 or N-570) or Certificate of U.S. Citizenship (Form N-560 or N-561).
Permanent Resident Card or Alien Registration Receipt Card (Form I-551).
Employment Authorization Document that contains a photograph (Form I-766).
Native American tribal document with photograph.
For children under the age of 16:
- A clinic, doctor, hospital, or school record.
- In the absence of the previous, a written statement signed under penalty of perjury by the parents or guardian stating date and place of birth (cannot be used in conjunction with a citizenship affidavit).
U.S. Coast Guard Merchant Mariner card.

What is the FPL chart and how does it apply to me?

FPL stands for Federal Poverty Level. It is used to determine your eligibility for certain programs and benefits, including savings on Marketplace health insurance, and Medicaid and CHIP coverage. It measures your income and your tax household size against an annual chart produced by the Federal government to determine eligibilities for Federal Assistance toward your health premiums. Here is a link to the 2023 FPL – https://www.coveredca.com/pdfs/FPL-chart.pdf

Where can I find the different metal tier plan comparisons?

The metal tier comparison chart demonstrates the differences between each of the four main metallic tiered plans as generated by the Affordable Care Act. They are Platinum (highest premiums, highest benefits), Gold (a little lower but still no deductible), Silver (mid range coverage with deductible), and Bronze (lowest premiums, lowest benefits). This chart will demonstrate each plan, what is subject to the deductible, comparison of particular health services, drug costs, out of pocket maximums, and the different enhanced Silver plans for qualified incomes. You can access the link here – https://www.coveredca.com/pdfs/Health-Benefits-table.pdf

What does OOPM (out of pocket maximum) mean?

From the healthcare.gov website – “The OOPM (Out of pocket maximum) is the most you have to pay for covered services in a plan year. After you spend this amount on deductibles, copayments, and coinsurance for in-network care and services, your health plan pays 100% of the costs of covered benefits.

How do I find out what “tier” my prescription drugs are?

Medicines typically fall into 5 drug tiers. The lower tiers are more common and usually well-covered. The higher the tier number means that it is considered more of a speciality drug. Tier 1 are usually generic drugs and tier 5 are special drugs.

What is the difference between tax credit, premium assistance, or APTC (advanced premium tax credit) mean?

They all refer to the same thing. Officially, Covered California refers to the federal subsidy, or federal financial assistance, toward our health insurance premiums, as the advance premium tax credit (APTC). It is the portion of your health insurance premium that the federal government pays in order for your health insurance costs to be considered affordable. It is based on your estimated annual income and tax household size, plus the plan rates for your particular zip code, and is granted based on the Federal Poverty Rate (FPL). For the current FPL table, use this link – https://www.coveredca.com/pdfs/FPL-chart.pdf

What is my “household” on the CoveredCA application?

A household includes the tax filer and any spouse or tax dependents. Another way to say it is that it is your “tax” household. You may have more people, such as adult children, parents, or friends, who technically live with you, but your household for health insurance purposes is limited to whoever you put on your taxes as a legal spouse or dependent (children up through age 26).

Do I need to estimate my income to the nearest dollar and cents?

Not really. To the nearest $1,000 is generally fine and will have a negligible effect on your tax return at the end of the year. For people who do know that exact fixed amount they they will earn, then by all means represent that number on your application, but for a guess, the nearest thousand is usually sufficient. Tip: Round up a little higher if you want to make sure you don’t have any repayment at the end of the year!

What if my income changes during the year?

You should report any income changes right away as they will now change your annual estimated income (which affects how much refund or repayment you may be responsible for). We are always happy to make any changes you need. Our CalHealth agents are completely free and trained to make and change reports you may need.

What errors or disadvantages might there be if I just enroll by myself?

There are literally hundreds of mistakes that we catch each year, in addition to the subscribers that CoveredCA sends our way to help fix mistakes. Everything from tax filing, to income, deductions, drug coverage, HMO vs PPO, in network and out of network, and a seemingly endless list of new mistakes we discover. Mistakes can result in higher premium, loss of coverage, huge repayments at the end of the year, or terrible drug coverage for your specific prescriptions. Since our services are completely an entirely free (as well as HIPAA compliant confidentiality), why would you want to do it yourself?

What if some of my kids qualify for MediCAL?

When you run a quote through CoveredCA it may come back that the parents qualify for a private plan and the kids qualify for a public sponsored plan through MediCAL. For many people this is exactly what they want and it lowers the amount of money the family is paying toward premiums and healthcare. There are also reasons why you may not want to have your kids on MediCAL. Your current pediatrician may not take MediCAL (and you do not want to switch). You may desire to have everybody on the same plan and in the same health clinic. You may live in a region where there is a scarcity of MediCAL clinics. There are ways we can assist you in order to avoid being placed on MediCAL.

How do I get help with an existing CoveredCA account?

Text, email, or call us right away. If you’d like to do it completely online, you can use the CalHealth website for that as well. We like getting to know our clients and personally assisting you to get the best service. Sometimes getting the bigger picture helps us help you. Contact us today! After 14 years of service, we’ve got his down!

Why do the rates I am being offered NOT match the quote I generated?

The quoting system is simply an estimate and does not always account for the various differences between counties. In general, the quotes should be within a few dollars or cents of the actual premiums. Most of the time they are the exact same.

Can you make my first payment for my CoveredCA premium?

Yes! We can make your first payment and set you up on Auto-pay or paper billing. Please keep in mind that many health plan sponsors now have a mobile app where you can pay your premiums as well!

I have complicated finances, can you help me with the income estimate?

Yes. We can help talk you through where do find your income estimates. If you have a CPA, or Tax Advisor, they can generally give you a picture of what your adjusted gross income (AGI) will be. The AGI, from your form 1040, is what CoveredCA uses to determine your annual income estimate.