Frequently Asked Questions
AFFORDABLE CARE ACT OR OBAMACARE
Q: What preventative services will be covered?
A: The covered preventive services are the recommended services listed as A and B by the US Preventive Services Task Force. See http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm
Q: Does ObamaCare require dental and vision coverage?
A: Dental and vision are a part of the 10 essential health benefits for children up to age 19. In 2014Covered California will offer pediatric stand-alone dental plans, but there may be an embedded plan that includes medical, vision, and dental all in one plan in the future.
Dental and vision coverage for adults are not required by ObamaCare, but will be decided on state-by- state and employer-by-employer basis. Covered California is expected to offer supplemental dental coverage for adults in the near future; however, individuals must pay 100% of the premium cost. Medi-Cal will restore limited dental coverage for adults in May 2014.
Q: How will ObamaCare affect immigrants?
A: Legal permanent residents who have been in the US for 5 years or more, as well as people residing under Permanent Residence Under Color of Law (PRUCOL), refugees, asylees, those on temporary work or student visas, and individuals granted Temporary Protected Status (TPS) have the same eligibility for programs as US citizens. For a complete list of who is eligible, see appendix. New legal permanent residents (less than 5 years) are eligible for Covered California and for Medi-Cal and to purchase insurance privately or through their employer. New legal residents who are adults without minor children living at home with incomes between 100% and 133% of FPL will be Covered California eligible rather than Medi- Cal eligible. California will use the premium assistance option to pay the Covered California premiums.
The undocumented cannot participate in Covered California or in full scope Medi-Cal, nor can individuals granted Deferred Action under the Deferred Action for Childhood Arrivals policy. They can be eligible for limited scope Medi-Cal to cover births and genuine emergencies. For families with citizen children and undocumented parents, the parents must report their income whether or not they file taxes. CalHEERS will verify residency status and length of time in the US through electronic crosschecks with the Department of Homeland Security. Income can be verified with paper documentation as an alternative to electronic crosschecks.
Q: How will ObamaCare affect people with insurance through their employers?
A: If you are already covered through your employer, there are no changes (except in some cases some additional protections to assure you, your family, and children up to age 26 can stay covered, benefits, and preventative services. Full-time employees with an offer of coverage from their employer are not eligible for premium or cost sharing subsidies in Covered California, unless coverage for the employee only is unaffordable (i.e. the employee’s share of self only coverage exceeds 9.5% of household income). Part-time employees without an offer of coverage from their employer are eligible for Medi-Cal, if their income is less than 133% FPL, or for Covered California, if their income is greater than 133% FPL.
Q: Do employers have to provide insurance to part-time employees? Do employers have to offer coverage to the spouse and children of full-time employees?
A: Small employers (less than 50 full-time equivalent employees) are not required to cover anyone. Large employers (50 or more full-time equivalent employees) are required to provide insurance to full-time employees (those working 30 or more hours a week). Employers do not have to cover part-time employees. Employers do not have to cover spouses of employees. We believe a large employer will be obligated to offer coverage for the children of full time employees.
Q: What programs are students eligible for?
A: Students are subject to the same eligibility guidelines as all other groups and also have the option of staying on their parents’ coverage until age 26. Some may have coverage offered by their college or university. Students should make sure their insurance plan has a network of providers near their school/residence.
Q: How will ObamaCare affect seniors?
A: ObamaCare will gradually shrink the Medicare donut hole for prescription drug coverage to nothing by 2020. Prevention and wellness services are also now covered through Medicare. Medicare coverage is sufficient to satisfy the individual mandate. Those who receive Medicare cannot receive premium subsidies in Covered California.
Q: I have Medicare, do I need to buy health insurance? Will I be fined?
A: No, you can keep your Medicare. The health reform law may lower the cost of your medicine. You won’t have to pay for preventive care like cancer screenings, vaccines, flu shots, and wellness visits.
Q: Can a person’s adult son/daughter stay on their insurance plan? What about their child’s spouse and children?
A: Children can remain on their parent’s insurance plan until the age of 26, regardless of marital status, student status, or geographic location. However, the child’s spouse and children are not considered dependents of the parent and cannot receive coverage under their policy. Children can also stay on a parent’s insurance plan if they are offered coverage through their employer. If they are not offered employment-based coverage, adult children can opt to apply for Covered California or Medi-Cal coverage. Parents are not obligated to keep adult children on their plan.
Q: I have Medi-Cal, do I need to buy health insurance? Will I be fined?
A: No, you can keep your Medi-Cal health insurance.
Q: So what is the Medicaid (Medi-Cal in California) expansion under ObamaCare?
A: This is one of the law’s important achievements. It will expand the eligibility requirements for Medicaid – the nation’s public health insurance plan – which mainly serves the poor. That’s going to give tens of millions of uninsured people across the country coverage. California’s Medicaid program – which is called Medi-Cal – is expected to grow by about 1.4 million people.
L.A. County has a program called Healthy Way LA, which in 2010 was restructured as a sort of “bridge to Medi-Cal.” Healthy Way L.A. is not health insurance, but it does give those people who will gain Medi-Cal insurance next year a head start, so to speak. It does that by giving them free access to services at county clinics and certain community health centers starting right now – as soon as they sign up.
Q: What happens to Healthy Way LA members on January 1st?
A: Healthy Way L.A. (HWLA) will in large part end on December 31, 2013 and it will be replaced by Medi-Cal. The idea is for a seamless transition between Healthy Way L.A. and Medi-Cal – those patients are supposed to just roll over automatically. The State of California is sending HWLA members a letter in October, a health plan choice packet in November, and a welcome to Medi-Cal packet with a Benefit Identification Card in December. Members should confirm that the medical home listed on all communication is correct. If so, they do not need to do anything. If it is listed incorrectly, members should make an appointment with an Health Advocate at their health center to make the correction as soon as possible.
Q: Is the new Medi-Cal eligibility up to 133% FPL or 138% FPL?
A: The new income eligibility for Medi-Cal is 133% of federal poverty level for parents and other adults (but not the aged and disabled) plus a 5% income disregard. So, with this 5% disregard, Medi-Cal is effectively covering individuals and parents with incomes up to 138% FPL. The updated and consolidated eligibility for children is 266% of FPL and for pregnant women under Medi-Cal, it is 213% of FPL; this is a consolidation of current income deductions and disregards and includes the 5% disregard. See the Federal Poverty Guidelines here: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Eligibility/Downloads/2013-Federal-Poverty-level-charts.pdf
Q: Can a Medi-Cal eligible person opt out of Medi-Cal and apply for coverage through Covered California?A: Individuals who apply through CalHEERS are determined either Medi-Cal or Covered California eligible based on their income level. You cannot choose to buy coverage through Covered California and receive subsidies unless you are ineligible for full scope Medi-Cal. You can, however, choose to buy coverage through Covered California without receiving subsidies. The reason for this is because the federal government pays 100% of the costs of the subsidies in the Exchange, but only 50% of the cost for traditional Medi-Cal. So, allowing those who are eligible for Medi-Cal to enroll in Covered California plans and receive subsidies would shift further costs from the states to the federal government. We think the one exception to this is for maternity coverage; pregnant women with incomes between 133 and 200% of FPL can have Covered California coverage or Medi-Cal coverage, but not both.
Q: Is the enrollment process for Medi-Cal changing?
A: The enrollment process for seniors, the disabled, those who are medically needy, those receiving SSI or TANF, and undocumented immigrants will remain the same and take place through local social services departments. Families, children, and other adults will enroll through CalHEERS. There is no open enrollment period – you may apply at any time for Medi-Cal.
Q: What will happen to current Medi-Cal recipients with a share of cost?
A: Those with household incomes below 133% (effectively 138%) of FPL will transition to Medi-Cal with no share of cost. Those with household incomes above 133% of FPL will qualify for Covered California; the premium and cost sharing subsidies are far more beneficial than Medi-Cal share of cost.
Q: Can a person who is low-income but has assets or savings qualify for Medi-Cal?
A: It depends on the age of the person and other factors. As of 2014, there will be no assets tests for Covered California and Medi-Cal, for those who are Modified Adjusted Gross Income (MAGI) eligible, that includes children, parents, pregnant women, and non-disabled, non-elderly adults. Asset tests will still apply for the rest of the traditional Medi-Cal eligibility categories, such as SSI, TANF (CalWorks), medically needy, seniors, the disabled, and anyone who needs long term care. A disabled individual with excess assets who chose the new Medi-Cal eligibility category would not qualify for long term care services without an assets test. An individual over 65 with excess assets and Medicare coverage would need to “spend down” their assets to the Medi-Cal resource limits to qualify for Medi-Cal.
Q: Can someone qualify for Medi-Cal if they own a home?
A: Asset tests are eliminated for families, children, and other low-income adults, but not for the aged and disabled. Seniors and disabled persons can keep their homes and still receive Medi-Cal benefits as long as they and/or their spouse live in it. There are different rules if the person permanently moves into a nursing home; if they want to, for example, transfer ownership of their home to their children, they should consult an attorney, as there are substantial penalties for transferring assets for less than fair market value. There are typically liens on homes for persons in long-term care.
Q: How is income determined for assessing eligibility?
A: Covered California counts the income of all household members (this may include step-parents, step children, and other family relatives) who are living in the household and are a part of the tax-filing unit. When applying for Medi-Cal or Covered California, applicants state their current income and then adjust it to reflect projected income for the benefit year. What is reported is then crosschecked with tax returns through the Internal Revenue Service (IRS) or the Franchise Tax Board. If the incomes differ significantly, applicants may be asked to explain the discrepancies. Upon filing taxes for that year, actual income will be compared to what was reported, and individuals will be responsible for any overpayments or receive rebates for any underpayments.
Q: If a person qualifies for Covered California, how long will it take before their coverage actually begins?
A: The new goal for enrollment is to have real time eligibility determinations for both Medi-Cal and Covered California; however in any case, Medi-Cal and Covered California must complete a person’s eligibility determination in no less than 45 days. If their application is processed and eligibility is verified within the first 15 days of the month, then coverage will start on the 1st of the next month. If eligibility is verified within the last 15 days of the month, then coverage will start on the 1st of the second following month (e.g. for verification completed January 27, coverage would start March 1).
Q: Can an older parent who is living with and is a dependent of an adult child be covered by a family plan through Covered California along with other members of the household?
A: Yes, if the household meets Covered California income eligibility requirements is claimed as a dependent on the household’s federal tax forms and the dependent parent and other members of the household have no other offer of affordable coverage, they can purchase family coverage through Covered California. In general, Covered California’s rules on income and household composition mirror the federal tax code. However, the dependent adult would also be eligible for Medi-Cal as an adult without minor dependent children if his/her income is below 133% FPL. For Medi-Cal, the dependent adult would be considered to have a household of one.
Q: Can undocumented immigrants apply for Medi-Cal or Covered California?
A: The undocumented cannot participate in Covered California or in full scope Medi-Cal, nor can individuals granted Deferred Action under the Deferred Action for Childhood Arrivals policy. They can be eligible for limited scope Medi-Cal to cover births and genuine emergencies. Since they do not qualify for the requirements for either program, they will not be fined for not having insurance.
Q: What happens to Healthy Way LA Unmatched program?
A: The program is remaining the same at this time.
Q: What if someone gets sick or seriously injured outside of open enrollment and they are uninsured?
A: A person’s eligibility for coverage will likely be assessed when they are treated for their injuries/sickness or at the point of service. Depending on their income, a person could be eligible for Medi-Cal or Medi-Cal share of cost, which could be retroactive three-months, or apply for coverage through Covered California during the next open enrollment period. Unlike Medi-Cal, coverage through Covered California is prospective only and enrollment is only available during annual open enrollment, except for special circumstances such as a job change, job loss or loss of insurance. The income eligibility threshold for Medi-Cal share of cost is far lower than Covered California, leaving an individual or family with a very large share of cost.
Source: Insure the Uninsured Project