Covered California
Outreach Training
Summary
Connecting Californians to
Care
Last Updated on
January 21, 2014
Covered California Outreach – Training Summary
Connecting Californians to Care
Last Updated: January 21, 2014
Table of Contents
Introduction
This document contains a summary of rules and regulations pertaining to Covered
California and individual market insurance enrollment. It is designed to serve as a
resource for volunteers who will engage in community outreach to educate about
Covered California and other insurance coverage opportunities made available by the
Affordable Care Act.
All comments or questions surrounding the information may be addressed to Connecting
Californians to Care:
Dylan Roby, PhD
Assistant Professor of Health Policy
& Management
UCLA Fielding School of Public Health
[email protected]
Jeff Fujimoto
Medical Student,
David Geffen School of Medicine at UCLA
[email protected]
Brandon Scott
Medical Student,
David Geffen School of Medicine at UCLA
[email protected]
Caleb Wilson
Medical Student,
David Geffen School of Medicine at UCLA
[email protected]
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Covered California Outreach – Training Summary
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Table of Contents
Covered California
 Overview of Covered California ...............................................................................
 Insurance Products Types Sold on Covered California ............................................
 Metal Tier and Minimum Coverage Plans ................................................................
 Plan Benefit Designs .................................................................................................
 Eligibility Requirements for Covered California ......................................................
 Enrollment Period and Start of Coverage ..................................................................
 Overview of How Premiums Are Determined ..........................................................
 Health Insurance Protections for Individuals and Families Implemented by the
ACA ...........................................................................................................................
 Important Considerations when Counseling on Health Insurance Decisions ............
9
10
Financial Assistance Programs
 Overview of Financial Assistance Programs .............................................................
 Restrictions to Financial Assistance Programs ..........................................................
 Overview of Premium Assistance (Tax Credits) .......................................................
 Eligibility Requirements for Premium Assistance ....................................................
 Determining Premium Assistance .............................................................................
 Applying Premium Assistance to Purchase Insurance ..............................................
 Illustrative Example of How to Calculate and Apply Premium Assistance ..............
 Premium Assistance Rebates or Penalties following Changes in Reported Income .
 Overview of Cost Sharing Reductions ......................................................................
 Eligibility Requirements for Cost Sharing Reductions .............................................
 Federal Poverty Level Percentage Table ...................................................................
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12
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15
16
16
17
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5
5
7
8
8
9
Medi-Cal
 Overview of Medi-Cal ............................................................................................... 18
 Eligibility Requirements ............................................................................................ 18
Coverage Opportunities for Immigrants
 Permanent Residents Who Have Lived in the US for Five or More Years ...............
 Permanent Residents Who Have Lived in the US for Less Than Five Years ...........
 Undocumented Immigrants .......................................................................................
 Medical care resources for Undocumented Immigrants and those not eligible for
Medi-Cal or Covered California ...............................................................................
20
20
20
20
Buying Individual or Family Coverage Outside of Covered California
 Similarities Between Shopping on Covered California and Shopping Outside Covered
California ................................................................................................................... 22
 Differences Between Shopping on Covered California and Shopping Outside Covered
California ................................................................................................................... 22
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Individual Mandate
 Individual Mandate Overview ................................................................................... 23
 Exceptions from Individual Mandate ........................................................................ 23
 Individual Mandate Penalties .................................................................................... 23
Appendix
 Glossary of Key Terms .............................................................................................
 Sample Script of Talking Points for Outreach Volunteers .......................................
 Healthcare coverage resources for undocumented immigrants and those ineligible
for Medi-Cal and Covered California .......................................................................
 Healthcare coverage resources for undocumented pregnant women or pregnant
women not eligible for Medi-Cal or Covered California ..........................................
 Important Links, Phone Numbers, and References ...................................................
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Table of Contents
Overview of Covered California
Overview of Covered California
Covered California is California’s Health Insurance Marketplace established under the
Patient Protection and Affordable Care Act (ACA). It provides individuals and small
business owners with the ability to shop for and compare health insurance coverage
options.
Covered California allows individuals to shop online, over the phone, and in person.
Through Covered California, Californians may learn if they qualify for federal subsidies
and tax credits used to make health care more affordable (see the Financial Assistance
Programs section for more information). Californians may also use Covered California
to assess if they are eligible for low-cost or no-cost health coverage through Medi-Cal.
To learn more about Covered California please visit www.CoveredCA.com or call
(800) 300-1506.
Insurance Products Sold on Covered California
Covered California sells health insurance products to two distinct markets:


Individuals and families – Covered California sells private insurance on the
“individual market” which consists of individuals and families who do not receive
Medicare and who do not receive employer coverage.
Small business owners – Covered California also sells private insurance to small
business owners (who provide insurance coverage to their employees) through the
Small Business Health Insurance Options Program (SHOP).
Volunteers should expect to predominantly discuss coverage opportunities for the
individual market.
Metal Tier and Minimum Coverage Plans
Covered California offers a variety of health insurance products that are standardized in
terms of services offered and out-of-pocket costs. The standard plans are categorized into
different levels known as Metal Tiers based on the plan’s Actuarial Value. Actuarial
value (AV) is defined as the proportion of healthcare expenses a health insurance plan
will cover for a typical group of enrollees. For example, in a plan with a 70% actuarial
value, the insurer will pay 70% of medical expenses while the member will be
responsible for paying 30%.
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There are four different metal tiers, each defined by its actuarial value. The medical
services covered by plans in Covered California are consistent across each plan
regardless of metal tier. The difference in metal tiers arises in the amount of money an
individual is responsible for paying—both in terms of premiums, deductibles, out-ofpocket expenses, and out-of-pocket maximums. Lower metal tier plans (e.g., Bronze
Plans) may have lower premiums but higher deductibles, out-of-pocket expenses, and
out-of-pocket maximums than higher metal tier plans (e.g., Platinum Plans).
In addition to metal tier plans, Covered California also offers Minimum Coverage plans.
These plans are high-deductible plans only available to individuals under the age of 30 or
individuals experiencing financial hardship. Minimum coverage products offer the
lowest premiums out of all Covered California products, but have the highest deductible
at $6,350 for an individual and $12,700 for a family. After the deductible is met, all
authorized medical services are covered by the health plan at 100%. The first three
primary care visits and one wellness visit are free. Minimum Coverage plans are
ineligible for tax credits.
An overview of the metal tier and Minimum Coverage plans can be found in Table 1.
Table 1: Overview of Metal Tiers and Minimum Coverage Plans
Eligibility*
Actuarial
Value
Premium
Charge
Deductible
Out-of-Pocket
Costs
Out-of-Pocket
Max
Financial
Assistance
Available
Free Services
Prior to
Deductible
Minimum
Coverage
Under Age 30
OR Financial
Hardship
Bronze
Silver
Gold
Platinum
All
All
All
All
~60%
60%
70%
80%
90%
$
$$
$$$
$$$$
$$$$$
Ind: $6,350
Fam: $12,700
Ind: $5,000
Fam: $10,000
Ind: $2,000
medical;
$250 brand drug
Fam: $4,000
medical;
$500 brand drug
None
None
$$$$$
$$$$
$$$
$$
$
Ind: $6,350
Fam: $12,700
Ind: $6,350
Fam: $12,700
Ind: $6,350
Fam: $12,700
Ind: $6,350
Fam: $12,700
Ind: $4,000
Fam: $8,000
No
Yes
Yes
Yes
Yes
3 Primary
Care Visits
1 Annual Visit
1 Annual
Visit
1 Annual
Visit
1 Annual
Visit
1 Annual
Visit
*Note: Only US citizens and legal residents are eligible for Covered California
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Plan Benefit Designs
Plan benefits are medical services that are approved and covered by the insurance
company. Benefits design is the health plan’s defined list of plan benefits, including the
amount a member is expected to pay for each medical service type.
Each plan in Covered California offers a standardized benefit design that varies only in
out-of-pocket expenses based on metal tier. Benefits offered are consistent across all
plans, regardless of metal tier. Table 2 illustrates the standard benefit designs by metal
tier.
Table 2: Standard Benefit Designs by Metal Tier
Coverage Category
Bronze
Deductible (individual)
$5000
medical &
drugs
Deductible (family)
$10,000
medical &
drugs
Preventive Wellness Visit
Copay*
No cost
Primary Care Visit Copay
Specialty Care Visit Copay
Urgent Care Visit Copy
Emergency Room Copay
Lab Testing Copay
X-Ray Copay
Generic Medicine Copay
Brand medicine Copay (after
drug deductible)
Imaging (MRI, CT, PET scans)
Silver
$2,000
medical
$250 brand
drug
deductible
$4,000
medical
$500 brand
drug
deductible
Gold
Platinum
No
deductible
No
deductible
No
deductible
No
deductible
No cost
No cost
No cost
$60 for 3
visits
$70
$120
$300
30%
30%
$19 or less
$45
$30
$20
$65
$90
$250
$45
$65
$19 or less
$50
$60
$250
$30
$50
$19 or less
$40
$40
$150
$20
$40
$5 or less
$50
$50
$50
$15
30%
$250
$250
$150
$6,350
$6,350
$6,350
$4,000
Annual Out-of-Pocket
individual
individual
individual
individual
Maximum Individual and
and $12,700 and $12,700 and $12,700
and $8,000
Family
family
family
family
family
Source: www.coveredca.com (Updated as of October 2013)
*Minimum plans receive 3 primary care visits and one wellness visit free prior to meeting
deductible. Bronze, Silver, Gold, and Platinum plans receive one free wellness visit.
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The ACA requires that each plan on Covered California cover a minimum set of benefits
known as Essential Health Benefits (EHB). These benefits include services such as
maternity care, mental health, and prescription drug coverage that were not included in
many health plans prior to 2014. The full set of 10 EHB categories include:
1.
2.
3.
4.
5.
Ambulatory patient services
Emergency services
Hospitalization
Maternity and newborn care
Mental health and substance abuse disorder services, including behavioral health
treatment
6. Prescription drugs
7. Rehabilitative and habilitative services and devices
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including dental and vision care
* Dental and vision are provided for children but not necessarily for adults
Eligibility Requirements for Covered California
Covered California is available to legal California residents (US citizens or immigrants
with permanent resident status).
Undocumented immigrants are ineligible from Covered California but may purchase the
same plans offered in Covered California outside of the Covered California marketplace.
One exception to this is Minimum Plans—these may only be purchased on Covered
California. Note: Financial assistance is not available for plans purchased outside of
Covered California. (See below for the similarities and differences between shopping on
Covered California and shopping outside Covered California).
Enrollment Period and Start of Coverage
For coverage year 2014 the enrollment period is between October 1, 2013 and March 31,
2014.


8
Enrolling in the first half of a month – If an individuals signs up for insurance
between the 1st and the 15th of the month, coverage will begin on the first of
following month (e.g., individuals who sign up on February 15 will start coverage
on March 1).
Enrolling in the second half of a month – If an individual signs up between the
16th of the month and the end of the month, coverage will not begin until the
month AFTER the following month (e.g., individuals who sign up on February 16
will start coverage on April 1.
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Overview of How Premiums are Determined
Premiums for health insurance plans purchased on Covered California are determined by:




Age – Age cohorts are factor for determining premiums. This means that for a
particular health plan, individuals in their 20s will have a premium price separate
from individuals in their 50s. Premiums for older individuals will typically be
more expensive than those of younger individuals.
Location of residency – Premiums are also determined by Pricing Regions based
on where an individual lives. There are 19 different pricing regions across the
state of California. Each pricing region may have a different premium for the
same plan. For example, premium prices for a 25 year old buying a particular
plan in Los Angeles County may have a different price for a 25 year old buying
the same plan in Orange County.
Size of Policy – Individual plans will be less expensive than family plans.
Actuarial value – Actuarial value is the proportion of healthcare expenses a
health insurance plan will cover for a typical group of enrollees (this is further
defined in the Metal Tier and Minimum Coverage Plans section above). Plans
with higher actuarial value will be priced higher than those with lower actuarial
values. In other words: $$ Minimum Plans < $$ Bronze Plans < $$ Silver Plans <
$$ Gold Plans < $$ Platinum Plans, where $$ = premium payment.
Modified adjusted gross income does not play a role in determining premium pricing,
but it does play a role in determining if an individual is eligible for financial assistance.
(See more details on the Financial Assistance Programs section below).
Health Insurance Protections for Individuals and Families Implemented by the ACA
The ACA instituted several insurance market regulatory changes in favor of improving
access to coverage. Several of the changes include:




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Guaranteed coverage – Adults and children are guaranteed health insurance
coverage and will no longer be denied coverage or charged abnormally high
premiums because of preexisting conditions.
Adult children up to age 26 may be added to a parent’s plan – Children must
subscribe to their own insurance polices once they turn 26 years of age.
No cost sharing for preventive services – Certain preventative services must be
provided to consumers free of charge. A list of these services can be found at
https://www.healthcare.gov/what-are-my-preventive-care-benefits/.
Ban on rescissions – Insurers are no longer authorized to revoke an insurance
policy retroactively (e.g., cancel an insurance plan after an individual has utilized
significant amounts of medical services).
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Important Considerations when Counseling on Health Insurance Decisions
Several factors should be considered when deciding on a health plan. Some
considerations include:
Utilization and Costs:
 Do the individual and/or his or her dependents make frequent trips to the doctor?
This will determine what metal tier the individual should consider. Those who
see the doctor more frequently may consider a higher metal tier plan with higher
premiums but lower out-of-pocket costs per service rendered.
 What types of medical services does the individual anticipate using? Those who
anticipate utilizing higher cost services may consider a higher metal tier plan with
higher premiums but lower out-of-pocket costs per service rendered.
 Does the individual prefer to pay more upfront in premiums or more on the backend in deductibles, copays, and coinsurance? This will determine if an individual
should consider a lower metal tier plan (lower premium, higher deductible,
copays, and coinsurance) vs. a higher metal tier plan (higher premium, lower
deductible, copays, and coinsurance).
Network:
 Does the individual have a preferred primary care physician? This will
determine what health insurer or health plan he or she should choose as each plan
network may provide access to different providers.
 Does the individual prefer to have access to certain hospitals? This will
determine what health insurer or health plan he or she should choose as each plan
network may provide access to different hospitals.
 Does the individual prefer an open network (many out-of-network services are
covered by the insurer but at a higher co-pay or co-insurance than in-network
services)? This will determine whether he or she should consider a PPO vs. a
HMO or EPO.
 Does the individual prefer to have access to specialists without the need of a
referral from a primary care physician? This will determine whether he or she
should consider a PPO or EPO vs. a HMO.
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Financial Assistance Programs
Overview of Financial Assistance Programs
To help improve the affordability of health insurance, the ACA stipulates that individuals
of certain income levels may receive financial assistance through the following programs:


Premium Assistance (Tax Credits) – Individuals with modified adjusted gross
income between 138% and 400% the Federal Poverty Level (FPL) may receive
tax credits (subsidies) to help pay for insurance premiums. These subsides are
essentially coupons an individual may use to reduce the amount he or she pays for
premiums out of pocket.
Cost Sharing Reductions – Individuals with modified adjusted gross incomes
between 138% and 250% FPL have the option of purchasing an upgraded Silver
plan that has lower out of pocket expenses for medical services.
Restrictions to Financial Assistance Programs:
Certain restrictions may prevent individuals from receiving financial assistance:
Affordable Employer Coverage – An individual is ineligible for the programs listed
above if he or she has Affordable Employer Coverage. This means this individual has
been offered employer-based insurance with a premium whose annual price exceeds
9.5% of that individual’s modified adjusted gross income.
Note: Affordable Employer Coverage is determined by the price of employer
coverage for an individual plan, NOT a family plan. I.E., an individual who is offered
an employer-based individual plan priced less than 9.5% of his or her income is ineligible
for financial assistance, even if his or her employer-based family plan is priced higher
than 9.5% of income.
Medi-Cal – Med-Cal eligible individuals are not eligible for financial assistance, as they
will be expected to enroll in Medi-Cal rather than Covered California.
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Figure 1 illustrates a decision tree for determining financial assistance eligibility.
Figure 1: Financial Assistance Eligibility Flowchart for Those Eligible for Covered
California*
*Note: Only US citizens and legal residents are eligible for Covered California and
financial assistance
Overview of Premium Assistance (Tax Credits)
Premium assistance is a tax credit subsidy provided to individuals with modified
adjusted gross income between 138% and 400% the Federal Poverty Level (FPL).
These subsides are essentially coupons an individual may use to reduce the amount he or
she pays for premiums out of pocket.
Eligibility Requirements for Premium Assistance
To be eligible for premium assistance:

12
An individual must have a modified-adjusted gross income between 138% and
400% FPL.
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

Table of Contents
He or she must not have an offer for affordable employer coverage (see more on
this in the Restrictions to Financial Assistance Programs section above).
He or she must not be Medi-Cal eligible. Medi-Cal eligible individuals do not
receive financial assistance for Covered California products as they are expected
to enroll in Medi-Cal.
Determining Premium Assistance
The amount an individual receives in premium assistance tax credits is the difference
between the cost of that individual’s second lowest priced Silver Plan and their calculated
premium cap. A premium cap is the maximum amount a premium assistance-eligible
individual pays for health insurance premiums annually if he or she were to purchase the
second lowest priced Silver Plan (purchasing a more expensive plan will call for the
individual to pay more than their calculated cap in annual premiums). Premium caps are
determined by a sliding scale based on modified adjusted gross income such that higher
income earners will have a larger cap that requires them to pay more in premiums
annually. Table 3 illustrates the premium cap sliding scale while Equation 1 illustrates
the formula behind how tax credits are calculated.
Table 3: Baseline Premium Caps Used to Determine Premium Assistance
Income as
Premium Cap as Percent of Modified Adjusted Gross Income
Percent of FPL
138.01% to 150% ~3% to 4%
150.01% to 200% 4% to 6.3%
200.01% to 250% 6.3% to 8.05%
250.01% to 300% 8.05% to 9.5%
300.01% to 400% 9.5%
Equation 1: Calculation of Premium Assistance
Applying Premium Assistance to Purchase Insurance
If an individual receives premium assistance, that individual may apply the tax credits he
or she receives towards the premium of a health insurance plan in any metal tier. This
means that if the individual chooses to purchase the second lowest priced Silver Plan, the
individual will pay his or her determined premium cap. If he or she chooses a plan
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outside of the second lowest priced Silver Plan, he or she may pay either more or less
than the premium cap, depending on the plan chosen.
Different premium payment scenarios may arise based on metal tier.




Bronze Plan – An individual may choose to use his or her tax credit to “buy
down” to a Bronze plan. In this case, the individual may apply the entirety of his
or her tax credit towards the cost of this plan. If the tax credit exceeds the cost
of premiums for that plan, the individual will pay $0 out-of-pocket in premiums.
If the premium for that plan exceeds the price of the tax credit, he or she must
pay the difference between the full premium price and the tax credit.
Silver Plan – If an individual purchases the second lowest priced Silver Plan, he
or she will only be responsible for paying his or her premium cap. Like the
Bronze Plan, buying the lowest priced Silver Plan may enable the individual to
pay less than his or her premium cap. If the individual purchase a more
expensive silver plan that exceeds the amount of the tax credit, he or she must
pay the difference between the full premium price and the tax credit.
Gold and Platinum Plans – If an individual purchase a Gold or Platinum Plan
he or she must pay the difference between the full premium price and the tax
credit.
Minimum Coverage Plans – Tax credits may not be used to purchase a
Minimum Coverage Plan. An individual must pay full price without
premium assistance for a Minimum Coverage Plan.
Illustrative Example of How to Calculate and Apply Premium Assistance
Below is an illustrative example illustrating how to calculate and apply premium
assistance:
A family of four makes $94,000 a year. Using the Federal Poverty Level Percentage
Table, this equates to just under 400% FPL. Assuming the family meets all other
eligibility criteria, they are eligible for premium assistance. Because their income is just
under 400%, their premium cap is 9.5% of their income, or $8,930.
Say their second lowest priced Silver Plan is priced at $10,000 annually. This price
exceeds their premium cap ($8,930), so they will receive premium assistance. Their
premium assistance tax credit is the difference between the price of the second lowest
Silver Plan ($10,000) and the family’s premium cap ($8,930). This equates to $1,070
($10,000 - $8,930 = $1,070). This $1,070 tax credit can be used to purchase any plan
other than the Minimum Coverage plans. Table 4 illustrates what the individual would
pay based on product price.
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Table 4: Sample Premium Prices Based on Premium Assistance (Illustrative Values)
Original Annual
Annual Premium with
Product
Premium
Tax Credit Subsidy
$0
$1,000
Lowest priced Bronze
($1,070 > $1,000)
$8,930
$10,000
Second lowest priced Silver
($10,000 - $1,070)
$10,930
$12,000
Lowest priced Gold
($12,000 - $1,070)
$900
Lowest priced Minimum-Plan $900
(ineligible for subsidies)
Now consider another family earning the same income ($94,000), whose second lowest
priced silver plan is priced at $8,000. This price does not exceed the family’s premium
cap ($8,000 - $8,930 = -$930). This family would therefore not receive any premium
assistance under this second scenario and would have to pay full price on whichever plan
they chose.
Premium Assistance Rebates or Penalties following Changes in Reported Income
For some individuals receiving premium assistance income may change over the course
of a coverage year in a manner that alters how much the individual should receive in
premium assistance based on income. Covered California will rectify any issues of
overpayment or underpayment in tax credits retroactively at the end of a coverage year.
At the end of a coverage year Covered California will use an individual’s tax files to
assess what that person’s income level was during that coverage year. If there is a
discrepancy between the income inputted when the individual applied for Covered
California and the income reported in the following year’s tax return, Covered California
will rectify this discrepancy by providing rebates for individuals whose actual incomes
were less than originally reported or by charging penalties for individuals whose actual
incomes were more than originally reported.
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Overview of Cost Sharing Reductions
Cost sharing reductions allow individuals with an income between 138% and 250% FPL
to purchase an upgraded Silver Plan that has lower out of pocket expenses for medical
services.
Cost sharing reductions upgrade the actuarial value (AV) of the individual’s Silver Plan
from a standard 70% AV to a higher AV. Recall that AV is defined as the proportion of
healthcare expenses a health insurance plan will cover for a typical group of enrollees
(e.g., in a standard Silver Plan with 70% actuarial value the insurer will pay 70% of
medical expenses while the member will be responsible for paying 30%). Upgrading a
Silver Plan’s AV will reduce the member’s out of pocket expenses but will not result in
any changes to his or her premium payments.
As an example, if an individual meets the cost sharing reduction eligibility criteria and
has an income 200% of FPL, this individual may purchase a Silver plan with 87% AV.
This means that this individual’s out of pocket expenses for medical services will be
lower because the health plan will pay for 87% of medical expenses rather than 70% (and
thus the member will be responsible for paying 13% of medical expenses rather than
30%).
Eligibility Requirements for Cost Sharing Reductions
To be eligible for cost sharing reductions:



An individual must have a modified adjusted gross income between 138% and
250% FPL.
He or she must not have an offer for affordable employer coverage (see more on
this in the Restrictions to Financial Assistance Programs section above).
He or she must not be Medi-Cal eligible. Medi-Cal eligible individuals do not
receive financial assistance for Covered California plans.
The amount of cost sharing reductions an individual is eligible for is determined by a
sliding scale based on income as a percent of FPL. Table 5 displays this sliding scale.
Table 5: Determination of Cost Sharing Reductions
Income as
Percent of FPL
138.01% to 150%
150.01% to 200%
200.01% to 250%
250.01% to 300%
300.01% to 400%
16
Cost Sharing Reduction (Actuarial Value of “Enhanced” Silver
Plan)
94%
87%
73%
70% (standard AV, income is ineligible for cost sharing reduction)
70% (standard AV, income is ineligible for cost sharing reduction)
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Federal Poverty Level Percentage Table
Please refer to Table 6 below when determining if an individual is eligible for premium
assistance or cost sharing reductions. You may also click here to visit the UC Berkeley
Labor Center’s calculator to estimate tax subsidies and Medi-Cal eligibility.
Table 6: Federal Poverty Level Percentage Table
Household
Size
1
2
3
4
5
6
7
8
For each
additional
person,
add:
100%
133%
138%
150%
200%
200%
250%
300%
350%
400%
$11,490
$15,510
$19,530
$23,550
$27,570
$31,590
$35,610
$39,630
$15,282
20,628
25,975
31,322
36,668
42,015
47,361
52,708
$15,856
$21,404
$26,951
$32,499
$38,047
$43,594
$49,142
$54,689
$17,235
$23,265
$29,295
$35,325
$41,355
$47,385
$53,415
$59,445
$22,980
31,020
39,060
47,100
55,140
63,180
71,220
79,260
$22,980
$31,020
$39,060
$47,100
$55,140
$63,180
$71,220
$79,260
$28,725
$38,775
$48,825
$58,875
$68,925
$78,975
$89,025
$99,075
$34,470
$46,530
$58,590
$70,650
$82,710
$94,770
$106,830
$118,890
$40,215
$54,285
$68,355
$82,425
$96,495
$110,565
$124,635
$138,705
$45,960
$62,040
$78,120
$94,200
$110,280
$126,360
$142,440
$158,520
$4,020
$5,347
$5,548
$6,030
$8,040
$8,040
$10,050
$12,060
$14,070
$16,080
Legend
Premium Assistance Eligible
Only
Premium Assistance and Cost
Sharing Reduction Eligible
Medi-Cal Eligible
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Medi-Cal
Overview of Medi-Cal
Medi-Cal is California's Medicaid program. It provides health care services for lowincome individuals, including families with children, seniors, persons with disabilities,
foster care, pregnant women, and low-income people with specific diseases such as
tuberculosis, breast cancer or HIV/AIDS.
Medi-Cal is financed by both the State and Federal government. For more information
on Medi-Cal, please visit: http://www.medi-cal.ca.gov/
Eligibility requirements
As of January 1st, the requirements for Medi-Cal have been standardized to apply to
almost everyone. Three factors principally determine one’s eligibility for Medi-Cal:



Family Size – Used to determine household income as a percent of FPL.
Household Income – Individuals up to 138% FPL are Medi-Cal eligible.
Pregnant women are covered up to 200% FPL and children up to 250% FPL.
Immigration status – Individuals must be legal residents (U.S. citizen or legal
permanent resident) to be Medi-Cal eligible. Undocumented immigrants are
ineligible for Medi-Cal.
On January 1, 2014, several changes were made to the Medi-Cal eligibility requirements,
including:





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Income threshold rose to 138% FPL.
Eligibility expanded to cover parents and childless adults (who were formerly
excluded from Medi-Cal).
Eligibility criteria was simplified for families and individuals (excluding the aged
(65 or greater) and disabled). Eligibility is now solely determined by modified
adjusted gross income. An asset test is no longer used unless an individual is
seeking long-term care services.
Former foster youth who were enrolled in Medi‐Cal at age 18 are now eligible for
Medi‐Cal up to age 26.
Healthy Way LA matched, as of January 1st 2014, is now Medi-Cal. All those
who were formerly in the Health Way LA matched were automatically transferred
to Medi-Cal.
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*Note: Immigration status may be a deciding factor in Medi-Cal eligibility. When
working with an individual ineligible for Medi-Cal, please refer to the following
sections listed below for medical care and healthcare coverage resources:



Medical care resources for Undocumented Immigrants and those not eligible for
Medi-Cal or Covered California
Healthcare coverage resources for undocumented immigrants and those ineligible
for Medi-Cal and Covered California
Healthcare coverage resources for undocumented pregnant women or pregnant
women not eligible for Medi-Cal or Covered California
For seniors, individuals with disabilities, those needing long-term care, those eligible for
both Medicare and Medi-Cal, and individuals in the Medically Needy program the
enrollment process and rules will remain the same. Individuals without legal permanent
residence may be eligible for a limited scope of benefits for emergency care and
pregnancies (a list of resources may be found in the appendix section).
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Coverage Opportunities for Immigrants
Permanent Residents Who Have Lived in the United States for Five Years Or More
Permanent residents who have lived in the United States for five years or more are
eligible for both Covered California and Medi-Cal.
Permanent Residents Who Have Lived in the United States for Less Than Five Years
Generally, permanent residents who have lived in the United States for less than five
years are eligible for Covered California but are ineligible for Medi-Cal. If they purchase
coverage through Covered California, they are eligible for premium assistance and costsharing reductions. There are certain exceptions to this rule.
Parents with children who meet Medi-Cal income eligibility criteria may still receive
Med-Cal through a provision that requires California to fund their insurance without
Federal funding (normally Medi-Cal is funded by both the Federal and State
Governments).
Adults with no children who meet Medi-Cal income eligibility criteria may be
temporarily placed into State-funded Medi-Cal (similar to parents with children) until the
spring (April or May) of 2014. At that point, they will receive coverage through Covered
California that is 100% subsidized by California (i.e., the State will pay their premiums).
Undocumented immigrants
Undocumented immigrants are ineligible for both Covered California and Medi-Cal.
They may purchase coverage outside of Covered California but are ineligible for
premium assistance and cost sharing reductions.
Medical care resources for Undocumented Immigrants and those not eligible for MediCal or Covered California
Most ineligible individuals will be able to receive care at County Clinics through the
Ability To Pay (ATP) program or at Community Partner Clinics through the Healthy
Way LA unmatched program. There are also numerous other programs available to
specific subsets of groups (i.e. children, pregnant women, men and women with certain
types of cancer and for the prevention of these cancers, etc…) that are of no cost if
specific income guidelines are met. Individuals are typically screened for all of these
programs at County, Community Health, or Community Partner Clinics.
Volunteers should direct undocumented immigrants to these resources. The
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appendix of this document also includes healthcare coverage resources for undocumented
individuals and undocumented pregnant women.
To locate a Community Partner Clinic, a Community Health Center or a County
Clinic where an individual could receive free care visit, please visit the links below:
1. http://www.ccalac.org/i4a/pages/index.cfm?pageid=3521
2. http://www.californiahealthplus.com/index.cfm/find-my-healthcenter/?search=true&lang=English&version=full
3. http://dhs.lacounty.gov/wps/portal/dhs
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Buying Individual or Family Coverage Outside of Covered California
California residents have the option of buying healthcare coverage outside of Covered
California.
Similarities between shopping on Covered California and shopping outside Covered
California


All plans that are available on covered California are also available outside of
Covered California, with the exception of Minimum Coverage plans.
Protections for individuals and families implemented by the ACA (see Health
Insurance Protections for Individuals and Families Implemented by the ACA
listed above) also apply to plans sold outside of Covered California.
Differences between shopping on Covered California and shopping outside Covered
California





22
Premium assistance (tax credits) is only eligible for plans sold on Covered
California.
Premiums for plans offered in Covered California may be lower than plans sold
outside of Covered California.
Networks may differ for similar plans sold inside and outside of Covered
California (providers that did not contract with plans in Covered California may
have contracted with similar plans outside of Covered California).
Cost sharing, deductibles, and drug coverage may differ between similar plans
sold inside and outside of Covered California.
Undocumented immigrants may purchase coverage outside of Covered California
but are ineligible for purchasing coverage in Covered California.
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Individual Mandate
Individual Mandate Overview
Starting in 2014, individuals will be subjected to a mandate requiring them to purchase
insurance or face financial penalties.
Exceptions from Individual Mandate
Individuals are exempted from the individual mandate penalty if any of the following
apply:







Part of a religion opposed to acceptance of benefits from a health insurance policy
Undocumented immigrant
Incarcerated
Member of an Indian tribe
Family income is below the threshold for filing a tax return ($10K for an
individual, $20K for a family in 2013)
Pay more than 8% of income for health insurance (after taking into account
employer contribution or tax credits)
Received coverage for the whole year through any of these sources:
o Medicare
o Medicaid or the Children’s Health Insurance Program (CHIP)
o TRICARE (for service members, retirees, and their families)
o The veteran’ health program
o An employer sponsored plan
o Individual insurance at bronze level or higher
o A grandfathered health plan in existence before the health reform law was
enacted
Individual Mandate Penalties
2014: $95 per adult and $47.50 per child (up to $285 for a family) or 1.0% of family
income, whichever is greater.
2015: $325 per adult and $162.50 per child (up to $975 for a family) or 2% of family
income, whichever is greater.
2016+: $695 per adult and $347.50 per child (up to $2,085 for a family) or 2.5% of
family income, whichever is greater.
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Appendix
Glossary of Key Terms
Health Insurance Product Terminology
Term
Benefits
Benefits Design
Coinsurance
Copay
Deductible
Essential Health
Benefits
In-Network
Services
Individual
Mandate
Medical
Providers
Modified
Adjusted Gross
Income
Network
Out-of-Network
Services
Out-of-Pocket
Maximum
Definition
Medical services that are approved and covered by the insurance
company
A defined list of plan benefits, including the amount a member is
expected to pay for each medical service type
A fixed rate an individual must pay out-of-pocket for medical
services based on the price of services rendered (e.g., 20% coinsurance means an individual must pay $20 for a $100 office visit)
A fixed amount an individual must pay out-of-pocket for every
medical service rendered (e.g., $10 per office visit)
The amount an individual must pay out of pocket before any
medical expenses are covered by the insurance plan
A set of 10 categories of benefits that all plans sold in Covered
California must provide for baseline coverage
Medical services covered by the health plan that are provided by
medical providers who are contracted into the plan’s network
A Government mandate requiring individuals to purchase insurance
or face financial penalties
A term for physicians, hospitals, and other health professionals
A determinant of income that includes annual wages, salaries, and
tips with the addition of certain benefits (e.g., alimony received,
unemployment compensation) and the subtraction of deductions
(e.g., alimony paid, student loans)
Used to calculate premium assistance, cost sharing reductions, and
Medi-Cal eligibility; Line 37 on a 1040 tax form can be used as a
proxy for income; more info on determinants for modified adjusted
gross income can be found here
List of medical providers whose services are covered by the health
plan
Medical services not covered by the health plan that are provided by
medical providers who are not contracted into the plan’s network
The maximum amount an individual or family can spend on innetwork healthcare coverage; once out-of-pocket medical expenses
reach the max, the patient will no longer have to pay for any
coverage received from in-network providers
For ALL Covered California plans the out-of-pocket-max is $6,350
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Health Plan Terminology
Term
Actuarial Value
Definition
The proportion of healthcare expenses a health insurance plan will
cover for a typical group of enrollees (e.g., a 70% actuarial value
plan indicates the insurer will pay 70% of medical expenses while
the member will pay 30% of expenses out-of-pocket)
A closed-network plan (out-of-network services are not covered by
EPO (Exclusive
insurer) that allows the subscriber to receive any in-network service
Provider
without the need of a pre-authorization from a primary care provider
Organization)
A health insurance plan that covers a subscriber + dependents
Family Plan
Health plans established before the passage of the ACA that are
Grandfathered
exempt from many changes required under the ACA.
Health Plan
Private insurance coverage (individual or family plans) that is
Group coverage
offered and/or subsidized by an employer
A closed-network plan (out-of-network services are not covered by
HMO (Health
insurer) that requires the subscriber to obtain pre-authorization from
maintenance
a primary care provider before receiving specialty
organization)
Private health insurance (individual or family plans) that is not
Individual
Coverage/Market offered by an employer
A health insurance plan that covers a single individual
Individual Plan
California's Medicaid program; Government-sponsored insurance
Medi-Cal
that provides health care services for low-income individuals,
(Medicaid)
including families with children, seniors, persons with disabilities,
foster care, pregnant women, and low-income people with specific
diseases such as tuberculosis, breast cancer or HIV/AIDS
Government-sponsored insurance offered (predominantly) to those
Medicare
over age 65 as well as to individuals with certain disabilities
A category of plans offered in Covered California defined by the
Metal Tier
amount a plan subscriber will be responsible for paying out of
pocket as determined by actuarial value; benefits covered by plans
are consistent across each metal tier but premiums, deductibles, outof-pocket expenses, and out-of-pocket maximums may vary
Minimum
(Catastrophic)
Plan
PPO (Preferred
Provider
Organization)
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Metal tiers include Bronze, Silver, Gold, and Platinum Plans
A low-premium, high deductible plan only available to individuals
who are under age 30 or individuals who received a waiver from
Covered California indicating they who have a certified financial
hardship
A plan that allows the subscriber to receive services without the
need of pre-authorization from a primary care provider; the plan
allows the subscriber to receive out-of-network services but at a
higher cost share (co-pay or co-insurance) than in-network-services
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Sample Script of Talking Points for Outreach Volunteers
Below contains an outline of key talking points for volunteers who will be speaking
with community members about Covered California:
Hi,
My name is ____________________ and I would like to talk to you about Covered
California and your options to sign up for health insurance.
Covered California is the new marketplace where families and individuals can obtain
health insurance in California. Through Covered California, individuals and small
businesses can compare different health insurance companies and learn whether they
qualify for federal subsidies and tax credits to help pay for their insurance. You may also
discover that you are eligible for low-cost or no-cost health coverage through Medi-Cal.
Individuals and families who make between 138 percent and 400 percent of the federal
poverty level may be eligible for premium assistance through Covered California. This
means that an individual making up to $45,960 and a family of four earning up to
$94,200 may be eligible for premium assistance. Individuals who make under 138
percent of the federal poverty level are eligible for Medi-Cal. This means that an
individual making up to $15,856 and a family of four earning up to $34,499 may be
eligible for Medi-Cal.
There are four different tiers to choose from when you buy health insurance. Those tiers
are Bronze, Silver, Gold, and Platinum. Each of the tiers are required to provide the same
10 essential health benefits. They are:
___________________________________________.
The difference between each of the tiers depends on how much you would like to pay
monthly for your plan, your premium. Based on how much you pay as your premium,
you will have different deductible amounts and shared cost when you utilize healthcare
services such as the emergency room and lab tests.
If you are under the age of 30 or can provide a certification that you are without
affordable coverage or are experiencing hardship, you may also qualify for minimum
coverage insurance. The minimum coverage plan has a higher deductible, but is also
minimally expensive.
Premium assistance is calculated based on where you fall relative to the federal poverty
level. Eligibility for cost-sharing subsidies that reduce the amount you pay out of pocket
when you get care is based on income level and family size.
Starting in 2014, there will no longer be discrimination for individuals looking to
purchase insurance with pre-existing conditions. Beginning 2014, insurance companies
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will be required to sell policies to everyone regardless of current or past health issues, and
they will be prohibited from using your health status to determine how much your health
insurance will cost. You can purchase health insurance regardless of any current or past
health conditions, and insurance companies cannot charge you a different premium.
There will be penalties for people who do not buy insurance. In 2014, an individual who
does not maintain minimum health coverage will face a penalty of $95 or 1 percent of
income, whichever is greater. In 2014, a family will be charged a penalty of $95 per
uncovered adult and $47.50 per uncovered child (up to $285 for a family) or 1 percent of
the family's income, whichever is greater.
For 2015, the penalty increases to $325 per adult and $162.50 per child (up to $975 for a
family) or 2 percent of family income, whichever is greater. For 2016, the penalty is $695
per adult and $374.50 per child (up to $2,085 for a family) or 2.5 percent of family
income, whichever is greater.
However, some individuals may be exempt from paying a penalty. They are:
-
People who would have to pay more than 8 percent of their income for health
insurance
People with incomes below the threshold required for filing taxes (in 2013,
$9,750 for a single person and $27,100 for a married couple with two children)
People who qualify for religious exemptions
Undocumented immigrants
Incarcerated individuals
Members of federally recognized American Indian tribes and Alaska Natives
By logging onto the Covered California website, you can see what plans are available and
how much it will cost you to buy a particular plan. The website will calculate the cost of
the plans with the premium assistance (tax credits) included for you. This is a wonderful
opportunity to get insured and protect you and your family against the potentially large
financial expenses associated with health-related accidents or incidents. You have until
March 31, 2014 to sign up for coverage through 2014.
Thank you for your time! I look forward to working with you.
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Healthcare coverage resources for undocumented immigrants and those ineligible for
Medi-Cal and Covered California
1. Restricted or “Emergency” Medi-Cal
a. Restricted Medi-Cal will cover emergency situations, health care for
pregnant women, kidney dialysis, nursing home care and treatment for
breast and cervical cancer.
2. Department of Health Services and Community Clinics
a. Access to healthcare for undocumented immigrants is offered at these
clinics. Visit http://www.californiahealthplus.com/ to find a clinic near
you.
3. The Healthy Kids program – call 1-888-452-2273 to apply
a. Eligibility
i. For children 0-5 years; children older than 5 are eligible for
Healthy Way LA unmatched.
ii. At or below 400% FPL
iii. Children must not be covered by Medi-Cal or any other publicly
sponsored health program to be eligible.
4. Family Planning, Access, Care and Treatment (PACT) - to apply call
1-800-942-1054
a. Family PACT is a family planning program that helps eligible
Californians avoid getting pregnant or causing a pregnancy when they are
not ready. Services include STD testing, prevention and treatment,
Contraceptive and emergency contraceptive use, HIV testing and
counseling, limited cervical cancer screening.
b. Eligibility – more info visit http://www.familypact.org/Clients/welcometo-family-pact
i. You must be a California resident (living in Ca for > 6months);
and
ii. Your income for your family size must be at or below 200% of the
federal poverty guidelines; and
iii. You must have no other source of health care coverage that can be
used for family planning services; and
iv. You want to prevent an unplanned pregnancy.
5. Every Woman Counts (EWC) – to apply call 1-800-511-2300
a. Provides cancer screening and treatment services for breast/cervical
cancer. Services include clinical breast exams, mammograms, pelvic
exams, pap smears, and more. This program is free to eligible
Californians.
b. Eligibility Requirements
i. Are at least 40 years of age (for breast cancer services) or at least
21 years of age (for cervical cancer screening services)
ii. Income less than 200 FPL
iii. Have no or limited insurance
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iv. Are not getting these services through Medi-Cal or another
government-sponsored program.
v. Live in California
6. Prostate Cancer Treatment Program (PCTP) works with IMPACT to apply
call 1-800-409-8252
a. Provides prostate cancer treatment for up to 12 months to eligible
participants
b. Eligibility
i. are 18 years old or older
ii. have a diagnosis of prostate cancer
iii. Income less than 200 FPL
iv. have no medical insurance, and do not qualify for Medicare or
Medi-Cal
v. live in California
7. Breast and Cervical Cancer Treatment Program (BCCTP) to apply visit
http://www.dhcs.ca.gov/services/Cancer/ewc/Pages/default.aspx
a. Provides treatment for Breast and Cervical Cancer (automatic follow-up
program for those in EWC or PCTP programs). Free services
b. Eligibility
i. Have been screened and found in need of treatment for breast (men
and women) and/or cervical cancer (women only), follow-up care
for cancer or precancerous cervical lesions/conditions by an EWC
or Family PACT provider
ii. Are a California resident
iii. Are a male of any age or any immigration status or are a female
under 65 years of age with non-citizen or unsatisfactory
immigration status
iv. Are a female 65 years of age or older; and/or have health
insurance, including share-of-cost Medi-Cal and/or Medicare
8. Child Health and Disability Prevention Program (CHDP) to apply call – 1800-993-2437
a. CHDP provides for the early detection and prevention of disease and
disabilities. The program pays for regular infant and child health
assessments or check-ups, immunizations, nutrition screening, lead
screening, vision and hearing tests, lab tests, dental assessments, outreach
and educational services, and referrals for further diagnosis and treatment,
if necessary, but not hospital care.
b. Eligibility
i. Age <20
ii. Income below 200% FPL
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Healthcare coverage resources for undocumented pregnant women or pregnant women
not eligible for Medi-Cal or Covered California
1. Pregnancy-only Medi-Cal – Apply at:
https://dpss.lacounty.gov/dpss/health/pregnant/medical.cfm?persona=pregnant
a. This is a restricted Medi-Cal plan that offers prenatal care, labor and
delivery services, family planning services, and postpartum care that lasts
for at least 60 days following the end of pregnancy. Free to eligible
women.
b. Eligibility
i. Pregnant women with incomes below 200% FPL and who do not
qualify for full scope Medi-Cal.
2. Access for Infants and Mothers (AIM) – Apply at
http://www.aim.ca.gov/Home/default.aspx
a. This program along with Medi-Cal provides care for pregnant women
through 60 days after delivery. Program cost 1.5% of AGI after
deductions
b. Eligible Requirements for AIM
iii. Less than 30 weeks pregnant and
iv. Has lived in California for greater than 6 months, and
v. Uninsured: You cannot have private health insurance or no cost
Medi-Cal, unless your private health insurance plan has a
maternity-only deductible or copayment greater than $500 as of
your date of application; and
vi. Within AIM income guidelines- Typically within 200-300 FPL,
but check http://www.aim.ca.gov/Costs/Income_Guidelines.aspx
for specifics.
3. Presumptive Eligibility Medi-Cal – to apply call 1-800-211-8040
c. Provides immediate, temporary coverage for prenatal services (except
delivery, family planning, and optional abortion procedures).
d. Eligibility Requirements for PE Medi-Cal
i. Visit http://www.dhcs.ca.gov/services/medical/eligibility/Pages/PE.aspx
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Important References and Phone Numbers
Important References
Calculator to Estimate Tax Subsidies and Medi-Cal Eligibility in California
http://laborcenter.berkeley.edu/healthpolicy/calculator/index_ca.shtml
Covered California Homepage
https://www.coveredca.com/
Covered California Shop and Compare Tool
https://www.coveredca.com/shopandcompare/
Covered California Health Plans Booklet
https://www.coveredca.com/coverage-basics/PDFs/CC-health-plans-booklet-rev3.pdf
Covered California Provider Directory (includes provider networks by health insurer)
https://www.coveredca.com/hbex/stakeholders/provider-directory/
Federal Poverty Levels (2013)
http://ccf.georgetown.edu/wp-content/uploads/2012/03/2013-Federal-PovertyGuidelines1.pdf
Glossary of Healthcare Terms
https://www.healthcare.gov/glossary/
Modified Adjusted Gross Income Determinants
http://laborcenter.berkeley.edu/healthcare/MAGI_summary13.pdf
Preventative Services Covered by Most Health Plans
https://www.healthcare.gov/what-are-my-preventive-care-benefits/
Important Phone Numbers
Covered CA: 800-300-1506
Medi-Cal: 800-541-5555
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