Covered California Lead Program FAQ

Transcription

1 Covered California Lead Program FAQ Agent Delegation: This link provides detailed instructions for delegation. Covered California Dedicated Phone Line for Agents: LISI Dedicated for Agent Questions: Date Added Questions and Answers 12/13/2013 Q: Are there step-by-step instructions anywhere on how to fill out an individual application on the CalHEERS system from a paper application? Yes. Covered California just released a step-by-step video HERE and an Agent Guide HERE. These are also available on the Covered California Agent Website and the LISI Informer on the Covered California Center page under Agent Guides. 12/13/2013 Q: If the calculator suggests Silver with subsidy, can the client select any subsidy plan for each family member? The Silver Tier is the only metal tier that can have the cost share reductions (CSR) and the additional premium tax credits (APTC). The application system will only reflect the health plans available in the consumer's region and the Consumer can select any of the health plans showing. 12/13/2013 Q: If the calculator suggests Silver without subsidy can the client select a higher plan (Gold or Platinum)? Yes, they can select any of the 4 metal tiers, BUT only the Silver plan can have the cost share reductions (CSR) and the additional premium tax credits (APTC). 12/13/2013 Q: When plans are suggested, does that mean it is for everyone in the family or can they choose different plans for each family member? Yes for everyone in the family. 12/13/2013 Q: Do we have the client enter their income from Line 37 on their 1040 or her W2 to determined if they are eligible for a subsidy? We have been telling consumers to use line 37 on the 1040 form, which should be their "Adjusted Gross Income". If you look at page 26 of the application, it does list the valid deductions, which mirrors the deductions from the 1040 form.

2 12/10/2013 Q: If a dependent is expected to earn income sometime during the year, for example a summer job, are they expected to include it? No, they can be listed as a dependent even if they file their own taxes as long as the dependent is under 26 yrs of age. 12/10/2013 Q: What should we do with questions that are very income specific and want to verify if they qualify for subsidies? The agent or broker should enter the info into the online application. The system will let them know if they qualify for assistance. The CoveredCA website has income qualifying information. 12/10/2013 Q: How can a broker submit proof of income or proof of residency other than doing it online? Via mailing the information to the Covered California secure PO Box address: Covered California PO Box West Sacramento, CA or by Fax: They need to reference their application and case number on the coversheet when they fax/mail the proof. 12/10/2013 Q: If employer-provided insurance does not include dependent or spouse coverage (not offered), can a spouse and dependent(s)qualify for coverage in the Individual Exchange? Can they qualify for subsidies or Medi-Cal? Under the new insurance rules that take effect in 2014, employees and their family members who do not have coverage through an employer will be able to buy insurance through Covered California s individual exchange. Depending on income level, family members might also qualify for subsidized coverage or no-cost coverage through Medi- Cal. 12/10/2013 Q: If the employer offers dependent or spouse coverage (with or without a % of premium paid) but the employee elects not to enroll them, can the spouse and dependent(s) qualify for coverage in the Individual Exchange? Can they qualify for subsidies or Med-Cal? Spouses and child dependents will be eligible for coverage in Covered California s individual exchange regardless of employer coverage offers. However, when dependent coverage is offered in an employer-sponsored plan (regardless of employer contribution to the dependent coverage) subsidy eligibility will be dependent on the affordability of the employee-only share of premium costs and if those costs exceed 9.5% of the employee s W-2 wages. Costs for dependent coverage are not part of the affordability calculation with respect to employer-sponsored coverage. So if the employer s offer of coverage is affordable according to this measure, neither the employee nor the dependents will be subsidy eligible. 12/05/2013 Q: I have faxed and mailed individual applications into Covered California and they are not yet showing up on my agent portal. What should I do? 1. Check your online portal account for new delegations notices several times each day, because as data entry occurs on the Covered California side, agent delegations are being constantly updated throughout their system. Agents must accept the delegations in order to move the application process forward.

3 Covered California has added (and are adding even more) staff to input the paper and faxed apps to address the backlog. Covered California staff are going to be adding individual application information up to the agent delegation section. And they will stop there. IMPORTANT NOTE: The submitting agent will need to complete the application online from that point. This means the agent will have to add the rest of the data from their copy of the paper application. Covered California is making applications with designated agents the top priority for data entry so that agents can complete their applications online as soon as possible. 2. If individual apps still are not showing up in the agent portal in the next 24 hours, agents should go ahead and create a new account for that individual application and enter the entire application online. Covered California will check CalHEERS before entering information check if the agent has already created an account to hopefully reduce duplicate apps. 12/05/2013 Q: Will there be further instructions on how to complete an application? Covered California will conduct a webinar next week (watch for an invite from Covered California) that will provide even better details and a refresher on the step by step instructions on how to complete the online application. This will also include instructions on how to recreate your agent pin, if you have forgotten your pin. 11/23/2013 Q: What if the consumer selected No Financial Assistance? The applicant may have selected the No Financial Assistance field erroneously because they may have thought that it was referring to Medi-Cal. This has been updated in the Coveredca.com application but these applicants may not be aware of the change.**walk your applicant through the Covered California Shop and Compare tool to provide an estimate of the applicant s eligibility for financial assistance. (Please remember the Shop and Compare tool only provides an estimate of eligibility and is not a replacement for determination. The application at Coveredca.com will determine eligibility.) 11/23/2013 Q: What if the consumer completed an application at Coveredca.com and included a lump sum amount? First, verify that they entered this correctly. Some consumers have mistakenly entered their annual income in the lump sum field which could then make them ineligible for financial assistance. Lump sum payments (including, but not limited to, gifts, prizes, income and property tax refunds) are counted only in the month received for Medi-Cal purposes and will be counted in the household annual income for tax credit purposes. Educational scholarships, awards or fellowships used for education purposes are excluded from consideration as income only for Medi-Cal purposes but will be counted for tax credit purposes; Certain types of income for American Indian/Alaska Native individuals are excluded only for Medi-Cal purposes but will be counted for tax credit purposes. 11/23/2013 Q: Some consumers may be eligible for Medi-Cal based on non-income related criteria.

4 What is that criteria? If the consumer selects one or more of the following they could be potentially eligible for Medi-Cal: Age 65 and older Disabled Pregnant Parent/caretaker relative Children 0-19 years old Undocumented or unlawfully present 11/23/2013 Q: Mixed Program Families: What should you do if you have a mixed family where the parents are eligible for Covered CA and the children are eligible for Medi-Cal Kids? First, select their Covered CA plan Second, contact DHCS to select their Medi-Cal Kids plan to match their Covered CA plan. 11/23/2013 Q: What are the reasons the applicant may be Ineligible for a Covered California Plan? a) Unlawfully Present or Undocumented: Consumers must meet the immigration eligibility requirements. (These individuals will not be even eligible to enroll in an unsubsidized plan. They cannot participate in Covered California at all but may be eligible for limited-scope Medi-Cal. ) To be eligible for a Covered California Health Plan, either with premium assistance or without, an individual must be a U.S. citizen, national or lawfully present. An individual is lawfully present if they are a qualified immigrant or are not a citizen but have permission to live and/or work in the U.S. Individuals who are lawfully present include, but are not limited to: Lawful permanent residents Refugees who are seeking Asylum Individuals paroled into the U.S. for humanitarian or public interest reasons Individual for whom deportation is being withheld Individuals granted conditional entry Individuals with temporary protected status from countries designated by the U.S. Department of Homeland Security as unsafe to accept their return Cuban and Haitain individuals paroled into the U.S. Individuals who have been battered or subjected to extreme cruelty and certain household members b) Married Filing Separately: To meet eligibility requirements for financial assistance, married individuals must file a joint tax return. Also consider, if a spouse is offered

5 coverage through an employer this could preclude them from being eligible as they have been offered affordable and comprehensive coverage. c) Financial Assistance: If they selected No Financial Assistance they will be directed to the unsubsidized application and will not be provided an eligibility determination for financial assistance. d) Dependents: If the applicant can be claimed as a tax dependent on someone else s tax return for the benefit year, the applicant will not be eligible for financial assistance. The tax filer who claims the applicant on his or her tax return must apply for financial assistance for the applicant. e) MEC - Minimum Essential Coverage: Applicants who are eligible for MEC are not eligible for financial assistance unless they fall in the exception described below. MEC includes, but is not limited to, government-sponsored coverage, such as Medicare or Medi-Cal, and employer-sponsored coverage that is both affordable and covers at least 60% of the costs of the benefits provided to the employee. However, there is an exception to this general rule. If an applicant is eligible for any of the following MECs but is NOT enrolled in the program at the same time he or she enrolls in a Covered California plan (i.e., no dual coverage), the applicant will be eligible for financial assistance, if otherwise eligible. The MECs that fall under this exception include: 1. Medicare part A coverage requiring payment of premiums. Coverage offered under Medicare for which the individual must pay a premium for Medicare part A coverage. 2. State high risk pools. Health coverage offered by the State under a qualified high risk pool, such as MRMIP (Major Risk Medical Insurance Program). 3. Student health plans. Self-funded health coverage offered by a college or university to its students. 4. Certain TRICARE programs. Coverage under the following TRICARE programs: (a) (b) (c) (d) The Continued Health Care Benefit Program; Retired Reserve; Young Adult; and Reserve Select. 5. Coverage for Veterans (VA plans). 6. COBRA coverage. NOTE: It is important to understand that if the applicant stays enrolled in one of the above MECs while also enrolled in a subsidized Covered California plan (i.e., having dual coverage), the applicant will have to pay the APTC he or she received while having dual coverage back to IRS when the applicant (or the tax filer claiming the applicant) files his or her tax return for the benefit year.