Health Insurance

Covered California: November 1st through January 31st

Medi-Cal: Year-round

Public Health Emergency (PHE) extends a special enrollment period to all eligible residents for Covered California. It was declared due to the COVID-19 pandemic and Monkeypox outbreak. It is currently set to end January 11, 2023. 60 days of advance notice will be given when the PHE is set to end.

An individual has 60 days from the date of a qualifying life event to enroll in health coverage or change their plan through Covered California.

What counts as a special enrollment opportunity? (Qualifying Life Events)

1. An individual earns less than 150 percent of the federal poverty level
2. Pandemic (e.g., COVID-19) or national public health emergency (PHE)
3. Paid the penalty for not having health insurance
4. Lost or will soon lose health insurance
5. Affected by wildfires or other publicly declared state of emergency
6. Newly qualifies for app-based driver stipend
7. Got married or entered into domestic partnership
8. Had a baby, adopted a child, or began fostering a child
9. Permanently moved to or within California
10. Gained citizenship/lawful presence
11. Returned from active-duty military service
12. Domestic abuse or spousal abandonment
13. Federally recognized American Indian/Alaska Native
14. Released from jail or prison

Premium Tax Credits and Cost-Sharing Reductions

What are Premium Tax Credits?

• Premium Tax Credits lowers the cost of the monthly premium
• You can choose to get the credit each month (Advanced Premium Tax Credits) or when you file taxes.

What are Cost-Sharing reductions?

• Cost-sharing reductions are savings available with certain health plans that helps to reduce the costs of deductibles, coinsurance and copayments.
• Cost-sharing reductions are only available through Silver tier plans

Medi-Cal

• Residency: California resident (You must either live or work in California)
• Immigration Status: Currently, undocumented individuals between 26-49 years of age can only qualify for restricted scope Medi-Cal. Starting January 1st 2024, ALL income-eligible Californians will be eligible for full-scope Medi-Cal, regardless of immigration status.
• Income: 0% – 138% federal poverty level (FPL)

Covered California

• Residency: California resident (You must either live or work in California)
• Immigration status: Immigrants who are not lawfully present do not qualify.
• Income: >138% – 400% FPL qualifies for financial support

Eligibility Chart Here

Documents Required

Proof of Identification

• ID/Driver’s License or
• Passport or
• Certificate of Naturalization or U.S Citizenship or
• Permanent resident card

Proof of California residency

• Evidence the applicant has registered with a public or private employment agency in California
• Current California driver’s license or identification card
• Current and valid California vehicle registration form in the applicant’s name
• Evidence the applicant is employed in California
• Evidence that the applicant has enrolled his/her children in a California school
• Evidence that the applicant is receiving public assistance in California
• Voter registration form of receipt, voter notification card, or an abstract of Voter of registration.
• Current California utility bill in the applicant’s name
• Current California rent or mortgage receipt in the applicant’s name
• Other documents to support Proof of California Residency

Proof of Income

• Paystub
• Tax Return Form
• Self-attestation form

Obtaining health insurance through Medi-Cal or Covered California is safe.
Obtaining and using health insurance through Medi-Cal or Covered California does not count as public charge (except for receiving long-term institutional care, such as a nursing home, at government expense under Medi-Cal). It is safe, and encouraged, for all individuals to enroll in health insurance and take advantage of their plan.

What can enrollers ask?

• Enrollers cannot ask personal questions that are not required as part of the enrollment process
• Enrollers cannot ask about the citizenship or immigration status of any family or household members that are not applying for coverage

There are typically three types of insurance plans, they are: HMO, PPO, and EPO.

• An HMO is a plan in which the insured has a designated primary care physician (PCP) and, should they wish to visit a specialist in network, must get a referral from their PCP. Under an HMO, out of network costs are not covered except in the case of emergency or urgent care.
• An EPO does not cover out of network services except in the case of emergency or urgent care. However, insured individuals in an EPO can visit in-network specialists without a referral from a PCP. Individuals in an EPO are not required to have a PCP.
• Individuals in a PPO are not required to have a PCP, and they are able to visit in-network or out-of-network specialists without a referral. However, costs are typically higher when an individual goes out of the network.

Metal Tiers in Covered California

• There are 4 metal tiers available: Bronze, Silver, Gold, and Platinum.
• Typically, as the metal tier increases in value, the monthly premium increases while the copays/deductibles decrease (more medical expenses are covered).

Annual Renewal
For Medi-Cal, coverage must be renewed every year for the insured individual to keep their benefits. For most individuals this is done automatically, but the county may send a renewal form requesting additional information.

For Covered California, renewal begins in October and members will have the opportunity to update any information and change their selected plan. If the member does not actively renew or change plans 30 days after the renewal notice date, they will be automatically re-enrolled into the same plan, if available.

What happens after I submit my application?
Covered California

1. Applicants will receive a notification letter within 45 days about which programs that a household will qualify for.
2. Once a plan is selected and the initial payment is made, coverage will begin the first day of the following month.

Medi-Cal

1. Applicants will receive a determination on their case, along with their benefits identification card, if approved, within 45 days.
2. If approved, individuals will receive mailed information about health plan options choices available in their county.
3. When an individual is approved, they can use Fee-for-Service Medi-Cal until they select a health plan.

What happens after I have enrolled in the health plan? How do I set up my first doctor’s appointment?
You will receive an enrollment package and membership ID card from the health insurance plan that you have selected.

If you do not already have a Primary Care Provider under the health plan (and are required to have one, I.e. HMO), call the health insurance plan or visit their website to identify nearby doctors and hospitals that are included in your health plan.

• You should be able to filter by options such as location and language
• Set up your new patient intake appointment with a PCP

IMPORTANT: All health plans are required to provide qualified interpreters, so do not be afraid to ask for one if needed.

All plans must include these essential health benefits:

• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity & newborn care
• Mental health & substance use disorder services
• Prescription drugs
• Rehabilitative & habilitative services & devices
• Laboratory services
• Preventive & wellness services & chronic disease management
• Services for children, including dental & vision care

Are mental health services included?

• Mental and behavioral health services are essential health benefits covered both under Covered California and Medi-Cal.
• These services include counseling, psychotherapy, inpatient services, and substance use disorder treatment

Are preventative health services included?

• Most plans include free preventive services (no copay or coinsurance required, even before the yearly deductible is met) when visiting a doctor in-network.
• Call your health plan to learn which preventative services are included
• Included services in Covered California

Here are some key terms to know about.

Summary of benefits and coverage (SBC): Summary of the health plan’s costs, benefits, covered services, and other important information

• How can I get an SBC? You will receive it when shopping for coverage, enrolling in coverage, and upon requesting it from your health plan.

Deductible: The maximum amount that you must pay out of pocket before the insurance will pay

Premium: The fixed amount you pay for your health insurance every month

Co-pay: A fixed amount paid for a covered service

• Usually plans with lower premiums have higher co-pays while plans with higher premiums have lower co-pays.

Co-insurance: The percentage of costs that you pay for a covered service after the deductible has been paid

Out of pocket maximum: The maximum costs that one will need to pay for covered services in a plan year. Afterwards the health plan will pay for 100% of the covered services.

• Deductibles, copayments, and coinsurance for in-network services count towards the out-of-pocket maximum