Kevin Knauss: Health, History, Travel, Insurance
Posts on the development and implementation of the California health insurance market place, application, account, enrollment, termination.
All individuals and households who had health insurance during 2015 will receive a Form 1095-x. How you received your health insurance will determine who sends the 1095-x to you. You may receive different 1095s based on whether you had Medicaid, private health insurance purchased through a Marketplace exchange like Covered California, or through employer based health insurance plan. Each of the 1095s will be appended with a different letter ( -A, -B, -C) depending on the issuer of the form.
One of the most baffling health plan descriptions is the 2016 Bronze 60 health plan that states that the member is responsible for 100% coinsurance after the deductible. Most people who read this immediately shake their head and think, “I have to pay for all of my health care services EVEN AFTER I meet the deductible?” There really is no reason to buy health insurance if it never helps with the costs. The second part of the equation, not always referenced, is the calendar year maximum out-of-pocket amount of the Bronze plan which does limit a health plan members health care expenses.
The Department of Health Care Services (DHCS) has developed a Medi-Cal household size flow chart. The DHCS Guide for Calculating MAGI Medi-Cal Individual Household Size was originally developed to help county eligibility workers ascertain the actual household size under the new Affordable Care Act (ACA) rules. The newly expanded Medi-Cal eligibility under the ACA revolves around on IRS definitions for tax dependents and non-filer rules. Because families can be so diverse and the rules regarding what constitutes a tax family so complicated, the flow chart for determining household size was created.
Even those people who hate Obamacare come running to it when they need help. A person who contacted me to clarify that he could enroll in an Obamacare plan because his Christian health care sharing ministry wouldn’t cover pre-existing conditions shows how people use these sharing ministries to dodge Obamacare and reveal their hypocrisy when they do need real health insurance.
While Covered California standard benefit design health plans have very specific limitations on member responsibility for in-network health care services, the coverage for out-of-network services can vary greatly between PPO health plans. The insurance carriers that offer PPO health plans through Covered California (Anthem Blue Cross, Blue Shield of California, and UnitedHealthcare) with out-of-network coverage seem to have made up their own rules for this PPO benefit. Because the Covered California individual and family health plans have such narrow networks, many families are finding that they must go out-of-network to receive certain health care services.
Anthem Blue Cross, following internal policies to protect agents, prevents their members from selecting their preferred health insurance agent through Covered California. The Blue Cross policy of not recognizing an agent delegation made by a household in their Covered California account prevents the selected agent from properly representing the family members and being compensated for his or her time. The Blue Cross agent of record policy occurs when the Covered California member originally enrolled with another agent or without an agent and the member is considered a house account.
Covered California has sent Certified Insurance Agents information and links on sensitivity and sales training for the Lesbian, Gay, Bi-Sexual and Transgender community. The sensitivity training presentation and social media icons were developed by Out2Enroll a national organization encouraging the enrollment of the LGBT community into Marketplace health insurance. While the overall information is good, there is underlying sales element that reduces the community down to dollar signs instead of human beings.
On a weekly basis I get calls from people telling me they can’t find doctors who will accept Covered California health plans. The prospective patient is told that the doctor will only accept off-exchange health plans and not Covered California health plans. This is after the health insurance company shows the physician as in-network. Are doctors really discriminating against Covered California consumers or do we just have a failure to communicate?
I screwed up big time on behalf of a man with a serious illness. The end result is that he will be without health insurance for the month of December. Even though there are other people who failed in this situation, I have to take the ultimate responsibility that he might have to shoulder thousands of dollars in health care expenses that would have been covered by health insurance. I broke the business rule of never following your heart, and always trust your gut.
The formula for determining how much premium assistance, also known as the Affordable Care Act premium tax credits (PTC), to lower your monthly health bill is complicated. At its core the formula uses the inputs of your age, MAGI, a special contribution percentage and the annual cost of the Second Lowest Cost Silver Plan. Plugged into the formula, these inputs determine if any Advance Premium Tax Credits (APTC) will be awarded to reduce your health insurance premium. Some people are surprised to learn they don’t qualify for any APTC even though their MAGI is below 400% of the federal poverty level.
