Covered California to allow family members to have different health plans

Covered California has updated their online application and enrollment program to allow families receiving premium assistance to select different metal tier levels and health plans for each household member. Previous to this update, only households who enrolled without qualifying for premium assistance could split the family member up between different plans. Beginning August 1, 2016, families receiving Advance Premium Tax Credits to reduce their monthly health insurance bills will have more consumer choice.

Different health plan for each family member

Since the inception of Covered California, any household receiving premium assistance had to enroll all family members in the same health plan with the same metal tier benefits. This meant that if one family member needed a higher benefit plan to address a chronic illness with lower cost sharing copayments, all the family members had to have this more expensive plan. This necessarily raised the monthly health insurance premiums for the entire family because some family members were excluded from enrolling in a less expensive health plan.

Select separate provider groups

For example, one family member may have specific physicians associated with a particular hospital and physicians group that are managing the individual’s health challenges. These doctors may only be in-network for a relatively expensive PPO plan offered in the area. Now, that family member can enroll in the PPO that includes those doctors while the other family members enroll in lower cost PPO or HMO plan that doesn’t include those providers.

Choose different metal tier levels, save money

Families can also split the household members between metal tier levels with the same or different health plans. Perhaps one family member has an impending surgery and a Platinum plan would be most appropriate for the year. The other family members can be enrolled in a Silver or Bronze plan with a much smaller monthly premium relative to the Platinum plan.

Switching from family to individual plans

The big downsides to the split enrollment are separate bills for each health plan and the potential loss of family deductible and Maximum Out of Pocket amounts. Currently, under family health plans, when two members of the household meet the family plan deductible, then it is met for the rest of the family members. This means the third family member who needs health care services may go straight into coinsurance without having to meet any deductible. This is similar for the annual Maximum Out of Pocket amount for families. However, under PPO plans there is often an in-network and out-of-network deductible and Maximum Out of Pocket column.

The Member Level Benefit of enrolling household members in different plans, as Covered California refers to it, will only really apply to Open Enrollment this November for plans effective 2017. Individuals and families with a qualifying event for a Special Enrollment Period will be able to take advantage of the changes for plans effective September 2016. Also, individuals and families who Report a Change to their Covered California may be able access the new household split benefit if the change allows for a new health plan selection. For instance, if a family moves from one rating region in California to a new rating region, they should be able to split the family members into different plans at that time according to Covered California.

16.7 Member Level Benefit Job Aid

Advanced Premium Tax Credit (APTC) eligible consumers will now have the ability to select different plans for each member of their tax filing household or custom group members into separate APTC eligible plans.

The household tax credits will be automatically disbursed across the selected individual plans or custom grouped plans.

Previously, the online application only allowed unsubsidized applications to select different plans for household members. APTC eligible consumers were only allowed to select one plan per tax filing household and did not disburse tax credits among household members.

This new feature allows consumers to choose a plan that may be best suited to their household member’s individual needs or network preference.

This Job Aid will help guide Certified Enrollers through the process of custom grouping household members and selecting multiple plans for an APTC eligible households.

Health Plan Selection and Regrouping

Plan selection begins after the Individual submits an application for coverage and has reached the Eligibility Results page. Consumer may also see plan selection options when a Report a Change produces a change in eligibility.

• To start, click on the Choose a Health Plan button, either from the Eligibility Results page or from the Consumer’s home page. The Household Enrollment Introduction page displays. All household members are listed with a description of their eligibility for Covered California Plans.
• Users will be navigated to the Household Enrollment Introduction screen

The online application will separate household members into unsubsidized, subsidized or Medi-Cal eligible groupings depending on their eligibility results.

• Households with both American Indian/Alaska Native (AI/AN) members and non-AI/AN members are grouped separately. Household members may choose to select an individual health plan, one plan for all, or a customized grouping.
• Click the Choose Health Plan button next to the household member to begin the plan selection process or the Regroup button to group the household in a different way.
• When clicking the Regroup button a Regroup Confirmation popup displays. Clicking the OK button redirects the user to the Qualified Health Plan – Plan Selection Method page where household members can be regrouped.

Plan Selection for Multiple-Person Households

• APTC Eligible households are given the following plan selection options:
  • One plan for all household members
  • Choose to have a different plan for each member
  • Custom-group specific individuals into a plan
• Depending on which option is selected above, the corresponding pop up window will display:
  • Plan Selection- One Plan for All
• Users may move forward with selecting a plan for the entire household under the same carrier
• Users must click on individual “Choose Health Plan” buttons for each household member and proceed through plan selection separately.

Custom Grouping

• Users must select group members by marking the checkbox next to each individual household member that will be included in the custom group.
• Once the group members are selected, users must click the “Add to New Group” button
• Group members will display together under “Persons” on the plan selection window. Users may click the “Choose Health Plan” button to proceed with plan selection for the group.

Grouping Restrictions

• American Indian and Alaskan Native (AI/AN) populations were previously unable to select AI/AN specific plans if some members of their household were not part of a federally recognized AI/AIN tribe.
  • AI/AN members may be grouped together on an AI/AN specific plan while other members of the household can select individual plans or choose to be grouped together.
  • AI/AN household members can also choose to be in the same non-AI/AN plan with non-AI/AN members. However, this will mean giving up certain Cost Sharing Reductions in the AI/AN plan that they would otherwise be eligible for.
• APTC eligible and unsubsidized family members may not be grouped onto the same plan.
  • Tax credits are disbursed across APTC eligible members only. Unsubsidized members cannot be included in the same group as their plan premiums do not include tax credit discounts.
• Medi-Cal eligible household members may not be included in any Covered California health plan eligible group.

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The Member Level Benefit update was part of a large program release to the CalHEERS system, 16.7. Other Covered California online application and enrollment changes are noted in the file below.

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