A year and half after the launch of Covered California the CalHEERS enrollment website is still a work in progress. Covered California released more instructional briefs on changes they’ve made to the California Health Enrollment Eligibility Retention System (CalHEERS) website. Just when Certified Insurance Agents thought they had figured out how to navigate CalHEERS, new improvements or features are implemented creating more questions. The Report A Change, Special Enrollment, and Health Plan selection procedures have been modified. In addition, Covered California gives a peek of the behind the scenes MAGI budget screens that consumers and agents can’t access.
Instructional job aids for Covered California enrollment
Any changes to the application such as income or household member composition need to be initiated with the Report a Change function from the consumer’s home page. There are a few new twists to this procedure added by Covered California. Each job aid can be downloaded after the section discussing it.
Remove or change status of household member
New options reflect more accurately the various household situations that are encountered in real life such as a young adult child, not claimed as a dependent by the tax filer, but who can be on the family policy until age 26. New options include-
- Removing the person from the policy only
- Removing the person from the tax filing household only
- Removing the person from the policy and tax filing household
- Removing the person not on the policy or tax filing household
Under the reason for the change a couple new situations have been add
- No longer a tax dependent
- Removed for fraud
Other Report A Change functions addressed in the job aid include
- Adding a household member
- Reporting a change of address for a household member
- Reporting a change to household income
- Changing the Application Type
Switching to tax credit assistance application type
A consumer’s application can now be changed from an unsubsidized case, individuals or families who initially declined assistance or the tax credits to lower their monthly health insurance premium, to a case where financial assistance from the Advanced Premium Tax Credits (APTC) is considered. This was difficult before this new functionality as some families had to withdraw and resubmit a new application. Many individuals who change jobs or add family members are eligible for the APTC and changing the application type makes this far easier. The Application Type drop down menu will only appear for cases that previously had not requested financial assistance. Changing the Application Type will not trigger the ability to change their health plan unless they have a qualifying event such as birth, adoption, marriage, divorce, etc.
Perhaps one of the trickier elements of the CalHEERS system is the Special Enrollment section. This part of the application is triggered even if you don’t have a qualifying event for a special enrollment outside of open enrollment but are merely reporting a change to household income. The Special Enrollment section has been expanded to include a variety of different reasons or qualifying events. Special Enrollments are very date sensitive with regards to when the qualifying event did or will take place.
Not all qualifying events will be approved by Covered California for a special enrollment period to gain health insurance. Without documented proof of the qualifying event Covered California may deny the special enrollment into a selected health plan. Consumers can apply for a special enrollment within sixty days after of the qualifying event had occurred or sixty days before the event is to occur such as the impending loss of coverage.
Covered California has added new drop down menus with a list of approved qualifying events for a special enrollment. For a change of income select “Other qualifying life event”. See more regarding special enrollments for reporting a change of income at Special Enrollment for changing income. What the job aid doesn’t explain is the different coverage date categories. These can be crucial to ensuring there isn’t a lapse of coverage.
|SEP Qualifying Event||Coverage Date Category|
|Lost of will soon lose my health insurance||MEC|
|Permanently moved to/within California||Regular|
|Had a baby or adopted a child||Life Event|
|Got married or entered into a domestic partnership||Regular|
|Returned from active military service||Regular|
|Informed of Tax Penalty Risk||Regular|
|Gained citizenship/lawful presence||Regular|
|Federally Recognized American Indian/Alaska Native||Regular|
|Other qualifying event – Income Change||Regular|
|None of the above||MEC|
Health plan selection update
Covered California also released an updated overview of the Choose a Health Plan section. Nothing much has changed to the selection process. Covered California could have clarified after Reporting A Change the application is submitted and CalHEERS always re-determines eligibility for APTC for everyone in the household. Consumers and agents must go through the process of selecting a new health plan, even if the same plan is kept. For a change of income the system will ask if the family wants to keep their current plan.
Hidden income Budget Worksheets
The final job aid released reviews the Budget Worksheet page that is only visible to Covered California service center representatives and county eligibility workers. This new job aid states,
Every time eligibility is determined (for example, an application is submitted, renewed, or a reported change is processed) the CalHEERS Business Rules Engine (BRE) generates a corresponding Budget Worksheet that can be viewed by an Administrator role (Admin), which includes:
- MAGI Medi-Cal Individual Monthly Income Budget -displays a monthly Individual budget for each household member
- Tax Credit & Cost Sharing Reduction Income Budget -displays the APTC (Advanced Premium Tax Credit) annual budget for the reported Household
Most of these pages hidden from the consumer’s view are a cross section of the household demographics and information from the income section. This helps the administrators review important information that might be impacting a household’s eligibility without having to switch to different sections of the application.
The Medi-Cal Soft Pause
We do learn that each individual on the application can be subject to what is a call a Soft Pause.
The Budget Worksheet displays a Soft Pause indicator for each individual. When a MAGI Medi-Cal Individual reports a change in circumstance which may affect their program eligibility, the consumer’s coverage is “paused” until the county evaluates whether the Individual is eligible for a Consumer Protection Program (CPP) or possibly Medically Needy (Non-MAGI Medi-Cal). This is referred to as a “Soft Pause.” The purpose of a Soft Pause is to maintain continued MAGI Medi-Cal eligibility while individuals listed below are considered for Consumer Protection Programs.
The administrators who can view this Budget Worksheet can also see the CalHEERS calculation of the income with respect to the federal poverty levels, cost sharing reduction levels (Enhanced Silver Plans), and the multiplier used for household members that are not lawfully present.
Not Lawfully Present Multiplier – If a number less than 1 displays, this indicates there are individuals in the tax filing household that are not lawfully present.
The number is calculated by including only the lawfully present household members in the household size. For example: A husband and wife claim two (2) children as tax dependents, one (1) child is not lawfully present (No citizenship or valid immigration status); therefore, the not lawfully present multiplier would be calculated as follows:
$19,790 (100% FPL for subsidy household for three (3) for benefit year 2015) and divide that by $23,850 (100% FPL for subsidy household for four (4) for benefit year 2015) which equals .08297 and <1
While consumers and agents can’t see this Budget Worksheet information, this job aid gives a little glimpse in the inner workings of the CalHEERS program. My hope is that it will help administrators more accurately pinpoint problems within a consumer’s application to correct the bad data so families are either properly allowed to enroll in a private health plan or transition smoothly to Medi-Cal.