Covered California Frequently Asked Questions

Open enrollment is the period during which people can purchase health insurance for the upcoming year. Open Enrollment for Covered California begins on October 15, 2018, and continues until January 15, 2019.

If you don’t enroll during open enrollment, you cannot purchase a Covered California health insurance plan unless you qualify for a Special Enrollment Period. This applies only if you have a “qualifying life event” such as loss of a job, getting married or divorced, having a baby, or aging off your parent’s plan. These are just some examples of the more common qualifying life events.

If you qualify for Medi-Cal, you can enroll at any time during the year. Medi-Cal provides free or low cost health coverage to Californians with limited incomes. You can apply for Medi-Cal online on www.coveredca.com.

There are two forms of federal financial assistance that help consumers afford coverage through Covered California:

• • Advance Premium Tax Credit (APTC) – A federal tax credit, taken in advance, which lowers your monthly health insurance premium. You may qualify if your annual income is between 138–400% FPL.
  • Cost-Sharing Reductions (CSRs) – A discount that lowers the amount you have to pay for deductibles, copayments, and coinsurance. Cost-sharing reductions also lower your out-of- pocket maximum — the total amount you have to pay for covered medical services each year. You may qualify if your annual income is between 138–250% FPL. If you qualify, you must enroll in a Silver plan to get the extra savings.

Last year President Trump signed The Tax Cut and Jobs Act of 2017, which included some provisions that affect health coverage under the Affordable Care Act. Beginning January 1, 2019, the penalty for choosing not to purchase health insurance—also known as the individual mandate—has been reduced to $0. This means you will no longer be penalized if you choose not to purchase health coverage in 2019 and thereafter. However, there is still an individual mandate penalty being enforced for the 2018 plan benefit year (for taxes filed in 2019).

Covered California recently announced that premiums will increase by an average of 8.7% in 2019. These rate increases are due, in part, to the Trump Administration and Congress’ decision to eliminate the penalty for individuals who choose not to purchase health insurance—also known as the individual mandate. Covered California said the rate increase for 2019 would have been closer to 5% if the individual mandate penalty had not been repealed as part of the Republican tax bill last year.

Fortunately, many consumers will be able to avoid paying increased premiums by switching to a lower cost plan in the same metal tier. According to Covered California, the average rate change for consumers who switch to the lowest-cost plan in the same metal tier is -0.7%. This means that many consumers can pay the same amount or less if they shop around. In addition, rate increases for consumers who receive federal subsidies will be less because the amount of financial help they receive will also increase.

Despite President Trump’s announcement in 2017 that he would no longer provide federal funding for cost-sharing reductions, consumers who are eligible for cost-sharing reductions will continue to receive them. Plans are required to keep the deductibles, copayments, and coinsurance at the lower amount regardless of whether they are reimbursed by the federal government. The advance premium tax credit is not changed by the elimination of funding for cost-sharing reductions. More information about the impact of this decision is included below.

Covered California planned ahead to protect most consumers from higher rates resulting from the elimination of cost-sharing reduction funding. Instead of using federal funding to pay for cost-sharing reductions, Covered California plans will add additional premium costs ONLY to Silver plans sold on the exchange to make up for the loss of the cost-sharing payments. Covered California structured the additional premium charge in a way that protects most Californians from having to pay higher premiums.

Most consumers who receive the advance premium tax credit will not see a change in the amount of premium they pay because they will receive a higher amount of tax credit to offset the Silver plan premium increases. Consumers can also use these increased tax credits to purchase plans in other metal tiers.

Consumers who do not receive tax credits to help pay their premiums have other plan options that do not include the surcharge. These consumers can avoid paying the surcharge by switching to a different Bronze, Gold, or Platinum plan or purchasing a nearly identical Silver plan outside of Covered California that does not include the surcharge. Covered California has required all health insurers to sell a plan outside of the Covered California marketplace that is nearly identical to the Covered California Silver plans, but without the additional premium cost to assist consumers in getting the most affordable plan possible.

Covered California’s Shop and Compare tool helps consumers compare their coverage options for 2019. Consumers will see the rates for the plans available to them in their area and find out if they qualify for financial assistance to help them pay for their coverage. The Shop and Compare tool is available at www.coveredca.com. Shopping around is really important and can help keep your coverage affordable. If you are planning to switch plans in order to lower premium costs, be sure the new plan includes a provider you trust and a drug formulary that meets your needs.

For the 2019 coverage year, Covered California announced that all 11 of its health insurance companies will be returning to serve consumers. More than 96% of consumers will have at least two health insurance companies to choose from and 82% of consumers will be able to choose from three or more insurance companies.

People living with HIV should check plan formularies to ensure their drugs for HIV and other conditions are covered, accessible, and affordable. There are some plans that should be avoided by people living with HIV because their drug formulary is inadequate. People living with HIV should also check with their doctor to make sure they accept the Covered California plan they are considering.

There are also programs available to people living with HIV that can help make coverage more affordable. The AIDS Drug Assistance Program (ADAP) helps ensure people living with HIV have access to medication. ADAP covers copays, coinsurance, and deductibles for HIV medications as well as other drugs on the ADAP formulary. The ADAP formulary includes more than 100 prescription drugs.

The Office of AIDS Health Insurance Premium Payment Program (OA-HIPP) helps people living with HIV afford their health insurance premiums. OA-HIPP covers monthly health insurance premiums as well as dental and vision insurance premiums (the vision plan must be included in the medical or dental plan). Individuals enrolled in OA-HIPP are also eligible for the medical out-of- pocket cost benefit, which covers outpatient medical out-of-pocket costs that count towards the individual’s annual out-of-pocket maximum including copays, coinsurance, and deductibles.

The Medicare Part D Premium Payment Program (MDPP) covers Medicare Part D and Medigap insurance premiums for people living with HIV who are enrolled in ADAP and a Medicare Part D prescription drug plan. Medigap policies are private insurance plans that cover Medicare copays, coinsurance, and deductibles. Individuals enrolled in MDPP are also eligible for the medical out-of- pocket cost benefit, which covers outpatient medical out-of-pocket costs that count towards the individual’s annual out-of-pocket maximum including copays, coinsurance, and deductibles.

The Employer Based Health Insurance Premium Payment Program (EB-HIPP) covers employer- based health insurance premiums as well as employer-based dental and visions insurance premiums (the vision plan must be included in the medical or dental plan). Individuals enrolled in EB-HIPP are also eligible for the medical out-of-pocket cost benefit, which covers outpatient medical out-of-pocket costs that count towards the individual’s annual out-of-pocket maximum including copays, coinsurance, and deductibles. You do not need to disclose your HIV status to your employer in order to enroll in the program.

People living with HIV may qualify for these programs if their annual income is below 500% FPL. To find the nearest enrollment site for these programs, call 1-844-550-3944. For more information, please refer to additional resources provided by the California Department of Public Health, State Office of AIDS at https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OAadap.aspx.

People living with hepatitis C should check plan formularies to ensure their drugs are covered and accessible regardless of fibrosis stage. People living with hepatitis C should also make sure the cost-sharing is affordable before enrolling in a new plan. Drug companies have patient assistance programs that may help lower the cost of your hepatitis C drugs. More information about these programs can be found at www.fairpricingcoalition.org/projects.

Be aware that Kaiser Permanente and some other pharmacies don’t currently accept copay cards, but you should be able to get reimbursed by the copay program if you can afford to pay for your medications upfront. Kaiser Permanente also has its own medical assistance program that serves people with incomes below 350% FPL.

ADAP covers hepatitis C drugs for all qualified individuals who are co-infected with HIV regardless of disease state or other considerations. However, it only covers a one-time course of treatment for hepatitis C under most circumstances. People who are co-infected qualify for ADAP if their annual income is below 500% FPL.

All Covered California health plans cover Truvada®, which is currently the only medication approved for PrEP. Prescription copays, deductibles, and other out-of-pocket costs, however, can make PrEP unaffordable for many individuals. The first thing you should consider when choosing a plan is which metal tier is best for you. While Bronze plans have lower premiums, their high deductibles and out-of-pocket costs are likely to make accessing PrEP unaffordable.

Once you have selected the appropriate plan, there are several copay programs available to help lower the cost of PrEP. Gilead, the pharmaceutical company that makes Truvada®, has a copay program that will cover up to $7,200 annually. Information about the copay program can be found at www.gileadcopay.com. Patient Access Network and Patient Advocate Foundation also have patient assistance programs for PrEP. More information about these programs can be found at www.fairpricingcoalition.org/projects.

Be aware that Kaiser Permanente and some other pharmacies don’t currently accept copay cards, but you should still be able to get reimbursed by the copay program if you can afford to pay for your medications upfront. Kaiser Permanente also has its own medical assistance program that can help people with incomes below 350% FPL.

If you need additional help paying for PrEP, you can now enroll in California’s PrEP Assistance Program (PrEP-AP). The program provides financial assistance with PrEP medication and related medical expenses.

9. • If you have private insurance (including Covered California), the PrEP-AP will pay for all PrEP-related medical out-of-pocket costs including deductibles, copays, and coinsurance. The program will also cover any medication costs not covered by Gilead’s copay assistance program.
   • If you don’t have insurance, the PrEP-AP will pay for all PrEP-related medical costs including doctor visits, HIV testing, and labs. You will be able to get the medication for free through Gilead’s patient assistance program. Uninsured individuals must go to a provider within the state’s “PrEP-AP Provider Network” to have their medical costs covered.
   • The PrEP-AP also provide assistance to individuals enrolled in Medicare. If your Medicare plan includes prescription drug coverage, the PrEP-AP will cover any copays for your PrEP medication. If your Medicare plan does not include prescription drug coverage, you will be able to get the medication for free through Gilead’s patient assistance program. All Medicare clients can enroll in the PrEP-AP to receive assistance with PrEP-related medical out-of-pocket costs.

You may qualify for PrEP-AP if your annual income is below 500% FPL. To enroll in the program, start by visiting an enrollment site in your area. An experienced enrollment worker will assist you with enrolling into both PrEP-AP and Gilead’s assistance program. A map with enrollment sites authorized to perform PrEP-AP enrollment can be found at https://cdphdata.maps.arcgis.com/apps/webappviewer/index.htmlid=6878d3a1c9724418aebfea96878cd5b2. For more information, please refer to additional resources provided by the California Department of Public Health, State Office of AIDS at https://www.cdph.ca.gov/Programs/CID/DOA/Pages/OAadap.aspx.

There are numerous resources available to assist consumers with questions:

11. • Covered California’s Service Center: 1-800-300-1506
    • Covered California’s website: www.coveredca.com
    • Local, free, and confidential help is also available from one of Covered California’s 14,000 certified agents and enrollers. Consumers can find local help by visiting www.coveredca. com/get-help/
    • Health Consumer Alliance offers free help if you have concerns or complaints about your health insurance company or access to medical care: 1-888-804-3536 or www.healthconsumer.org

If you’re living with HIV, you should seek assistance from someone knowledgeable about HIV programs and how they interact with Covered California. If you are unable to find an HIV-experienced certified agent or enroller, consult with an HIV case manager or benefits counselor. If you qualify for ADAP, you can find the nearest enrollment site by calling 1-844- 550-3944.

If you’re considering taking PrEP, you can chat with a knowledgeable PrEP navigator at www.pleaseprepme.org. This website also contains a statewide directory of doctors with experience providing PrEP. If you qualify for PrEP-AP, you can find the nearest enrollment site by calling 1-844-550-3944.