I need to understand income levels on Cov CA chart for the Silver 94 plan.  

I have seen some info that specifies Inc level can be as low as approx $11,500 or 100% of poverty level if not eligible  for

full-scale scope of benefits Medi-Cal‘.??

The reason that the Covered CA Income – FPL chart below used to show Share of Cost or Cost Sharing Reduction (CA Health Care Foundation 2010 Report)  above 100% is

If the member’s income is less than >138% to  less than <150% they qualify for Enhanced Silver 94.   The earlier chart shows less than  > 100% as  in some states, NOT California,  Medi-cal is for those under  <100%excerpt of 8.4.2015 email  California has adopted Medi-Cal expansion, so in CA if you make less than 138% of FPL you get Medi-Cal, not Cost Sharing Reduction – Enhanced Silver.  

because Medi-Cal requires participants to pay Share of Cost if they make more than 100% of the FPL.  If they make below 100%, at that point Medi-Cal will absorb complete cost for coverage. If you have any other questions, please let us know.  Email Rec’d from Covered CA 11.28.2014 12:15 PM

Full Scope of Benefits?

Means you get all the benefits that Medi-Cal has to offer.  Learn More Teen Health Rights * Our website on Medi-Cal.

Waiting period:

For lawfully present immigrants who are seeking health insurance coverage through Covered California, there is no “waiting period” or “five year bar” for eligibility for Covered California and there is no minimum income requirement for eligibility for premium assistance and cost-sharing subsidies if they are not eligible for full-scope Medi-Cal. https://www.coveredca.com/hbex/toolkit/PDFs-answers/immigration.pdf

Historical - Federal Poverty Level & Program Chart - Cost Sharing Reduction - Enhanced Silver at 100% of FPL is only theoretical
Historical – Federal Poverty Level & Program Chart – Cost Sharing Reduction – Enhanced Silver at 100% of FPL is only theoretical
Medi-Cal 100 to 138% FPL - Historical
Medi-Cal 100 to 138% FPL – Historical

Clarification from Fellow Agent Max Herr

Theoretically, a person could have income greater than > 100% and FPL, reject Medi-Cal and APTCs, but still be eligible to enroll in a Silver 94 health plan.  If, at tax filing, their income actually was greater than  > 138% FPL, by purchasing health insurance through CoveredCA, they would be eligible to receive the refundable tax credits because they would technically not be ELIGIBLE for Medi-Cal at that point. 

PPACA says premium tax credits are “available” to qualifying taxpayers whose incomes are between 100% and 400% of FPL (no tax credits at all for persons who earn less than 100% FPL — of course that doesn’t make any sense either — but it prevents certain children from filing tax returns and collecting tax credits).  Then the PPACA says you cannot have the credits if you are ELIGIBLE for any government-sponsored health plan (i.e., Medi-Cal, Medicare, Tri-Care, etc.).  And, of course, no credits for persons who have an “offer” of affordable health insurance from their employer (or from their spouse’s/parent’s employer — does not apply to persons over age 19 or older unless carried as a dependent on mommy’s or daddy’s Form 1040).

Technically, the chart is accurate, (note that this explantion was written when the Covered CA chart showed 100 to 138% of FPL as eligible for Silver 94?)  because it reiterates what the PPACA says, and what CoveredCA regulations permit (income > 138% and < 250% FPL = Silver CSR eligible).  In actual practice, however, it’s a piece of crap — if a person is earning less than <138% FPL when they apply at CoveredCA, and ask for “help” paying their health insurance premiums, they are automatically swept into Medi-Cal (and, of course, children are eligible for Medi-Cal up to 266% FPL, although they can be opted out by checking NO to the “Does this person want help” box on the app — which we were never told last year).   Wonder why we are now voter registration assisters?

So how does a person with income > 0% FPL and NOT qualify as eligible for Medi-Cal?  One way is to be an illegal immigrant.  But illegal immigrants can’t have tax credits either, so the chart is meaningless to them, too.

However . . . a person whose stated/estimated income at enrollment time is greater than  > 138% and less than < 250% FPL would qualify for CSRs —   Their income could change over the course of the year to less than < 138% FPL (i.e., unemployed, reduced hours, failure of their MLM venture, etc.) and they would immediately be eligible for Medi-Cal if they report the change, or they could stay on their CSR plan by choice and by paying the premium (but not change from Silver 73 or 87 to Silver 94 — they would automatically be swept into Medi-Cal instead).  As long as their income is 100% FPL or more for the year, they will get the tax credits, which are “refundable” (the excess unused credits are payable to the taxpayer when they file their Form 1040).  I don’t think the IRC/regulations disqualify a person from receiving the tax credits in a scenario such as this — the person could legitimately claim they had a reasonable expectation of returning to work, increased hours/pay, etc., and did not expect their income to remain in the eligibility range.  I believe the “eligibility” criteria is assessed at enrollment application time.

People heard that they will lose their home if they are on Medi-Cal (i.e.,”asset recovery”) — which we know is not an entirely accurate statement, but whoever heard about asset recovery prior to 2014 unless their parents were in a nursing home and needed Medi-Cal to pay the cost?

Child Pages


4 comments on “Share of Cost? 100 to 138 FPL? Q & A Income Chart

  1. My current pay stub as of last week says I made 21,314.05 that’s including Holiday Vacation OT & sick pay & my regular earnings are 19,922.42 I have 2 children & I am receiving CAL-fresh I have been receiving Medi-cal & now it’s redetermination time will I still qualify for benefits?

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