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San Francisco Marin Medical Society Blog

Covered California FAQs for Physicians

In 2010, Congress passed historic sweeping health care legislation, the Patient Protection and Affordable Care Act (ACA), which reformed the individual and small group health insurance markets and, beginning in 2014, will provide health insurance to much of the nation's uninsured. Under the ACA, two-thirds of California's uninsured may be covered by private insurance through a health insurance exchange purchasing pool. California's exchange, Covered California, began enrollment on October 1, 2013 – with coverage beginning on January 1, 2014.

The SFMS and CMA have compiled responses to some of the most commonly asked questions physicians and health care providers may have about Covered California. Click here to download a printable copy of the FAQs.

What is Covered California?

Covered California is the new marketplace where Californians can compare and purchase health coverage. Through Covered California, many patients will be eligible for financial assistance to help pay their premiums and even co-pays.

Through Covered California, individuals and small businesses can compare different health insurance companies and learn whether they qualify for federal subsidies and tax credits. Californians will also be able to find out if they are eligible for low-cost or no-cost health coverage through Medi-Cal.

How will Covered California impact my practice?

The impact on physician practices will vary greatly depending on the mix of patients in your practice and the extent to which you contract with Covered California plans. Millions of previously uninsured Californians will now be eligible for health insurance through Covered California and Medi-Cal. Your patients with employer-sponsored coverage are not likely to see significant changes in their coverage.

Which patients can buy coverage through Covered California?

Legal California residents, except for currently incarcerated individuals and legal minors, are eligible to buy insurance through Covered California.

If a patient has access to affordable health insurance through an employer or government program, he or she can purchase coverage through Covered California but may not qualify for financial assistance.

Which patients are eligible for subsidies through Covered California to purchase coverage?

Premium assistance is available to individuals and families who meet certain income requirements and do not have access to affordable, adequate health insurance through their employers.

Eligibility for premium assistance is based on family income and the number of people in the family. The size of the premium assistance is calculated on a sliding scale, with those who make less money getting more financial assistance. Individuals with incomes up to $45,960 and a family of four with an income up to $94,200 may be eligible for premium assistance.

Will my Covered California patient be able to continue to see me?

You will have to be contracted with a Covered California plan and your patient will have to select that plan. Each health insurance plan has a specific list of doctors and hospitals that are considered in-network providers for covered services.

Patients should be advised to verify with the individual plan that a particular doctor’s or hospital’s services will be covered under that plan. Covered California will provide a searchable online directory so that patients can see which health plan networks contain a particular doctor or hospital.

Reimbursement/Contracting Questions

SFMS members and their staff have free one-on-one access to CMA's practice management experts through the CMA reimbursement helpline at (888) 401-5911 or CMA can provide assistance to SFMS members on any questions about the exchange, other reimbursement issues , contracting, or general practice management issues.

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