Applications to Covered CA On and Off Exchange Health Plans. Provider Search Update.

(The following information does not apply to you if you are on an employer group plan or on Medicare.)

There appears to be a great deal of confusion as to where to submit an application and the role of an agent.
Much of the confusion stem from the failure of the CoveredCA media advertising to mention that in addition to the Covered California Exchange, there is also a whole marketplace of health plans and insurance carriers available to consumers OUTSIDE of the Covered CA Exchange (Off-Exchange). The major difference is that you may only apply for a subsidy INSIDE the CoveredCA Exchange (On-Exchange). But if you don’t qualify or need a subsidy, you may apply outside where all the same plans are also available at the same rates, plus additional carriers and plan choices.

In addition, the Covered CA advertising also fails to mention that agents (Certified Insurance Agents) like myself are available to help consumers to quote, evaluate and apply to BOTH On and Off Exchange plans. And that there are no fees for our services. And no difference in premium. And that we offer free ongoing service.

(A) To apply to a plan INSIDE the Covered CA Exchange (On-Exchange):
You must go to to apply. Please designate me as your agent (look for “Find Help Near You”). Step by Step instructions for applying:

(B) To apply to a plan OUTSIDE the Exchange (Off-Exchange), please use the following links to apply:

Anthem Blue Cross (Deadline Dec. 23rd):

Blue Shield (Deadline Dec. 15th):

Health Net (Deadline Dec. 15th):

Kaiser: (Deadline Dec. 15th):

Note: If you miss the Dec. 15th deadline, you may still apply for a non-subsidized health plan through Covered CA. The only difference is that you will need to provide income and immigration information (to be shared by several Government agencies) even though you are not requesting a tax subsidy.

Provider Search

Anthem Blue Cross revised Provider Search
Go to
RHS under “Useful Tools”, click Find a Doctor.
On LHS Choose Doctor or Hospital #1
#2 Type Name of Doctor or Hospital
#3 Enter radius in miles and zip code.
#4 Enter State and Plan Type or network.
1. Plan Network for Covered CA Exchange:
a. Pathway X HMO Individual via Exchange
b. Pathway X PPO Individual via Exchange
c. Pathway X EPO Individual via Exchange
2. Plan Network for Non-Exchange:
a. Pathway HMO Individual
b. Pathway PPO Individual
c. Pathway EPO Individual

Blue Shield of CA Provider Finder
(Be sure to “Select a Plan” first before you search.)

Health Net Provider Finder

We offer one stop shopping and can help you with all of these plans. Please call us at 925-284-2000 if you encounter any problems in this application process. We are prepared to help you.
Thank you for reading.
Phil Lee

Obamacare — What You Should Do Next with your Health Plan

(This information applies only to Individual & Family health plans. It does not pertain to Employer group plans, employee plans or Medicare plans.)

Today, everything has changed once again! In a press conference this morning, President Obama announced that he wants policy cancellations to be delayed for one year.

How and whether this will be implemented will be decided by the HHS (Dept. of Health & Human Services), the California Insurance Commissioner, Dave Jones, and each insurance company. The final information will trickle down to us after these decisions are made. We don’t know yet when that will be.

Our phone has been ringing non-stop since this announcement. I will give you what we know and suggest some next steps.

1. Before you make any move, please follow the instructions on the piece “Choose an On or Off Exchange plan” to figure out if: (a) you qualify for a subsidy, (b) if your providers are on the network of the 2014 plans and (c) if your prescription drugs are on the formulary lists of the 2014 plans.
2. If you are on a grandfathered plan, you do not need to change anything unless you want to. Your plan will continue as is with the same benefits, provider network, and formulary lists.
3. If you are on a plan where you have received a cancellation notice for Dec. 31. This may be delayed until Dec. 2014. We are waiting for information on this.
4. If you have received a notice that your plan will be “mapped” to a new plan Jan. 1st, this also may be delayed until Dec. 2014.
5. If you want to change plans on Dec. 1st, please contact us.
6. If you received a large rate increase and want to consider other carriers and plans on Dec. 1st or Jan. 1st, please contact us.
7. If you qualify for a subsidy and want a Covered CA plan, please contact us for advice, online enrollment instructions and a paper application.

Please contact me know if you would like me to receive the following attachments:
A. “Choose On or Off Exchange plan” helps you to choose a plan inside or outside the Exchange (with screenshots).
B. “Fillable CoveredCA application” is a fillable Covered CA paper application in pdf format.
C. “Application Screenshots CovCA” takes you step by step to start an application, set up a Profile and Designate an Agent with screenshots).
D. “Agent Designation Screenshots” shows you how to designate an Agent (with screenshots).

Phil Lee

Why you should not rush into a Covered California Exchange health insurance plan right now.

• The online enrollment is still hampered by glitches and delays.
• Most of the carriers are only offering “skinny” networks of slimmed down providers within the Exchange plans.
• The Covered CA website and the carrier websites have either not been able to do Provider searches, or have been giving wrong results.
• The carriers have not yet released rates and details for their Off-Exchange health plans. This means that you cannot right now get a complete picture of what all is available in the marketplace.
• There will be 3 categories of health plans available on Jan. 1st.: Covered CA Exchange plans, Off-Exchange Mirror (Standardized) plans, and Off-Exchange non-Standardized plan.

You will have time to make a proper decision once all the information is out.
• The open enrollment period extends to March 31.
• The deadline for the Jan. 1st enrollment is Dec. 15th.
How to decide whether to buy an On-Exchange plan or Off-Exchange plan:
• If you know that you qualify for a Subsidy (Premium Assistance), then you have to purchase an Exchange plan such as a Bronze plan in order to get the subsidy.
• If you know that you don’t qualify for a subsidy, then you should purchase an Off-Exchange plan or Off-Off-Exchange plan, without subsidy.
• To find out if you may qualify for a subsidy, go to

What to do Next?
• Certified Insurance Agents are expected to have the ability to provide you with complete quotes for all plans in the marketplace (in and out of the Exchange) sometime in Nov.
• The health insurance carriers are expected to have the correct provider network list online by Nov.
• There is no cost to use Insurance Agents who are certified by Covered CA to provide this ongoing service to you.

Phil Lee

Health Care Reform (ACA) Implementation Jan. 1st, 2014 – California Updates

Latest Updates

Individuals and Families
• Insurance Carriers are expected to release their health plan offerings for 2014 on Oct. 1st.
• The major carriers offering Individual/Family plans in the Bay Area will be Anthem Blue Cross, Blue Shield, Health Net and Kaiser.
• Individual & Family purchase mandates and penalties will go into effect on Jan. 1st. Large Employer Group (50+ Employees) mandates and penalties, however, have been postponed to 1/1/2015.

Small Employer Groups (50 or fewer employees)
• Model Notices — All Employers are required to give “Model Notices” to all their employees by Oct. 1st, and to new hires within 14 days of hire. This is a Dept. of Labor mandated notice, that talks about employees’ and dependents’ options, under ACA, to employer and individual health coverage, Exchanges, subsidies and tax credits.
• Previously, this Model Notice law carried a penalty to Employers of $1,000 per employee for non-compliance. Last week, the Dept. of Labor announced a waiver of the penalty for non-compliance. But they still want employers to send out those notices.
• Anthem Blue Cross will not be offering any Small Group health plans within the Covered California Exchange. But they will be offering a wide selection of non-standardized plans outside of the Exchange.

Large Employer Groups (50+ employees)
• Model Notices — Penalties waived, see above.

Medicare Individuals
If you are on Medicare, you are mostly unaffected by the implementation of ACA on Jan. 1st.

Phil Lee

Implementation of ACA (Health Care Reform)

California Health Care Insurance Exchange Updates
Many developments have occurred since my last update. I will give a brief recap of the most important items that may impact your personal health care insurance situation.
Due to the large number of regulations and sheer volume of information related to health care reform. I will give you brief summaries of the most important items, in bullet point fashion. I have divided the items into 4 categories so that you only need to read the category that’s relevant to you.
You may choose to buy health plans either inside the California Exchange (Covered California) or outside. The only difference is that if you want either a subsidy or a tax credit, you have to choose an Exchange plan.

Your objective should be to:
1. Be insured.
2. Find the most affordable plan for your needs.
3. Qualify for a subsidy or tax credit, if you are eligible.

Individuals and Families
1. Major carriers participating in the Individual Exchange will be Anthem Blue Cross, Blue Shield, Health Net and Kaiser.
2. The guarantee-issue rule for individual health plans will go forward as planned on Jan. 1st. Individuals and Families may enroll between Oct. 1st 2013 and March 1st 2014. Enrollment effective dates will be Jan. 1st or later.
3. Starting on Oct. 1st, Individuals and Families may start choosing and applying for Individuals health plans within Covered California (the State Individual Exchange) or from plans available outside the Exchange. Plan choices within the Exchange are likely to be more limited than plan offerings outside of the Exchange. However, if one needs a federal subsidy based on their income, they may only apply for plans within the Exchange.
4. Agents who are certified by the Exchange may offer health plans both inside and outside of the Exchange, and may assist consumers in applying for subsidies.
5. Federal and Cal Cobra will continue to be offered to terminated employees.

Small Groups (under 50 employees)
1. Major carriers participating in the Group Exchange, aka SHOP, will be Blue Shield, Health Net and Kaiser.
2. Tax credit will be available to employer groups with low salaried employees.
3. Most insurance carriers allow existing groups to renew early in Nov. or Dec. of 2013 so that they will not be subject to the new Jan. 1st ACA-compliant plans and rates for another 12 months.
4. 2 employee groups consisting of only the owner and spouse will no longer be allowed.
5. 1099 employees will not be considered employees for group eligibility.
6. Employer groups in CA must have 51% or more of its employees in CA in order to qualify. Out of State employees may enroll in an Individual/Family plan in their own state.
7. Agents who are certified by the Exchange may offer health plans both inside and outside of the Small Group Exchange, known as SHOP.
8. Flex Spending Account Salary Deferral limit of $2500 for 2014.
9. Employer Model Notices requirement – On Oct. 1st or within 14 days of hire.

Large Groups (50+ employees)
• The employer mandate to provide a minimum level of health insurance to employees, along with the associated penalties; have been delayed to Jan. 2015.

• ACA and the Exchanges are not expected to affect Medicare.

For More Information:
Please go to the official website for the California Exchange, aka Covered California, at You will find:
• Summaries of Exchange plans that will be available.
• Sample rates for Exchange plans for your age in your zip code.
• A calculator to help give you some idea if you might qualify for a subsidy.

Phil Lee

Guarantee Issue Health Insurance Coverage for Children in California

The California Department of Insurance has issued guidance on this one provision of the Health Care Reform legislation.
Insurers in California must now offer coverage to children on every non-grandfathered individual policy that it sells. The Open Enrollment Period goes from Jan. 1st 2011 to March 1st 2011.
Children, including those with pre-existing conditions who have previously been denied coverage, may now be guaranteed issue.
Click link below for full text of regulatory guidance from the California Department of Insurance:

Click link below to obtain market rates:

© Philip W Lee,,


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Lee Health Insurance Services | Healthcare Insurance Agency, Individual Health Insurance, Family Health Plans, Group Medical Insurance, Small Business Health Insurance, Whole & Term Life Insurance, Dental Insurance, Health Care Reform Assistance, Covered California Insurance Exchange Plans, Medicare Supplement Insurance, Medicare Advantage, Medigap Plans, Anthem Blue Cross, Kaiser Permanente, Blue Shield of CA, Health Net, Cigna, Aetna, Contra Costa County CA, Pleasant Hill, Danville, Concord, Berkeley, Martinez, Albany, Oakland, San Ramon, Alameda, Santa Clara, Campbell, Milpitas, Cupertino, Sunnyvale, Saratoga, Fremont, Palo Alto, Newark | 935 Moraga Road, Suite 240, Lafayette CA 94549 (925) 284-2000 or Toll-Free, (800) 286-7445