Article
Article Title:
Mixed Program Family
Domain:
Individual Market: Eligibility and
Enrollment
Subject:
Eligibility for Individuals and
Families
Topic:
Single Streamlined Application
Subtopic:
Using the Application
Date Published:
12/10/13; updated 3/6/14
Department:
Policy
Primary Author:
Goldman, Zachary
Content Owner:
Abernethy, Jessica (CoveredCA)
Legal Approval Owner:
Hosseini, Bahara
Status:
Published
Introduction
1 or 2 paragraphs that can be used to set context or be used as talking points
Because there are many ways to qualify for Medi-Cal and varying income requirements, families may find that
some household members qualify for Medi-Cal while other family members qualify for premium assistance and
cost-sharing subsidies through Covered California. These families are called “mixed-program families.” In
particular, there will be many families with children eligible for Medi-Cal and parents eligible for premium
assistance because children are eligible for Medi-Cal at significantly higher income levels than adults – 266% FPL
for children compared to 138% for most adults.
Covered California and Medi-Cal are committed to making enrollment and retention as simple as possible for
mixed-program families.
Key Points 3-5 bullet points




Individuals in a mixed-program family will face different costs because Medi-Cal provides health coverage
with low or no costs while Covered California health plans require payment of premiums and other costs
such as co-pays and coinsurance.
In some cases, mixed-program family members will be able to be in the same health plan with the same
providers (i.e. doctors). In other cases, however, mixed-program families will have different health plans and
possibly different providers. For questions about the health plans available, mixed-program families can call
Covered California at 1-800-300-1506. Covered California will be able to answer questions about its own
plans and can transfer those with questions about Medi-Cal plans to the appropriate resource. Consumers
can also call Medi-Cal Health Care Options staff directly at 1-800-430-4263 for questions about Medi-Cal
plans.
Mixed-program families will be able to sign in to their account on www.CoveredCA.com to change their
address, update their income, or edit other information. If a family’s income or size changes, it is very
important that the family report these changes promptly in order to redetermine their eligibility and
recalculate their premium assistance.
Premium assistance through Covered California is based on the household size and income and the number
of family members who are enrolling in a Covered California health plan. For example, if the children are
Today’s Date: 3/23/2016
Page 1 of 5
Article
Key Points 3-5 bullet points
eligible for Medi-Cal but the parents are not, the premiums they will pay will be based only on insuring the
parents.
Details Elaborate key points
Mixed-Program Families
Even though all family members apply for health coverage together, each member of the household is evaluated
individually and it is possible that some members of the household qualify for Medi-Cal while others will qualify
for premium assistance, and possibly cost-sharing subsidies, through Covered California. The income
requirements vary for different populations in Medi-Cal. For example, children and pregnant women qualify for
Medi-Cal at higher incomes as compared to childless adults.
Because eligibility criteria for each program are different, it may not be possible for the entire family to be
enrolled in a single program. People who are eligible for Medi-Cal are not eligible for premium assistance in
Covered California. People who are eligible for Medi-Cal may, if they so choose, opt out of Medi-Cal and
purchase a full-cost health plan through Covered California. By doing so, these individuals would be giving up
high quality coverage at low or no cost for a health plan that requires monthly payments (i.e. premiums) and
other costs (i.e. co-insurance, deductibles, co-pays).
Choosing a Plan and a Doctor
Depending on what Covered California and Medi-Cal health plans are offered in a given region, all the members
of a mixed-program family may not be able to have the same health plan or see the same doctor. In some
regions, it may be possible for a mixed-program family to have the same health plan or go to the same doctor.
Covered California’s “Find Your Doctor” search tool will allow consumers to search by doctor and find health
plans that contract with those doctors. For individuals eligible for Medi-Cal, Health Care Options staff can help
the mixed-program family enroll in a Medi-Cal plan and find a doctor in their area. Consumer can talk to MediCal Health Care Options staff by calling 1-800-430-4263. Covered California and Medi-Cal are working closely
together to best serve mixed-program families.
Updating Your Information
Mixed-program families will be able to sign in to their account on www.CoveredCA.com to change their address,
update their income, or edit other information. If a family’s income or size changes, it is very important that the
family report these changes promptly in order to redetermine their eligibility and recalculate their premium
assistance.
Costs
Costs will be different for family members who are enrolled in different programs. Medi-Cal generally offers
services free or with low out-of-pocket costs, whereas health insurance plans through Covered California will
require payment of a monthly premium and usually includes some costs at the time of service.
Calculating Premium Assistance
Premium assistance through Covered California is based on the household size, household modified adjusted
Today’s Date: 3/23/2016
Page 2 of 5
Article
Details Elaborate key points
gross income (MAGI) and the number of family members who are enrolling in a Covered California health plan.
Medi-Cal and Covered California representatives can help you determine if you are eligible for premium
assistance.
Scenarios 2-5 scenarios
Scenario 1
The Smith Family wants health coverage. The parents, Jim and Stacy, are currently uninsured but their two
children are enrolled in Medi-Cal. Jim and Stacy are eligible for premium assistance if they enroll in a health plan
through Covered California. Starting January 1, 2014, Jim and Stacy can have affordable insurance through a
private health plan while their two children will continue to have Medi-Cal coverage through a Medi-Cal
managed care health plan. The Smith’s premium assistance is calculated using the household size, household
income, and the cost of the second lowest silver plan that covers both Jim and Stacy. Jim and Stacy may be able
to enroll in the same health plan their children are in depending on what Medi-Cal plans and Covered California
plans are available in their county of residence.
Scenario 2
Joe and Amy Peterson are having their first child. Because Amy is pregnant and their income meets Medi-Cal
eligibility requirements for pregnant women, Amy is eligible now for Medi-Cal. Joe, on the other hand, qualifies
for premium assistance through Covered California and will be eligible for coverage starting January 1, 2014.
Even though the Petersons are a family of two people, with one more on the way, they are a mixed-program
family because Amy will receive health coverage from a Medi-Cal managed care plan and Joe will receive
affordable health coverage from a health plan in the Covered California marketplace. Depending on whether
the same plans contract with Covered California as with Medi-Cal, they may be able to enroll in the same plan.
Once their baby is born, the baby will be automatically eligible for Medi-Cal for the first year of life. Their
income will be recalculated now that they are a family of three, and if their income for 3 is below 138% of the
Federal Poverty Level, Joe and Amy will be eligible for Medi-Cal, too. Once the baby is born, it is very important
that the Peterson’s notify Covered California of the increase in family size because it may affect Joe’s eligibility
for Covered California health plans and premium assistance and it will make them eligible for a special
enrollment period to enroll in a Covered California health plan or change plans.
FAQs Frequently asked Questions and Answers. This will be used for a variety of different uses including Certification Exam
Questions, Marketing/Communications, etc.
What if a family does not want mixed coverage? How can all members of a family be on one plan?
If a family does not want to be enrolled in multiple programs, a family can decline Medi-Cal coverage, but those
eligible for full-scope Medi-Cal cannot qualify for premium assistance or cost-sharing subsidies. The family
should think twice before opting out of Medi-Cal, because Medi-Cal offers high quality health care for very low
and sometimes no costs. Families eligible for Medi-Cal may not be able to afford unsubsidized coverage and
going without coverage may expose the family to financial risk. Individuals can view Medi-Cal plan options here:
http://www.dhcs.ca.gov/individuals/pages/mmcdhealthplandir.aspx
Today’s Date: 3/23/2016
Page 3 of 5
Article
FAQs Frequently asked Questions and Answers. This will be used for a variety of different uses including Certification Exam
Questions, Marketing/Communications, etc.
Can family members decline Medi-Cal and get subsidies with Covered California?
No, subsidies such as premium assistance and cost-sharing subsidies are not available for individuals who are
full-scope Medi-Cal eligible, even if they decline Medi-Cal. Individuals, if they so choose, can decline Medi-Cal
and purchase a Covered California health plan at full cost. Again, this will rarely be affordable for these families
who should be advised of the health and financial risks of declining free or low-cost, comprehensive coverage.
How can a family all become eligible for Medi-Cal?
Medi-Cal eligibility is based on income and other factors. An entire family is eligible for Medi-Cal only if all
members of the household meet the Medi-Cal criteria. If a family wants assistance with determining Medi-Cal
eligibility, call Covered California at 1-800-300-1506 or a County Medi-Cal eligibility office.
What happens to a mixed-program family if their income or family size changes?
If a family’s size or income changes, they should notify Covered California within 30 days of the change.
Eligibility for Medi-Cal and premium assistance in Covered California is based on income and family size. A
change in a family’s income or family size could affect eligibility in Medi-Cal or the amount of premium
assistance through Covered California.
What are the income levels at which a family becomes mixed-program family?
Medi-Cal eligibility is based on income and other factors such as a child’s age. The income levels for Medi-Cal
differ for different ages. For example, children between the ages of 6 to 19 may be eligible for Medi-Cal if the
family income is at or below 266% of the Federal Poverty Level (FPL). Most adults are eligible for Medi-Cal with
income up to 138% FPL. Pregnant women and infants up to age 1 may be eligible for Medi-Cal with incomes up
to 213% FPL. If a family wants assistance with determining Medi-Cal eligibility, they should call their County
Medi-Cal eligibility office or Covered California at 1-800-300-1506.
What kinds of cost-sharing subsidies can mixed-program families receive?
Like premium assistance, cost-sharing subsidies are based on one’s federal poverty level. Mixed-program
families may be eligible for cost-sharing subsidies if their household incomes are at or below 250% of the FPL. If
a family’s FPL is between 100 and 150% and are ineligible for full-scope Medi-Cal, they may be eligible for an
Enhanced Silver 94 plan. Enhanced Silver 94 has an actuarial value of 94%, which has a higher actuarial value
than a platinum plan. If a family’s federal poverty level is between 150 and 200%, they may be eligible for an
Enhanced Silver 87 plan. If a family’s federal poverty level is between 200 and 250%, they may be eligible for an
Enhanced Silver 73 plan.
Supporting Materials Please include the title and all relevant links to Scripting; step action table; charts/visuals; helpful
hints; flowcharts; publications or materials. (The majority of Covered California developed materials should be stored in
SharePoint)
Today’s Date: 3/23/2016
Page 4 of 5
Article
Supporting Materials Please include the title and all relevant links to Scripting; step action table; charts/visuals; helpful
hints; flowcharts; publications or materials. (The majority of Covered California developed materials should be stored in
SharePoint)
Bibliography/Reference Material (Links and citations to law/regs; advocates’ material; CovCA formal background)
http://www.dhcs.ca.gov/provgovpart/Documents/SPD%20Guide%20_Eng.pdf
http://www.dhcs.ca.gov/individuals/pages/mmcdhealthplandir.aspx
Key Words (Top Search words to find article)
Mixed-program family, mixed-eligibility, Medi-Cal, mixed-family, mixed-status
Today’s Date: 3/23/2016
Page 5 of 5