What Is Covered California Conditional Eligibility?

Conditional Eligibility Quick Guide

Published by Covered California for agents to assisting individuals and families with meeting documentation requests for final eligibility determination.

Covered California consumers in a conditional eligible status will receive a reminder notice from Covered California that informs them they need to provide documents to prove they are eligible to continue their health insurance and/or financial assistance through Covered California.

Conditional eligibility notices will be sent to affected Covered California consumers who have not resolved their inconsistency and submitted documents 45 days after their eligibility determination. These reminder notices are available in English and Spanish, only.

Consumers will need to submit valid documentation for one or more of the following reasons:

• Citizenship
• Lawful Presence
• Incarceration
• Deceased Status
• Income
• Social Security Number

The notice will list which household member is conditionally eligible for coverage, their inconsistency reason, and the documentation each household member is required to provide to clear the inconsistency.

Click here for a list of acceptable documentation.

For Incarceration Status, the Attestation of Non Incarceration Status Form is now available on CoveredCA.com. The consumer can use this form to attest to their Non Incarceration Status if applicable. Remind consumers: The documents provided are confidential and will only be used to determine eligibility for health insurance programs. The documents are not used for immigration enforcement purposes.

Schedule

Conditional eligibility notices will be sent to affected Covered California consumers on a daily basis corresponding with the date of eligibility determination. Consumers have 95 days to clear the inconsistency by submitting acceptable documentation or correcting the information so that it is verified electronically via the Federal Data Hub.

This 95 day period is called the Reasonable Opportunity Period (ROP).

Reasonable Opportunity Period (ROP)

At initial application, annual renewal, or when a consumer reports a change (RAC), Covered California verifies the consumer’s information against available electronic sources to verify the information provided.

If the consumer’s information cannot be verified by the electronic sources (called “inconsistency”), the consumer may be determined to be Conditionally Eligible for Advanced Premium Tax Credit (APTC)/Cost Sharing Reductions (CSR) and/or Covered California plan enrollment as a whole.

Consumers have 95 days from the date of the eligibility determination to either:

• Provide documentation to verify their application information
• Correct their application information
• Attempt to have the electronic source corrected

Next Steps

The consumer can upload, fax, or mail their documentation. More than one document may be required. (Agents can also upload images of the specific documents directly into the consumer Covered California account.)

If documentation has already been provided, no action is needed. Covered California will contact consumers directly if additional information is needed.

Advise consumer to submit legible copies only and not the original documents. A cover page is included to fill out if the consumer is faxing or mailing their documentation.

If a consumer is having difficulty in obtaining valid documentation by the Reasonable Opportunity expiration date, the consumer can call the consumer service center to provide a date when the documentation will be received.

Terminated Consumers

Consumers terminated for failure to submit acceptable verification for citizenship/lawful presence, deceased status or incarceration have 30 days from their termination date to call the consumer service center to request reinstatement of coverage. Example: consumers terminated on 4/30/17, must call by 5/30/17, not 5/31/17.

If the consumer does not call and provide the documentation by the end of the 30 days following the termination date, consumers must submit a new Special Enrollment application and provide a Qualifying Life Event.

Note: Covered California will not auto-terminate cases in Carry Forward status (pending Medi-Cal evaluation); however, a mixed household Covered California enrollment will be terminated if the Covered enrolled consumers remain inconsistent after the ROP expiration date.