Author Archives: Coverage California

About Coverage California

Coverage California provides original news and commentary for California residents, concerning the changing insurance market place.. Information from Coverage California should not be construed as legal or tax advice, rather as the personal opinions of its chief contributor, Marc Derendinger, Sr., which are based on his 30 years experience as an industry observer and market participant. Marc Derendinger is also a columnist for The Vanguard, the official publication of the San Jose Police Officers' Association, which has published his insurance column since 2002. Additional facts: • 2002 to present: Advisor to the State of California Department of Health Services’ California Partnership for Long-term Care, an innovative public-private program, bringing long-term care insurance to California employers. • 2007 CALPELRA Conference Speaker, concerning non-CalPERS Long-term Care Insurance alternatives for public agencies • Currently the president of A. Francois Derendinger Insurance Agency, Inc., located in San Jose, California, which has served the Northern Califonria community for 54 years. Past and present customers include the City of Santa Clara, City of Campbell and City of San Jose, as well as dozens of private organizations and start-ups throughout California. The firm is licensed with the California Department of Insurance under license number 0563986.

Blue Shield Comments On Future of the ACA

Breaking News:  Blue Shield of California responds to questions following the Presidential election, about the future of the ACA (Affordable Care Act).  This is a detailed announcement, so grab a cup of coffee:

Blue Shield and the Future of the ACA

Click & Quote directly from Blue Shield of California

[Attention: Anthem Blue Cross plan holders should read Anthem cancels CovCA plans for majority of California beginning 2018]

The Future of the ACA (Affordable Care Act)

“…While we do not yet know the full outcome, we do know that the ACA and Covered California is working for over 21 million Americans and repealing or replacing it would not be a simple or fast process.”

Repealing the ACA was a central platform of the Trump campaign. However, no one knows yet how comprehensive an ACA repeal Trump would seek or how quickly the Trump Administration would act on this issue. Though we do not have concrete answers about what lies ahead, we do have a sense of what could be on the way. In the interest of transparency, we will share what our Policy team is anticipating.

Three executive actions could occur as early as January 20, 2017

  1. End enforcement of the ACA mandate: the administration could order the Treasury to stop enforcing the penalty on taxpayers who do not enroll in health insurance, which would lead to lower enrollment.
  2. Halt payment to insurers for cost-sharing reduction (CSR) subsidies: the payments Blue Shield and other plans receive for providing cost-sharing subsidies for low-income enrollees are being challenged in court. The Trump Administration could stop defending this lawsuit. This would have a real financial impact and lead to significant disruption in the market.
  3. Prevent payments related to the transitional reinsurance program: Republicans have argued that payments from the transitional reinsurance program must go to the Treasury before health plans. The administration could redirect $5 billion owed to plans for the 2016 plan year, which would zero out payments that are expected in mid-2017.

Congress could act quickly to repeal key provisions before attempting to replace the entire ACA, which would require bipartisan support.

  • Repeal by budget reconciliation: the Republican Congress could repeal portions of the ACA with budgetary implications such as ACA tax credits, the Medicaid expansion, the individual and employer mandate penalties, and various ACA taxes used to pay for health reform. However, the core market reforms could stay in place, like guaranteed issue and dependent coverage to age 26.
  • Introduction of replacement legislation: we already have an idea of what a Republican proposal would include, e.g., high risk pools, buying across state lines, and changes to the Medicaid program.

“It is important to remember that we have navigated a series of policy changes for several years now and have overcome those challenges with teamwork and commitment to members. We are familiar with the prospect of reform. We are dedicated to continuing our efforts to transform the healthcare system to one that is sustainably affordable in 2017.”

As we prepare for what is ahead, our mission remains at the center of our strategy: to ensure all Californians have access to high-quality health care at an affordable price. Our team is already mobilizing to work with leaders at the state and federal levels.

We intend to carry the voices of our members with us as we work with the new administration toward our mission. We will do our best to make sure that you have the latest information on new developments and how we respond to them.

Blue Shield and the Future of the ACA

The Future of the ACA

Opinion:  Blue Shield of California seems committed to supporting the good features of the Affordable Care Act.  In many California counties, Blue Shield is the only insurer to offer a true PPO plan, adding credibility to their Not-For-Profit status and commitment to support the future of the ACA.

Blue Shield and the Future of the ACA

Click & Quote from Blue Shield’s Secure Server

UnitedHealthcare To Quit Covered California

Another health plan joins the California wall-of-shame, as Covered California announces the departure of UnitedHealthcare. Existing members can continue on through December 31, 2016, allowing them time to find a new plan during the Fall 2016 Open Enrollment.

UnitedHealthCare quits Covered California

UnitedHealthcare Quits Covered California

According to Covered California, UnitedHealthcare’s presence in the Covered California individual marketplace is small, at one tenth of one percent. Yet the impact will be greatly felt in some Northern California regions, where only three plans are available to consumers.

Health plan consolidation is already contributing to the lack of viable options in California. For example, in 2005 United Health Group purchased PacifiCare, which had previously acquired FHP, who had acquired TakeCare in 1994.

Some long-time market stakeholders fear “consolidation” plays into the hands of California legislators who are pushing for a single, government-run plan. They wonder if some legislators go beyond “cheering” for the Affordable Act’s demise, and would stoop so low as to sabotage its successful implementation?  Are there more democrats than republicans, hoping for Obamacare’s demise? Really?

UnitedHealthcare Regions in California

Region 1Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne, Yuba
Region 9Monterey, San Benito, Santa Cruz
Region 11Fresno, Kings, Madera
Region 12 San Luis Obispo, Santa Barbara, Ventura
Region 13Mono, Inyo, Imperial

As the individual marketplace continues to deteriorate, the small group market has gained a firmer footing, including stable PPO networks and easier participation rules with Kaiser and traditional PPO plans.  Is it time to review available small group plans?   Reserve your appointment early for Open Enrollment, which begins this November.  Find local assistance in San Jose, Santa Clara and the San Francisco bay area or via telephone, throughout Northern and Southern California..

or view online pricing, free of charge

I Don’t Need Vision Care

“I don’t need glasses so I don’t need Vision Care”

Honestly, how would Vision Care benefit me, if my vision is perfect?  Experts argue every person can benefit from an annual vision care exam. How?

  • During the VSP WellVision Exam, your eye doctor does much more than just determine your prescription for eyeglasses or contact lenses.
  • Your doctor will also check for common eye diseases, assess how your eyes work together “as a team” and evaluate your eyes as an indicator of your overall health.

Some Medical Conditions Are Easier to Detect Through The Eyes

Are you between Age 20 and 74? One of the nation’s leading vision care plans found its doctors were the first to diagnose diabetes in over 30% of cases.

Watch 64 second video on Diabetic Retinopathy, the leading cause of new cases of blindness between the ages of 20 and 79.

Early Detection Is Key

Eye Doctors are the first to detect these medical conditionsIn a large percentage of cases, before other healthcare providers
for Diabetes34%
for Hypertension39%
for High Cholesterol62%
Even with perfect vision, an annual eye exam can detect medical conditions that other healthcare providers won't diagnose until later. After detection, members are then referred back to their primary care physician. Early detection is the key.

A Vision Care Plan protects you and your family.  Watch this video about Vision Service Plan’s affordable new vision plan for individuals and families:

Vision Care from VSP

Watch this Video

Additional Resources

  1. How much does it cost?
  2. Find A VSP Doctor
  3. Call or Text Questions to an authorized sales representative: (408) 475-8219
  4. Download a Paper Application

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VSP Doctor Network: The Biggest, The Best

Your VSP doctor has met the highest credentialing requirements, so members are getting the most expert care available.

VSP Individual Plan Application Link

VSP Individual Plan Information

  • Choose from over 32,000 VSP doctors, many who offer weekend and evening hours for your convenience.
  • Over 60,000 access points, conveniently located in medical offices and retail settings.
  • How are VSP doctors licensed?   VSP optometrists are Therapeutic Pharmaceutical Agent (TPA) certified and ophthalmologists are American Board of Ophthalmology (ABO) certified.  VSP chooses doctors carefully based on their professional licensing, work history, education, malpractice history, professional liability and ethics.
  • Are ophthalmologists covered?  The VSP network doctor list includes highly skilled and professionally certified optometrists and ophthalmologists.  Whether your VSP doctor is an optometrist or ophthalmologist, you will receive a comprehensive vision exam and you can purchae glasses and contacts in their office.

Additional Resources

VSP Doctor Search

  • Download an Application for individual or family coverage.


Find a VSP Doctor for the VSP Individual Plan

New Vision Service Plan For Individuals

Previously available to larger corporate employers, Vision Service Plan now offers the VSP Individual Plan to pretty much anyone who lives in the service area:


Vision Service Plan

  1. How much does it cost? Get Rates!

  2. View VSP benefit details of this new program here
  3. Start a Vision Service Plan application for individual or family coverage
  4. 100% Vision Service Plan Satisfaction Guarantee!

Open Enrollment is year-round!  Learn how to enroll right now.






“Millions of people are without vision coverage, and we want to increase access to care for those who wouldn’t otherwise be covered through an employer,” said Ken Stellmacher, Senior Vice President & General Manager of VSP Individual Plans. “Our mission is to help people see, and one of the ways we do that is by supplying brokers with a valuable product that is affordable for their clients. Also, with adult vision care not offered as part of the new public health insurance exchanges, this is a great avenue to make vision care easily accessible to consumers.

Vision Service Plan for Individuals & Families


More than 50 percent of Americans are without vision coverage.1 In an effort to increase access to care, VSP® Vision Care, the nation’s largest not-for-profit vision services and benefits company, recently launched a program for insurance brokers to sell individual vision plans directly to consumers.

Authorized brokers can now sell VSP individual insurance plans through a website hosted by VSP that allows clients to self-enroll. The vision plan, created exclusively for brokers, provides individuals and families the same high-quality eye care that VSP offers through employers­—directly to individuals who don’t have access to vision care. Like VSP’s employer-sponsored plans, the individual plan also offers the lowest out-of-pockets cost in vision care with a satisfaction guarantee.

1Source:  Vision Council (June 2013 Vision Watch Vision Correction Standard Report, Table 26A) Read the full press release right here.

Additional Resources


For Individual and Family Health Plans, view online pricing, free of charge.

Shopping California Health Insurance

Shopping California Health Insurance? Smart consumers with existing insurance policies are returning to the California group insurance market.  Don’t be stuck with your plan for another year.

Shopping California Health Insurance Locally

View online pricing, free of charge.

New Sutter Health Plan Includes PAMF Doctors

PAMF doctors are found in few health plans in Covered California. Even if you go to the individual private market, PAMF doctors are found in one or two individual plan plans, if you are lucky.

Exciting news is…in 2016, a new Sutter Health Plan will include PAMF doctors in many parts of the bay area.

Rates, PAMF Doctors, and More

Get rates and Download the Application.

Additional Sutter Health Plan Resources:

  • Side By Side Quick Comparison of Sutter Health Plan Options
  • Download and Review a sample Individual Bronze Plan EOC
  • Download and Review a sample Individual Silver Plan EOC
  • Download and Review a sample Individual Gold Plan EOC
  • Download and Review a sample Individual Platinum Plan EOC
  • Download Enrollment Guide
  • Download the Application
  • Get Rates

or view online pricing, free of charge


Sutter Health Plan has Affordable Coverage

If you’re looking for affordable health care coverage, Sutter Health Plus offers a variety of HMO products for individuals and families in Northern California.

The doctors, hospitals and other service providers in network (e.g. PAMF) have a strong commitment to personalized, convenient, high-quality care.

Sutter Health Plus membership has its benefits, including access to:

  • A nationally recognized network of local providers and hospitals e.g. Palo Alto Medical Foundation
  • Comprehensive medical benefits
  • Pharmacy coverage
  • A 24/7 nurse advice triage line
  • Wellness
  • Free preventive care services, e.g. annual well visits, immunizations
  • Coverage for emergency care anywhere in the world
  • My Health Online allows members who chose a provider (who offers this service) to schedule appointments, email doctors, view test results etc. There is also a mobile app

Watch the Health Online Video

As the individual marketplace continues to deteriorate, the small group market has gained a firmer footing, including stable PPO networks and easier participation rules with Kaiser and traditional PPO plans.  Is it time to review available small group plans?

View online pricing, free of charge

9 Risk Factors Applying To Covered California

In addition to the advantages, we have documented at least 9 disadvantages i.e. 9 risk factors applying to Covered California.  Despite limited media attention, these factors require caution and understanding, because of the potential for problems after you apply to Obamacare.

9 Risk Factors Applying To Covered California

9 Risk Factors Applying To Covered California

We encourage California residents to study the balance of this report carefully, in order to make the best decision for your family.

9 Risk Factors Applying To Covered California

9 Risk Factors Applying To Covered CaliforniaDescription of RiskPossible Solution
Risk Factor 1The State of California (via county social services agency) verifies the financial information on your CoveredCA application and has the power to make you “ineligible” for CovCA insurance if there are discrepancies between the application, filed income tax returns, immigration documents etc.Understand that CovCA uses last year’s tax return information to estimate your APTC subsidy, however the true amount will not be known until you file this year’s tax return. Work with a Certified Agent who can discuss these issues with you.
Risk Factor 2The verification of your application occurs during an indeterminate period of time, usually between January and August, but usually after you have cancelled your former insurance.
Risk Factor 3A frequent and undesirable outcome of the agency’s application verification process is that your insurance is revoked and you are temporarily placed in Medi-Cal, pending approval by a Medi-Cal eligibility case worker. Medi-Cal representatives will use the authority of the State of California to issue a system-generated freeze, named “soft-pause” on your file at CovCA. It effectively prevents Covered California IT engineers from “fixing” or undoing this Medi-Cal action. Your only recourse is to personally visit the county social services agency and attempt to determine the identity of your case worker, and then to arrange a meeting in the hope of opting out of Medi-Cal.
Risk Factor 4Placement into Medi-Cal, outside of “open enrollment” season is not a qualifying “special event.” This prevents you from re-applying elsewhere, since no health plan will accept your application until the next open or special enrollment.If this occurs during an open enrollment period, you can re-apply directly to Kaiser or another health plan. Otherwise, you will have to stay on Medi-Cal until the next Open or Special enrollment period.
Risk Factor 5Involuntary loss of health insurance could result in losing access to your personal physician(s).There is really no remedy, except to find a Medi-Cal doctor or specialist and transfer your chart.
Risk Factor 6Involuntary placement into Medi-Cal mid-year could occur during a course of treatment, surgery etc.We have observed cases where this has happened, and it is unfortunate.
Risk Factor 7Split Family Coverage: Since Medi-Cal eligibility for children is at 250% of FPL, compared to 138% for Adults (in most cases), a common outcome of a family application is that the adults are processed for CovCA insurance with a subsidy, but the children are declared ineligible and are pended for Medi-Cal.Work with a Certified Agent who can estimate the probability of this occurrence and will be prepared to submit child-only applications directly with the insurance carrier (off-exchange) to avoid Medi-Cal. It may be necessary to submit dual applications (on and off exchange) if the open enrollment deadline is near.
Risk Factor 8f your income increases during the year, your APTC subsidy could be less, resulting in you having to repay the IRS for part or your entire APTC subsidy.Ask your Certified Agent to lower the monthly APTC subsidy to give a safety margin. When you file your tax return, you will get the difference paid to you, assuming you are eligible for it.
Risk Factor 9If the IRS determines you were eligible for qualified, affordable employer-sponsored health coverage, your APTC subsidy will be reversed, subjecting you to penalties and interest.When an employer offers an employee health insurance, a report is sent to the IRS, identifying the employee by name and social security number, even when you decline the coverage. This is how the IRS cross-checks this information. If you declined coverage, you may still qualify for the subsidy via an exception. Work with a Certified Agent or your tax preparer to see if you qualify for the exception.

Caution is advised when you buy Obamacare through CoveredCA. To read more about the pros and cons of Covered California in general, and whether you should buy the Obamacare Kaiser plan, read this story at

View online pricing, free of charge

Re-Shopping Obamacare For Better Covered CA Insurance

New York Times writer, Margot Sanger-Katz is suggesting consumers should be re-shopping Obamacare coverage. The article argues the savings could be substantial. Even the Health and Human Services agency discovered last year that “Returning Consumers Who Shop Save Money.”

Re-Shopping Obamacare

As the individual marketplace continues to deteriorate, the small group market has gained a firmer footing, including stable PPO networks and easier participation rules with Kaiser and traditional PPO plans.  Is it time to review available small group plans?

View online pricing, free of charge

“Returning Consumers Who Shop Save Money.”

Re-Shopping Obamacare

Re-Shopping Obamacare

Change Kaiser Group Health Insurance To Covered California?

FAQ Kaiser Group Health Insurance and Covered California

Question: We are a non-profit organization located in California: Is there any advantage if we change our Kaiser group health insurance plan to Covered California?

Answer: Yes, there are advantages of buying Kaiser group health insurance through Covered California. For example, many non-profits can take advantage of a special tax credit under the Patient Protection And Affordable Care Act, if eligible (read the rest of this article at

Finding Help Locally

or view online pricing, free of charge

Compare off-exchange and Covered California Kaiser Small Business Plans using our free online rate calculator.