CalHEERS

Covered CA certified plans are available in the California Healthcare Eligibility, Enrollment and Retention System (CalHEERS). The Covered CA website (www.CoveredCA.com) allows clients to access online tools that help them compare coverage among the health plans, determine their eligibility, and enroll in coverage.

CalHEERS has the Business Rules Engine (BRE) to determine client eligibility for MAGI MC, APTC, CSR, or QHP. All MAGI MC eligibility determinations occur in CalHEERS, but CalSAWS remains the system of record for all MC cases. Eligibility Workers (EWs) enter information into CalSAWS which interfaces with CalHEERS via the Electronic Health Information Transfer (eHIT).

CalHEERS validates information via the Federal Hub and sends a Determination Eligibility Response (DER) to the External Referral Subsystem in CalSAWS with the healthcare application and eligibility information.

In certain situations, CalHEERS may approve MAGI MC eligibility and send eligibility directly to MEDS.

Example Example  If a family completes an application in CalHEERS and all family members are determined eligible for MAGI MC and all information is verified via the Federal Hub, then CalHEERS will automatically send that information directly to MEDS in addition to the DER sent to CalSAWS. Clerical staff completes application registration for the ERD and assigns it to the EW. The EW uploads the information into CalSAWS. 

Related Topics

Affordable Care Act

Coverage Enrollment Period