|
|
Employer-Sponsored Coverage
If a client's employer-sponsored coverage is affordable, the client is not eligible for APTC. If an employer-sponsored health plan covers the client (the employee) but not the family and is less than 9.5% of the family's income, the plan is considered affordable.
The client may pay more than 9.5% of the family's income on premiums for the spouse or family coverage, but affordability is determined by the amount the employee pays for self-only coverage from the employer. If the employee's coverage is less than 9.5% of the total family income, the spouse and dependent coverage are automatically determined affordable even if the family coverage is over 9.5% of the total income.
If the employee-only coverage is less than 9.5% of the family income, the family is not eligible for APTC.
Loss of Employer-Sponsored Coverage Due to a Strike or Lockout
Individuals engaged in a strike or lockout with their employer may lose their employer-sponsored coverage due to the dispute. When this happens, the individual should be screened for Medi-Cal using the appropriate budgeting method outlined in the Medi-Cal HB Chapter 7. If the individual is not eligible for Medi-Cal and eligible for a Covered California plan with premium assistance, they will be eligible for the maximum premium subsidies through the Covered California system. Eligibility staff must assist the individual in completing the report a change process in CalHEERS and select "strike lockout" as the reason for losing coverage. For CalHEERS systems entries [Refer to JOB AID (JA): REPORT A CHANGE].
Related Topics