Key Takeaways
- Medi-Cal is California's Medicaid program providing health coverage to low-income residents
- Covered California is California's health insurance marketplace offering individual and small group coverage with premium subsidies
- California State Disability Insurance (SDI) provides short-term disability benefits and Paid Family Leave (PFL)
- CLIFHIGA (California Life and Health Insurance Guarantee Association) protects policyholders when insurers become insolvent
- California participates in the Long-Term Care Partnership Program for Medicaid asset protection
California State Insurance Programs
California operates several important state programs that insurance producers should understand when helping clients evaluate coverage options.
Medi-Cal (California Medicaid)
Medi-Cal is California's Medicaid program providing healthcare to low-income residents:
Who Medi-Cal Covers
| Population | Income Limit (approx.) |
|---|---|
| Adults (expansion) | 138% Federal Poverty Level (FPL) |
| Pregnant women | 213% FPL |
| Children | Higher limits by age |
| Seniors/Disabled | SSI-related eligibility |
Medi-Cal Benefits
- Doctor visits and hospital care
- Prescription drugs
- Mental health services
- Long-term care
- Dental services
- Vision care
- Prenatal care
- Preventive services
Exam Tip: Medi-Cal is California's name for Medicaid. Unlike most states, California provides dental and vision coverage for most Medi-Cal recipients.
Covered California
Covered California is the state's health insurance marketplace:
What Covered California Offers
| Feature | Description |
|---|---|
| Individual Plans | Qualified Health Plans (QHPs) for individuals/families |
| Small Business (SHOP) | Plans for employers 1-100 employees |
| Premium Tax Credits | Federal subsidies for eligible purchasers |
| Cost-Sharing Reductions | Lower out-of-pocket costs for Silver plans |
Metal Tiers
| Tier | Approximate Value |
|---|---|
| Bronze | 60% actuarial value |
| Silver | 70% actuarial value |
| Gold | 80% actuarial value |
| Platinum | 90% actuarial value |
Special Enrollment Periods
Outside of open enrollment, individuals can enroll if:
- Loss of other coverage
- Marriage, divorce, or domestic partnership
- Birth or adoption
- Move to new service area
- Becoming a citizen or lawful resident
California State Disability Insurance (SDI)
California's SDI program provides short-term disability benefits:
SDI Coverage
| Feature | Detail |
|---|---|
| Who's Covered | Most California employees |
| Funding | Employee payroll deductions |
| Benefit Amount | 60-70% of wages (up to max) |
| Maximum Duration | Up to 52 weeks |
| Waiting Period | 7 days (illness) or day of injury |
Paid Family Leave (PFL)
PFL is part of SDI and provides benefits for:
- Caring for seriously ill family member
- Bonding with new child (birth, adoption, foster)
- Military family leave
| Feature | Detail |
|---|---|
| Duration | Up to 8 weeks |
| Benefit Amount | 60-70% of wages (up to max) |
| Job Protection | Separate from FMLA |
Voluntary Disability Insurance
Employers can offer approved private disability plans that:
- Replace SDI
- Must meet or exceed SDI benefits
- Are called Voluntary Plans (VP)
- Funded by employee contributions
California Long-Term Care Partnership Program
California participates in the LTC Partnership Program:
How It Works
- Purchase a Partnership-qualified LTC policy
- Use benefits for qualifying care
- If benefits exhaust, apply for Medi-Cal
- Asset protection: Keep assets equal to benefits received
Example
| Without Partnership | With Partnership |
|---|---|
| Spend down to $2,000 | Protect assets up to benefits paid |
| May lose home equity | May keep home and protected assets |
| Standard Medi-Cal rules | Enhanced asset protection |
Partnership Policy Requirements
- Must meet federal and California requirements
- Inflation protection required (age-based)
- Must be sold by certified producers
- Must be certified as Partnership-compliant
CLIFHIGA (California Life and Health Insurance Guarantee Association)
CLIFHIGA protects California policyholders when insurers become insolvent:
Coverage Limits
| Policy Type | Maximum Coverage |
|---|---|
| Life Insurance Death Benefit | $500,000 per life |
| Life Insurance Cash Value | $250,000 per policy |
| Annuity Present Value | $250,000 per contract |
| Health Insurance Benefits | $500,000 per individual |
| Disability Income | $500,000 per individual |
| Long-Term Care | $500,000 per individual |
What's Covered
- Individual life insurance
- Group life (California residents)
- Annuities (fixed)
- Health insurance
- Disability insurance
- Long-term care insurance
- Medicare Supplement
What's NOT Covered
- Surplus lines policies
- Self-funded employer plans
- Investment portions of variable products
- Amounts above coverage limits
- Policies from unlicensed insurers
- Interest rate guarantees (some)
Producer Restrictions
Producers CANNOT:
- Use CLIFHIGA as a selling point
- Advertise guaranty association coverage
- Compare to FDIC insurance
- Imply policies are "guaranteed" by fund
Exam Tip: Producers cannot use CLIFHIGA coverage as a selling point. California's $500,000 life insurance death benefit limit is higher than many states.
Producer Responsibilities
When advising clients about state programs:
What Producers Should Do
- Be Aware - Know about available state programs
- Refer Appropriately - Direct to resources when applicable
- Compare Options - Help compare private vs. state options
- Stay Current - Keep up with program changes
What Producers Should NOT Do
- Guarantee eligibility for state programs
- Provide tax or legal advice
- Discourage appropriate private coverage
- Make false statements about programs
What is Medi-Cal?
What is the maximum California State Disability Insurance (SDI) benefit duration?
What is the CLIFHIGA maximum coverage for life insurance death benefits?
Can California insurance producers advertise CLIFHIGA coverage as a selling point?
What is California Paid Family Leave (PFL)?
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