By Sara Lee, Supervising Attorney, Health Consumer Action Center (Health Unit)

Living on modest means, Sophie (fictitious name) qualified for and was enrolled in a Covered California (CC) healthcare plan that provided her with a premium payment subsidy. Current with her premium payment through the end of November, she was surprised when she received a notice stating her plan was terminated, effective November 1st.

Suffering from a health condition that puts her at high risk for COVID-19, losing coverage in the middle of a pandemic was overwhelming to her. At a loss about what to do and in distress, she called us, CLA SoCal’s Health Consumer Action Center (Health Unit), for assistance.

Sophie told me as far as she knew, her case was sent to Medi-Cal and that she didn’t understand why. Based on her 2020 reported income, this should not have happened as she and her household members were clearly eligible for a CC plan with subsidy, and not Medi-Cal. I advised her that if her case was sent to Medi-Cal, then she should have continued with her CC plan coverage until found eligible for Medi-Cal to avoid a gap in coverage. I then quickly moved forward to resolve the matter.

We submitted an inquiry on Sophie’s behalf to Covered CA escalation unit. Through our contact with Covered CA, we learned that Medi-Cal/County’s closure of their review of Sophie’s coverage is what triggered the erroneous termination of her enrollment in the CC plan. The cause for the termination appears to be a glitch in the system. After the discovery came to light, Sophie’s CC plan was swiftly reinstated, to her great relief, and her case was fully resolved.

Although Sophie’s case was successfully closed, the Health Unit’s work was not entirely done. We have identified two other cases with the same issue and addressed it with Covered CA requesting they further investigate and confirm if a system issue/glitch is involved and if so, resolve it. The Health Unit not only provides direct legal assistance on health care access and coverage eligibility issues to health consumers like Sophie, but we also engage in systemic advocacy to help improve access to healthcare and health insurance coverage.