Qualifying Events for California Children

How to Get the Best Health Insurance Rates for California Children (Ages 0 to 18)

If you are looking for medical coverage for a child who lives in California and is under age 19, note that the child’s rate may be subject to a surcharge. See below to find out how you can keep the California child health insurance rates at the lowest possible level.

Children ages 0 through 18 cannot be denied health insurance, however, their rates are subject to adjustment if certain conditions exist. In California, a child’s premium could be rated-up if he or she:

  • Did not have prior Insurance the last 90 days before the application date.
  • Has a pre-existing medical condition.
Squiggly Son and Father

Prior Insurance

In accordance with California State Bill AB 2244, a 20% surcharge may be applied to your child’s premium if he or she was uninsured for 90 days prior to submitting an application for medical coverage. If the child had health benefits sometime during the 90 day window, the 20% surcharge will not be assessed.

The surcharge can be avoided if your child was insured sometime during the last 90 days and evidence is provided. The proof required is a certificate of creditable coverage, which is provided by the insurance company that covered your child during the 90 day window. If the child was uninsured the past 90 days and the 20% is assessed, it will continue to be applied for 12 months.

When applying for California child health insurance with Kaiser Permanente, it is ideal to apply via paper application so you can include a copy of the creditable coverage certificate. An alternative is to apply online and fax the certificate within 14 days. If the form is not available at the time of the enrollment, the child’s premium will be surcharged. The 20% can be reversed if the proof of prior insurance is provided within 60 days after the application date.

Pre-Existing Medical Condition

If your child has a health condition, especially one that is serious, recurring, or chronic, a surcharge could be applied to the premium. The amount of the surcharge will depend on the severity of the health condition. The surcharge could be lower if your child had a qualifying event, documentation on the qualifying event is provided, and you submit an application within 63 days of the event. A qualifying event is a life event or situation that the state of California has deemed as a “qualifying event”. See the checklist below for a list of qualifying events and the supporting documents required.

CHECKLIST
Qualifying Events. If any of the situations below apply to your child:Send a copy of the listed paperwork:
Loss of medical coverage from a public program, such as Medi-Cal, Healthy Families, or Access for Infants and Mothers Program (AIM).
  • A letter from the public program evidencing the loss of benefits
Loss of group insurance
  • Letter from the employer advising of the termination and the reason for the decision, or
  • Letter from the insurance company advising of the plan termination.
Employer discontinued sharing the cost of the premium
  • Statement letter from the employer, or
  • Letter from the insurance company
Newborn
  • Birth certificate or
  • A letter from a hospital evidencing proof of birth
Adoption
  • Adoption papers
Divorce or legal separation
  • Filed court papers and Creditable coverage certificate
Court-ordered mandate
  • Court order requiring insurance for the child
New California resident
  • Proof of address, i.e. a copy of a rental agreement or utility bill in the parent’s name, dated within the last 63 days.
Death of a policyholder
  • Death certificate or a telephone call from the surviving parent or guardian and Creditable coverage certificate
Open Enrollment. Birth Month: Send a copy of the listed paperwork:
The month of a child’s birthday is considered as an open enrollment period by the state of California. If you apply for your child during their birth month, it will affect their premium in the same way as a qualifying event will, in that the surcharge for a pre-existing condition, if any, will be lower.
  • Birth certificate

* Note: Please write the child’s name in the top right-hand corner of each document to keep your records together.

For additional information regarding qualifying events for California child health insurance, click here.

 
 
 
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