By MATTHEW HOLT
Strap in for a dramatic tale in which our hero battles bureaucracy and logic to try to get his health insurance back.
About 20 years ago lots of Americans, especially Californians who bought health insurance from Blue Shield of California, found that their coverage was cancelled without them knowing about it. That practice called “recission” got lots of attention during the run up to the ACA, and was banned by it. Now if you want to buy insurance and you pay for it, the insurance company has to sell it to you and can’t cancel it after the fact.
Or so I thought.
Post ACA most people who don’t get their insurance through an employer, or Medicare or Medicaid, now buy it via a very regulated “individual market” on a state-based or Federal exchange. Generally, the insurance they buy is heavily standardized (with bronze, silver or gold levels) and what they pay for insurance is heavily subsidized based on income. It’s those subsidies that were increased in the pandemic and extended in the Inflation Reduction Act (IRA) during the Biden administration. The subsidies were the topic–still unresolved–of the latest government shutdown. (Yes, yes, I know the shutdown is over—for now).
It’s pretty much impossible to buy individual insurance outside the exchange, although if you have Scott Galloway levels of wealth you can avoid buying insurance altogether and pay cash and you might be better off, or you can join some quasi-religious health share organization and take your chance. But for most people you are way better off buying on the exchange because that’s the only way you can get those subsidies.
I live in California and remain an under-employed blogger, and a few times in my recent life I have not been married to someone with health insurance provided by their employer. It happened in 2016-17 and again two years ago. No, not what you’re thinking. I didn’t get kicked to the curb by my wife, but in 2022 she got laid off by her employer and decided not to get another job. For the first year of that period (2023) we did not buy via the exchange, but used COBRA. That means we bought into her previous company’s insurance using our own money because it was cheaper than buying on the exchange. Two reasons for this. First, she got a severance package that made our combined incomes too high to get a subsidy and secondly, the ACA plans charge by age, whereas employers pay a flat fee for all employees. That made the exchange plan more expensive than the employer plan. (No prizes for guessing who in our family is old and expensive!)
But COBRA only lasts a year, and then it was time to head back to Covered California.
This starts a process where you try to figure out which plan offered is the cheapest, yet includes your and your family’s doctors, and which one has the lowest associated fees for the stuff you use the most (usually pediatric visits in our case). Turns out that in our case is the Blue Shield Trio 73 HMO. My inability to understand why it’s called Trio 73 reveals why no one calls me a marketing genius.
The other thing you have to figure out is what level of subsidy you get. As mentioned, the IRA passed in 2022 extended the pandemic emergency increase in subsidies for people with higher incomes. But then again, you have to figure out what your income will be when you sign up. Like the audience laughing at an obvious punch line a comedian hasn’t gotten to yet, those of you running ahead of me will have worked out a slight problem here.
I was signing up for a 2024 health plan in 2023. But I had to guess what my 2024 taxable income would be. Like many self-employed people with extremely variable income I had no idea what that final income would be until I filed my 2024 taxes in October 2025 (given I take the IRS extension). In other words, almost two years after I chose the plan. It turns out that in California, the people who track your income are not your health plan, nor the exchange but instead your local county health department. So in November 2023 I guessed my 2024 income and had to tell the local county what that guess is via some affidavit. The county health department actually called me to check that my estimate was correct. Or at least was what I told them it was. Remember this for later.
Meanwhile I sign up on what I regard to be a very complex web site run by Covered California, and select the aforementioned Blue Shield HMO. It covers One Medical and UCSF theoretically via the Brown & Toland IPA, and leads to lots of fun and games in terms generating much content for me on this blog and Linkedin.
As it turns out, I was sent for an echocardiogram by my primary care doctor this past summer to check if I had a heart. While many of you were surprised at the answer (yes, I do), apparently it’s got a congenital disorder that needs a little help.
This gets us to November 2025 (last month!) with your brave hero going back onto the Covered California exchange trying to figure out whether the cardiologist recommended by my primary care doc is covered by the 2026 version of the Blue Shield plan I am on, or whether I need to switch. I could now digress and tell you the late Ian Morrison’s formula for choosing a health plan but I will hold that for the next telenovela article as of course that process is a fricking mess too!
In order to try to do that I login to the Covered California site and see I have a notice that I am not eligible for health insurance. I am confused.
The next day my wife gets a letter from Blue Shield telling her that she and my kids have a new insurance member number and a new primary care doctor. And at the kids’ next visit to One Medical (also in November) they tell her that they are no longer their primary care doctor and the visit may not be covered. By the way, I think I have been told my primary care doctor has changed 3 times while I have been on this HMO in the past 23 months and at no time do I recall my actual primary care doctor’s name or One Medical being on the shiny new ID card they send me. But they still pay for my annual wellness visit with my One Medical PCP. So I assume it doesn’t much matter.
While my wife is getting a new card and new membership number, I get a letter from Blue Shield saying I am not eligible for insurance, and my plan is cancelled as of November 30th.
You might surmise I am a little puzzled. After all they can’t cancel insurance any more, and I’d already paid for November.
So I head to the Covered California website to try to figure out what happened. After a lot of digging, I get into the first of many long message chats with their human agents. To be honest they are all trying hard and even though you start off 27th or so in the queue you get someone quite quickly. (They do not though have a ChatGPT-like intelligent AI support agent though which several companies now use).
It turns out that Covered California has decided I am not a US citizen.
I go into my status, dig through all the questions I answered and there it is. Citizenship box checked as “no”. To be fair, I may have made that mistake when I signed up 2 years ago. But it’s worth pointing out that I had insurance in 2016 & 2017 via Covered California, and had it from January 2024 to November 2025 before anyone decided anything was wrong. As far as I am aware no one cared enough to notify me before telling me my insurance was cancelled.
Still presumably easy enough to fix. I go into my application and check the box saying citizen. It then asks me if I was naturalized. Foolishly (and truthfully) I check the box for “yes”. It then asks me for my naturalization number. Well that 25 year old certificate is in a safe somewhere, so I ignore that request and head back to the online chat. Turns out there’s a way I can upload documents, and one of the ones allowed is a passport, so I do that.
I assume all is well and that I’ll be reinstated. A little too optimistic.
I also have a suspicion that I know what has triggered all this.
Remember that issue of trying to guess your income for the future from two years ago? Well In mid-October 2025 I (well, my accountant) finally got my 2024 taxes into the IRS. Sadly my 2024 income was rather lower than my optimistic estimate, and on my tax form I actually got a rebate because I had overpaid my premium. In other words I got some tax back from the IRS because I had not received as big a subsidy from Covered California in 2024 as I was entitled to. (How that transfer works between Trump and Newsom I do not know!)
In the flurry of letters and notices from Covered California in November 2025, some of them increased my subsidy for 2025 which meant that for the remaining month of 2025 my family’s premium went down. On the other hand, at the same time my insurance was cancelled, and I got a notice that my children might be eligible for Medicaid (Medi-Cal in California). Was this because of my lower than expected 2024 income or was it because I had put that my wife had $0 income in 2025 on the form? I am still unsure of that answer.
However, I then got a letter from the County Health Department asking me to prove my citizenship and to again put in an affidavit for my income. I headed back to the Covered California online chat to try to sort it out. Despite being logged into the site, and giving them the reference number of my last 3 chats, I still have to tell them my name, date of birth, address, inside leg measurement and how many games the SF Giants won in 1993 to get them to verify me. Their advice was to call the County.
I call the Marin County Health Department. Their phone line is only open at very specific times like 2-4 on Tuesdays when the moon is in retrograde. When you call back during those times, they play you about 4 minutes worth of messages, then put you through a long phone tree. At the end of the phone tree they tell you the average hold time is, I kid you not, 2 hours. If you really need the County’s help, I’m not sure that’s the way an average low income Medi-cal recipient is going to get it.
Now, no one told me this, but eventually after a little googling I found that there’s a web site called BenefitsCal. You can register for this website for County services, and one of the things you can do is upload proof of citizenship. So like I had done with Covered California, I uploaded my passport.
A few days later, I go back to the Covered California site, and see a message/letter dated November 18 than I am temporarily reinstated on my plan. During my next long online chat with Covered California—you knew I was going to have one—they tell me that I am officially recognized as a citizen and therefore eligible for the insurance I have had from them for nearly 4 years!
As it happens I have a long standing appointment with Andrew Diamond at One Medical on December 1 to discuss that heart condition. I arrive at the desk and they tell me that Blue Shield says I don’t have insurance. Sitting in the waiting room, I call Blue Shield who confirm I don’t. I tell the Blue Shield rep that not only was I reinstated on November 18 but that their website confirms in my profile that I am covered. The rep tells me nicely that it can take 10 business days to show. Why the website and their rep’s system show different things I don’t know. I tell One Medical not to put in the claim for a week or so
Meanwhile while I have her on, I ask the rep if she can change my PCP of record back to One Medical and do the same for my wife and kids. She looks up Andrew Diamond and the name of every One Medical doctor I can find on their site that my kids have seen. (One Medical does a nice visit history list).
None of them are in her system.
The One Medical receptionist suggests that I call back and get someone else “because if appears to be totally random with them”.
The end of this part of the telenovela is that I call Blue Shield 3 days later. I was mostly asking about which of their plans that cardiologist was covered on, and of course they couldn’t tell me that and referred me back to Covered California’s website! (more on that next episode!). But they have now found me in their system, and I notice that my subscriber number has changed.
But while I had the rep on, I asked who my primary care doc was. It was still someone I had never heard of. Could I change it to One Medical, I asked? Give me a name and I’ll try, the rep said. Andrew Diamond, I wondered? Yes, of course was the reply. So now my PCP is my actual correct PCP.
So being really bold, I asked can I change my wife’s and my kids PCP to One Medical too? Yes but I need their permission? I understand needing my wife’s permission but why do I need my kids? Well they are over 10 years old! I took the phone to my wife who was in the next room and they got her permission to change her PCP also to Andrew Diamond (who isn’t her PCP but is at least in One Medical).
Later in the day, my wife is driving the kids to swimming, She calls Blue Shield and asks to change their PCP. The rep makes the change without asking for my kids’ permission! As the One Medical receptionist said, “it appears to be totally random with them”.
***
So as of December 4, 2025 we as a family are signed up for the correct health plan with the correct PCP, and we hope it works retroactively for any November visits.
Of course, who the hell—other than an under-employed health care blogger generating content—has the time to deal with this complete mess? In every other country in the world you get the equivalent of a social security card and show up at any doctor or hospital and get treated. Americans are rats in a health care maze looking desperately for cheese that keeps getting moved.
Oh, and I still have to figure out the right plan for January 2026….three weeks from now.
Matthew Holt is the founder/publisher and sometime author of THCB
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