The 48-year-old, who works as the office manager at a nonprofit, can get emergency care through a narrow set of benefits the state makes available to immigrants without legal residency. And she has been able to get mammograms, X-rays, and blood tests at clinics that charge according to income. But it can take a long time to get such appointments, and they are often far from home.

“It’s very frustrating, because you have to have the time to go, and you can’t just lose a day of work,” says Milagro, who asked that her last name be withheld due to fear of immigration authorities.

Milagro and her husband are among the more than 700,000 immigrants ages 26-49 expected to newly qualify for full health insurance come Jan. 1. That’s when California takes the final step in opening up Medi-Cal, the state’s health care program for low-income residents, to everyone who meets eligibility requirements, regardless of their immigration status.

As I have frequently reported, getting quality care through Medi-Cal can be a challenge. But this population — often household breadwinners who can’t afford to get sick — stand to gain far better access to services such as primary and specialty care, routine dental checkups, prescription medications, inpatient hospital care, lab tests, scans, and mental health services.

New enrollees will join more than 655,000 children, young adults through age 25, and adults 50 or over who have already signed up for Medi-Cal through previous expansions to residents lacking legal authorization, according to the most recent data from the state Department of Health Care Services.

Advocates for immigrants note that people without health insurance are generally sicker and die younger. “This is life-changing for people to now be able to go get regular checkups, get labs drawn, see if they might be diabetic or have high blood pressure,” says Sarah Dar, policy director in the Los Angeles office of the California Immigrant Policy Center.

Milagro says she is excited about what is coming. “I never had regular checkups when I was younger,” she says. “Now, I am more conscious of the fact that I need to take care of my health.”

Extending full Medi-Cal coverage to eligible individuals in the 26-49 age range regardless of immigration status is projected to cost the state $1.4 billion in the first six months and $3.4 billion a year upon full implementation.

The state’s estimate of just over 700,000 new enrollees is based on the number of people in the age group who are already signed up for a narrower set of benefits, known as “restricted scope” Medi-Cal, including Milagro. They will be automatically switched over to full Medi-Cal on Jan. 1. The state has begun mailing notices informing them of expanded benefits and directing them to choose a Medi-Cal health plan unless they live in a county with only one plan.

The remaining residents in the 26-49 age range covered by this expansion will be harder to reach because the state does not know who, where, or how numerous they are. Patient advocates, community groups, and county welfare offices face a number of obstacles: language barriers, wariness of governmental agencies, and fear that signing up for public benefits could jeopardize the chances for legal residency.

One challenge is to convince immigrants that being on Medi-Cal is unlikely to affect their future immigration status under the so-called public charge rule. Advocates point out that California doesn’t share enrollees’ information with federal immigration authorities anyway.

But the fierce anti-immigrant sentiment that was so prevalent during the Trump administration and lingers as the nation gears up for the 2024 elections “sent a message to these communities that they should live in the shadows and are not deserving of benefits,” says Dar.

Even those already in the restricted version of Medi-Cal will be a challenge to reach if their contact information is not up to date. And they could be unaware that they were part of Medi-Cal at all. If, for example, they had a health crisis, were taken to the emergency room, and were simply asked by hospital staff to sign some paperwork to cover their treatment, they might not understand what a mailing from Medi-Cal means.

And some may fear any contact by the government. Lena Silver, director of policy and administrative advocacy at Neighborhood Legal Services of Los Angeles County, says she conducted a training session where a woman who works with day laborers said many of them were afraid to open the envelopes they’d received.

The Department of Health Care Services is spearheading an outreach campaign in 19 languages that includes ads on radio, TV, and social media.

Potentially complicating matters is the fact that the expansion of health benefits to this last ― and largest — group of immigrants coincides with the so-called Medi-Cal unwinding, in which over 900,000 beneficiaries and counting have been disenrolled, mostly due to incomplete paperwork, as pandemic-era exemptions expire.

Immigrants with restricted Medi-Cal must also demonstrate their continued income eligibility in the unwinding, which can be confusing when such a request is piled on top of notices informing them of their newly expanded benefits.

If you, a friend, or a loved one is an immigrant without legal residency, resources are available to help navigate the Medi-Cal enrollment process. A page on the Department of Health Care Services website (dhcs.ca.gov) explains the expansion and contains an FAQ in multiple languages detailing the new benefits that come with it.

If you need help enrolling in a Medi-Cal plan or filling out forms to demonstrate your eligibility, try the Health Consumer Alliance (healthconsumer.org, or 1-888-804-3536). Community clinics are also good sources, as are county offices that administer Medi-Cal.

Brenda, a 33-year-old Los Angeles County resident who also asked to withhold her last name because she lacks legal immigration status, says it will be “a big old blessing” to get full Medi-Cal benefits. She arrived from Mexico as a child and has had to pay for most health care needs out of her own pocket. She rarely goes to the doctor, she hasn’t seen a dentist in three years despite toothaches, and her glasses are five years old.

Come January, she plans to be screened for breast cancer and diabetes, which runs in her family. And, she says, “I definitely want to fix my teeth. I always wanted a Colgate smile.”

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She was taken to a hospital in Clovis, a city in Fresno County, near where the Reisz family lives. But the severity of Megan’s injuries — four broken ribs and a partially collapsed lung — prompted doctors to transport her 12 miles by ambulance to the Level I trauma center at Community Regional Medical Center in Fresno.

While Megan was still recovering at home from her injuries, she received a $2,400 bill from the ambulance company — after the family’s health plan had paid nearly $2,200.

“When we received the bill, I thought our insurance company was processing the claim incorrectly,” says Jennifer Reisz. An attorney, Reisz says she then spent hours on the phone with the health plan, the ambulance company, and a few consumer advocates. She learned that the ambulance company was not in the health plan’s network and was permitted to bill patients for any uncovered portion of its charges — a practice known as balance billing.

Starting Jan. 1, ground ambulance operators will be barred from doing that, thanks to a new law signed by Democratic Gov. Gavin Newsom. California is the 14th state to provide some protection against balance billing for ground ambulance rides.

At the federal level, an advisory committee established under the No Surprises Act is working on a plan to address the problem nationally.

Both the federal law, which took effect in 2022, and a California law that predates it largely banned balance billing for hospital care and air ambulance services, but not ground ambulance services.

And that is hardly fair, since patients have zero control in a medical emergency over which ambulance company responds, whether it is in network, or how much it will charge.

In California, nearly three-quarters of emergency ground ambulance rides result in out-of-network bills. The average surprise bill for a ground ambulance ride in California is $1,209, the highest in the nation, according to a December study.

The new law, which applies to about 14 million Californians enrolled in state-regulated commercial health plans, limits how much a non-network ambulance operator can charge patients to the amount they would pay for an in-network ambulance.

The law also caps bills for uninsured people, stipulating they can’t be charged more than the Medi-Cal or Medicare rate, whichever is greater. (Medi-Cal is California’s Medicaid program, providing coverage to people with low incomes or disabilities.) And it prohibits ambulance operators and debt collectors from reporting patients to a credit rating agency or taking legal action against them for at least 12 months after the initial bill.

Under current law, people in distress sometimes decline to call an ambulance for fear of a huge bill, putting themselves or a loved one at risk, says Katie Van Deynze, policy and legislative advocate for Health Access California, which sponsored the legislation. With the new law, she says, “they will have peace of mind.”

Existing laws already protect Medicare and Medi-Cal beneficiaries from surprise ground ambulance bills. The new law does not cover the nearly 6 million Californians enrolled in the subset of employer-sponsored health plans that are federally regulated.

The advisory committee working on a federal fix agreed last week on nonbinding proposals that would, among other things, prohibit balance billing for the vast majority of ambulance rides and cap patients’ financial liability at $100. The committee plans to formally report its recommendations to Congress early next year for potential legislation.

Under California’s new law, patients can expect to save an average of nearly $1,100 per emergency ambulance ride and over $800 per nonemergency ride in the first year, according to a legislative analysis conducted earlier this year.

Health plans will be required to pay ambulance operators the rates set by county authorities, which the study said would increase the average amount insurers pay per ride by around $2,000.

Since ambulance rides account for a tiny percentage of overall health plan spending, those increases should not raise premiums by much.

But local authorities might be tempted to hike ambulance rates over time to increase revenue for publicly run ambulance operators, such as fire departments, says Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. That could prompt health plans to raise ambulance copays, offsetting some of the consumer savings from the new law, Adler says.

Jenn Engstrom, director of CalPIRG, an advocacy group that helped shepherd the law through the legislature, notes there will be built-in accountability, since the legislation requires public reporting of ambulance rates. “If we notice that things start to skyrocket, there will be a need for legislative action or local action,” Engstrom says.

Reisz says the ambulance company that transported her daughter wrote off the bill after she made it clear she had no intention of paying it — and after her health plan ponied up a little more. But as she notes, not everyone is a lawyer adept at arguing their cause.

Even if you are no rhetorical wizard, you can take simple steps to protect yourself against errors or ambulance operators that disregard the new law.

Check your insurance policy to know your deductible and any copay or coinsurance should you ever need an ambulance. If you get an ambulance bill, don’t pay it right away. Check your insurer’s explanation of benefits to make sure what it says you owe matches what you think your cost-sharing amount should be. If the bill is higher, the ambulance company may be trying to pull a fast one. Call the ambulance company and tell them they need to knock the bill down. If they don’t, file a complaint with your health plan and include a copy of the bill.

If you disagree with your plan’s decision, or it takes more than 30 days for the plan to respond, take your complaint to the regulator.

The new law requires your insurer to tell you if your health plan is regulated by the state and thus subject to the statute. If it is, the regulator is likely to be the Department of Managed Health Care. You can contact that agency online (www.healthhelp.ca.gov) or by phone at 1-888-466-2219. If your health plan is regulated by the Department of Insurance, you can file a complaint online (www.insurance.ca.gov) or call 1-800-927-4357.

Another good resource is the Health Consumer Alliance, which offers free legal assistance in multiple languages. Call 1-888-804-3536.

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The office was already closed, but the whole eye care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again — heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure, or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A 2016 study published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing, or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit Prevent Blindness and Regeneron Pharmaceuticals, showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, founding director of the Southern California Eye Institute at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost, and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions — or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting refractive errors, which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects about 3 million people in the U.S., attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is five times as prevalent among African Americans as in the general population.

Nearly 10 million in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some 20 million people age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: Half of people 75 and older have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic group at high risk for certain eye diseases.

And don’t forget children. Multiple eye conditions can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, a clinical spokesperson for the American Academy of Ophthalmology and executive director of the Glaucoma Center of San Francisco.

Minimize stress, get regular exercise, and eat a healthy diet. Also, quit smoking. It increases the risk of major eye diseases.

And consider adopting habits that protect your eyes from injury: Wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone, and wear goggles when working around the house or playing sports.

The Prevent Blindness website offers information on virtually everything related to eye health, including insurance. Other good sources include the American Academy of Ophthalmology’s “EyeSmart” site and the National Eye Institute.

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

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The 60-bed safety-net residential treatment center in Santa Fe Springs, run by Los Angeles Centers for Alcohol and Drug Abuse, has a dedicated detox room, on-site physicians and nurses, substance abuse counselors, licensed therapists, and other practitioners. It offers group counseling as well as individual and family therapy, and it endorses the use of medications for addiction treatment, such as buprenorphine and naltrexone, which are increasingly considered the gold standard.

Willard Sexton, a staff member and former Allen House patient, says the most important part of his job is speaking with each resident daily. Most of them, like him, came to treatment straight from jail or prison, and he knows as well as anybody how stressful it is to stop using.

“It’s similar to grief and loss,” says Sexton, 35. “The drug was their best friend for a long time.” Interacting with them, he says, helps him in his own ongoing recovery.

At a time when drug use is among the nation’s gravest public health crises, a visit to the Allen House offers key lessons: Addiction is a chronic illness requiring constant vigilance, there’s no one-and-done solution, and relapses are part of the journey to recovery. Peer mentoring is an invaluable element of drug counseling, since people who have plodded the difficult path from dependence to sobriety understand the mindset of patients on a visceral level.

And most importantly for those who feel despair in the grip of addiction, there is hope. “Recovery happens,” says Michelle Doty Cabrera, executive director of the County Behavioral Health Directors Association of California. “Every single day people come into treatment and succeed in addressing their substance use disorders.”

Drug-related overdoses kill almost as many Californians as lung cancer, more than diabetes, and two to three times as many as car accidents, according to a report by California Health Policy Strategies, a Sacramento consulting group. The report showed there were about 11 times as many fentanyl-related deaths in 2021 as in 2017, accounting for more than half of overdose fatalities. And addiction can ruin lives even if it doesn’t end them.

But proper care for substance use disorders can still be hard to find. Experts in the field say residential treatment beds are in short supply. A pandemic-driven shortage of health care workers has hit the drug treatment world. Unscrupulous operators, with an eye on their bottom lines, may take advantage of people desperate for any answer. Commercial insurers often deny treatment requests or propose cheaper alternatives.

Some treatment programs shun anti-addiction medications that have proven effective. Physicians, nurse practitioners, and other providers with the requisite training can prescribe these drugs in California, but too few seem willing or able to do so — though that could change now that federal law no longer requires them to get a special waiver.

A page on the website of the Substance Abuse and Mental Health Services Administration (www.samhsa.gov) allows you to find practitioners in your area who treat patients with buprenorphine.

There’s no one-size-fits-all solution for addiction. Treatment can differ depending on the substance — opioids, alcohol, or methamphetamine, for example. And people with substance use problems come from all walks of life: Some are straight off the streets or out of jail or may have serious mental or medical conditions that require additional care. Others may be otherwise healthy with good jobs and insurance. If a clinic tries to sell you on a standardized treatment program, cross the place off your list.

And if someone tells you that after one stint in their program you or a loved one will be drug-free for life, run the other way. For many people, addiction is a chronic condition that ebbs and flows over many years. Too often, patients in the throes of an overdose are revived and then discharged with no follow-up.

“If we talked about treating other chronic illnesses like diabetes or asthma in the same way we often approach treating substance use, people would think we were crazy or would sue the doctor for malpractice,” says Bradley Stein, a psychiatrist and senior physician policy researcher at the Rand Corp.

Finding the treatment that is right for you or a loved one will take legwork.

Whether it should be a residential or outpatient program depends on multiple factors. People who need to be shielded from exposure to a dealer or a toxic domestic situation, require detox, or have mental health or medical conditions on top of their drug use generally are better off in a residential setting, says Randolph Holmes, medical director of the Los Angeles Centers for Alcohol and Drug Abuse. Outpatient settings are more suitable for people with stable lives and better health or those transitioning from residential treatment, he says.

The cost of treatment can vary widely depending on duration and the patient’s circumstances. In some cases, it can reach tens or hundreds of thousands of dollars.

Various websites allow you to search for nearby addiction treatment. The Substance Abuse and Mental Health Services Administration has a treatment locator at www.findtreatment.gov, or you can call its help line at 800-662-HELP (4347). Shatterproof (www.shatterproof.org) is another source for finding treatment. In California, the Department of Health Care Services publishes a list of substance use help lines by county.

If you’re on Medi-Cal, California’s version of the federal Medicaid program for low-income residents, your county is a good place to start. It can point you to several options, at least in more populous areas. Almost all patients with the Los Angeles Centers for Alcohol and Drug Abuse, for example, are Medi-Cal enrollees.

If you have commercial insurance, call your health plan first. Parity laws require insurers to cover substance use treatment, though they often find reasons not to provide the treatment your provider recommends. If your plan denies you treatment you think you need, you can file an appeal. The Department of Managed Health Care (www.dmhc.ca.gov), the state’s primary health plan regulator, has a help line (888-466-2219) that can assist in appealing your case. Or you can do it online. If the department does not regulate your plan, it can steer you in the right direction.

And remember that recovery is a long-term commitment.

When Sexton first started using in his early 20s, his drug of choice was meth. He later started smoking it with heroin and fentanyl mixed in, he says.

Several years ago, Sexton spent 45 days in residential rehab and got clean. Then he started seeing a woman who was addicted to heroin. He thought he’d help her get sober but ended up doing drugs with her instead. He landed in jail for two months, and a judge ordered him back into residential drug treatment.

Sexton says he continues to actively pursue his recovery even as he helps others do the same. “There are bumps in the road, but I feel like I’m in a Range Rover,” he says. “I’m not going to spill my coffee.”

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You will likely hear and see public messages over the coming weeks urging you to update your contact information. Heed them.

Then, sometime between now and next spring, you’ll probably receive mail from the agency that administers Medi-Cal in your county telling you if you are still eligible for the safety-net health insurance program or asking for more information about your employment status, income, and household size. An information request would likely come in a bright-yellow envelope containing a roughly 20-page form about six weeks before the start of your renewal month.

Be on the alert: Medi-Cal is warning about scammers who have been contacting enrollees and requesting a fee to help people renew coverage. Don’t fall for it. No payment is required to renew your coverage.

But be sure to open your mail and respond to any official request for personal information. And be aware that updating your information could push you off Medi-Cal if your income has risen or if you have access to other insurance.

If you need help with any of this, especially that daunting renewal form, keep reading.

Medi-Cal, the state’s version of the Medicaid health insurance program for low-income residents, has embarked on a 14-month effort to reexamine the eligibility of its nearly 15.8 million members. It is part of the massive “unwinding” being undertaken by all state Medicaid programs after three pandemic years during which their rolls swelled. States had agreed, in exchange for extra funding from the feds, not to boot anyone except in cases such as fraud, death, or a move out of state.

On April 1, Medicaid restarted the annual eligibility checks that had been the norm before the pandemic. It will be the biggest shake-up in U.S. health coverage since the Affordable Care Act, though it cuts the opposite way: Between 8 million and 24 million people will likely be bounced from Medicaid nationally, including an estimated 2 million to 3 million in California.

To minimize the number of enrollees dropped unnecessarily, California’s Department of Health Care Services, which runs Medi-Cal, has launched a $25 million advertising and outreach campaign that will send messages in 19 languages. The department is enlisting the assistance of nearly everyone who has contact with Medi-Cal enrollees: county offices, health plans, medical providers, advocacy groups, and volunteers. And it got $146 million in supplemental funding to help counties cope with the unprecedented number of renewal decisions.

But some patient advocates, health plan executives, and community clinic administrators worry it will not be enough to help all enrollees who could lose coverage if they can’t be reached or don’t respond — especially transient and homeless people and those with language or cultural barriers.

Less than two months before the start of the unwinding, multiple counties, including Fresno and Sacramento, reported staffing shortages and the need to train eligibility workers.

Laura Sheckler, deputy director of policy at the California Primary Care Association, which represents about 1,300 community clinics statewide, says the nearly $60 million in state funds earmarked for “navigators” to assist Medi-Cal enrollees is not enough for her group’s members to provide all the help that will be needed. The association has asked lawmakers for another $60 million.

Some Medi-Cal members already know where they stand. Anthony Kelley, a 53-year-old single dad, is one of them. Kelley, who lives with his 14-year-old son, Nicholas, in Pacifica, California, temporarily lost his job as a driver for a concrete company in the early days of the pandemic and signed up for Medi-Cal. He got his job back about a month later, along with access to employer-sponsored health coverage, but he has stayed on Medi-Cal for the past three years. His son has been on Medi-Cal since he was born.

When San Mateo County sent Kelley a renewal form, he called and was told his $58,000 annual income likely meant he and his son would lose Medi-Cal coverage. Now, he’s waiting for that to happen.

“It sucks for my son,” Kelley says, adding that he fears Nicholas could lose his doctors. “But we’ll deal with it.”

If you are anxious or uncertain about what you need to do, don’t fret. Help is available.

You can call or visit your local Medi-Cal office to update your personal information or ask for assistance. The Department of Health Care Services (www.dhcs.ca.gov) lists on its website all county Medi-Cal agencies, with addresses, phone numbers, and links. You can also call Medi-Cal’s help line (800-541-5555).

If you want to avoid potentially long lines or telephone hold times, consider signing up for an account at www.benefitscal.com or www.mybenefitscalwin.org. Doing so will allow you to update your personal and financial information online and find your renewal date.

Another great resource is the Health Consumer Alliance (888‑804‑3536 or www.healthconsumer.org), which can help you navigate the complexities of renewal, or contest a termination decision you think is unwarranted. Community clinics, which provide care for nearly one-third of Medi-Cal enrollees, often have navigators on-site who can help fill out forms and answer questions. L.A. Care, the largest Medi-Cal health plan, has 11 centers across Los Angeles County that will offer help to anyone who needs it, not just its members. Fresno County has 14 such centers. Check with your health plan for similar resources.

Under a state law, SB 260, if you are bumped off Medi-Cal but still have income low enough to qualify for an insurance subsidy through Covered California, the state’s insurance marketplace, you will be auto-enrolled in a plan the exchange deems to be the best value at the lowest cost. Once notified of the plan selection, you will have 30 days to accept it, choose another plan, or decline coverage altogether.

“This doesn’t need to be all doom and gloom for people who have Medi-Cal,” says David Kane, a senior attorney at the Western Center on Law & Poverty.

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The federal government recently fixed a controversial Treasury Department rule tied to the Affordable Care Act that denied assistance to many families whose workplace coverage busted their budgets.

Because of the so-called family glitch, if a worker had access to employee-only coverage deemed affordable under federal guidelines, a spouse or dependents could not get help to buy a health plan through Covered California, the state’s ACA insurance marketplace, even if it was not affordable to put them on the employer plan.

This affected an estimated 5.1 million people nationally, more than half of them children, since employers often contribute only to an employee’s premium, leaving workers to pay full fare for other family members.

Under a new rule that took effect Dec. 12, if the cost of having you and your family on a workplace plan exceeds an affordability threshold — set at 9.12% of household income for 2023 — your spouse and dependents could qualify for financial aid to purchase insurance through Covered California. Affordability will be determined by how much you would have to pay to have them — and you — on your employer’s cheapest health plan.

ACA insurance subsidies come in the form of federal tax credits that can be taken upfront or settled with the IRS when you file your taxes the following year.

Estimates from the UCLA Center for Health Policy Research and the UC Berkeley Labor Center show that 391,000 Californians previously excluded from subsidies in Covered California would be eligible for them under the new rule. Of those, an estimated 149,000 would likely enroll in a Covered California plan. Those switching from an employer-sponsored plan would save an average of $1,478 per person in 2023, according to the two centers.

“Fixing the family glitch is a critical step in really delivering on the promise of the ACA,” says Jessica Altman, executive director of Covered California. “If you don’t have affordable coverage from another source, the marketplace is where you should be able to come for affordable coverage.”

So, if you are paying too much to cover your family members on your employer’s health plan, it is definitely worth finding out whether you can get a tax credit to help pay their premiums on a Covered California plan. But finding the answer is complicated and will take considerable legwork.

If you have steady employment, this year’s income will probably be a good proxy for 2023, adding any pay raise you expect for the coming year. You’ll also need to calculate how much you would pay for your employer’s lowest-cost health plan — both for employee-only coverage and for family coverage. If the cost for you alone is under the 9.12% threshold, you will not qualify for a subsidized Covered California plan, even if your spouse and dependents do. That means a family could be split between two policies, with separate deductibles and different provider networks.

You also need to determine whether the lowest-cost plan offered by your employer meets the minimum coverage standard under the ACA. That means it must cover at least 60% of your total allowed medical expenses during the year and provide sufficient coverage for hospital and physician services. If it does not meet those requirements, you and your family might be able to get a subsidized plan through Covered California, depending on your income.

If two spouses have access to employer coverage, you’ll need to perform this exercise for both options.

Is your head spinning yet? You’re not alone.

“This stuff is just really complicated,” says Kevin Knauss, an insurance agent in Granite Bay. “And how can we possibly expect families that are doing all kinds of different things — kids, Christmas — to really focus on this stuff?”

But don’t ignore the new rule, because you could be leaving money on the table. Covered California has a worksheet to help calculate your eligibility for subsidies. Your human resources department might be willing to help you fill it out. Or you could seek professional help, whether an insurance agent or other certified enroller. You wouldn’t need to pay a penny for either.

To find an insurance agent or certified enroller, log on to Covered California’s website (www.coveredca.com) and click on the “Support” tab. Or call 800-300-1506. Covered California has a very useful FAQ all about the fix to the family glitch.

The enrollment period for 2023 coverage started on Nov. 1 and runs through Jan. 31. You have until Dec. 31 to buy coverage that starts Jan. 1. If you buy coverage in January, it starts Feb. 1.

The family glitch fix isn’t the only new thing with Covered California. Starting in 2023, you can put a dependent parent or stepparent on your health plan, as long as they are not eligible for or enrolled in Medicare.

And, in case you missed it, Congress extended through 2025 the supplemental tax credits that increase aid to people who were already getting some before and are available to many middle-class households that did not previously qualify for financial assistance.

The idea behind the expanded financial help is to limit the amount people spend on health care premiums to no more than 8.5% of household income, no matter how much money they make.

Knauss said he talked to a man in Marin County who was seeking a Covered California health plan for his family of four and qualified for a monthly subsidy of $1,400, even though he makes $200,000 a year. Being over 60 and living in Northern California, an expensive region, pushed his family’s premium to a level that opened the door for significant financial assistance, Knauss said.

If you are already enrolled in Covered California, don’t simply renew coverage for 2023. Prices and provider networks can change from year to year, and there might be a new, cheaper option in your region. So shop around.

And whether you are new or returning to Covered California, know what your medical needs are likely to be. If you have a condition that requires intensive services, you might consider paying a higher premium in exchange for lower deductibles and coinsurance when you seek care.

Happy hunting.

Jessica Altman is the daughter of Drew Altman, who is president and CEO of KFF. KHN is an editorially independent program of KFF.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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If you feel the way I do, the answer is neither. I cringe at the thought of my body burning up at well over 1,000 degrees Fahrenheit or being pumped full of toxic chemicals and spending the rest of eternity in a cramped box 6 feet underground.

So here’s another question: How do you feel about having your body reduced to compost and used to plant a tree, grow flowers, or repair depleted soil in a forest?

Human composting doesn’t mean you’re tossed into a bin with potato peels, crushed eggshells, and coffee grounds. Rather, you’d be placed in a metal or wooden vessel, enveloped by organic materials such as wood chips, alfalfa, and straw, and then slowly reduced to a nutrient-packed soil. The process can take six weeks to six months depending on the methods used.

I don’t know about you, but I like the sound of that (at least compared with those other two options).

“I never felt like I had an option that works for me until now,” says Assembly member Cristina Garcia (D-Bell Gardens). She authored a bill, signed last month by Gov. Gavin Newsom, to legalize human composting in California.

California becomes the fifth state to allow this method of body disposal, commonly known by the more scientific-sounding name “natural organic reduction.” Colorado, Oregon, Vermont, and Washington have legalized the practice, and legislation is pending in several other states.

The California law takes effect in 2027, allowing time for regulators to establish the rules that will govern human composting in the state.

But it’s never too early to start planning for your death.

Heather Andersen, a 68-year-old consultant and former hospice nurse in Seattle, says she has already chosen to be composted when she dies because it is much easier on the environment than burial or cremation.

“We’re actually enhancing the Earth rather than taking away from it,” she says. And there’s a spiritual dimension to her decision, she says, since she’ll be “going back to being part of the whole cycle of life.”

Andersen, who is in good health, purchased a prepaid composting plan from Recompose, a Seattle-based green funeral home whose founder, Katrina Spade, is widely viewed as a pioneer of natural organic reduction for humans.

One naturally reduced human body can yield anywhere from 250 to 1,000 pounds of soil depending on the method used and the type and volume of organic materials mixed with the body. That’s enough to fill several wheelbarrows or the bed of a pickup. Once the process is complete, many families take a small box of the soil and donate the rest to conservation projects or flower farms.

Of course, being composted after death is not for everybody. For example, the California Catholic Conference objects to the new law. The methods involved, it said in a statement, “reduce the human body to a disposable commodity, and we should instead seek options that uphold respect for both our natural world and the dignity of the deceased person.”

Those who have chosen to have their bodies composted are generally motivated by ecological concerns.

With natural organic reduction, ”what we are in fact doing is taking everything that continues to be alive in a human body after the human being leaves it and turning it into something that can actually nurture the planet,” says Holly Blue Hawkins, of Santa Cruz County, whose Last Respects Consulting offers death planning services.

After death, the human body retains numerous elements and minerals that are nourishing to plants, including carbon, calcium, magnesium, nitrogen, and phosphorus.

Traditional burials pose many problems. The formaldehyde in embalming fluid puts funeral workers at risk for problems such as an irregular heartbeat, a dangerous buildup of fluid in the lungs, and, over time, cancer. Moreover, the toxic substances in embalming fluid can leach into the soil.

Not to mention that there just isn’t enough land in cemeteries for everyone to have their own plot indefinitely into the future.

Cremation, on the other hand, emits numerous pollutants that are harmful to humans, as well as millions of tons of carbon dioxide every year. And the percentage of people choosing cremation is growing fast, primarily because it is cheaper than a burial. Cremation is projected to account for 59% of body disposals this year and 79% by 2040, according to the National Funeral Directors Association. With about 3 million Americans dying each year, that’s a lot of bodies burning up.

Human composting has emerged only recently as an alternative to burial and cremation.

Since Recompose opened in December 2020, the company has composted fewer than 200 bodies. “Obviously, that’s a tiny fraction of the people who die in Washington state,” Spade says. But 1,200 customers have prepaid for natural organic reduction, which she believes is a sign of its growing appeal.

Many funeral entrepreneurs view human composting as a significant business opportunity in a $20 billion industry.

“Our owners have been holding discussions about expanding across the country as more states legalize it,” says David Heckel, advance planning consultant at The Natural Funeral in Lafayette, Colorado.

Return Home, a green funeral home in Auburn, Washington, encourages website visitors to “join the #idratherbecompost movement” and fill out a form letter urging their state legislators to legalize human composting.

Dying isn’t cheap, and composting is no exception. The cost of natural organic reduction ranges from $3,000 to just under $8,000, depending on which company you choose. The companies typically offer on-site ceremonies for an extra charge. That compares with an average funeral cost of just under $7,000 for a cremation and just over $9,400 for a traditional burial with a casket and vault.

Recompose, Return Home, The Natural Funeral, and Earth Funeral, of Auburn, Washington, all say they plan to set up shop in California after the new law takes effect. But Californians who want to return to the Earth as compost don’t have to wait until 2027.

All those companies offer prepaid plans and will arrange transport to their facilities out of state, for an extra fee, if you or your loved one dies before they are up and running in California — or if you live in a state where natural organic reduction is not legal. They will typically mail you or your family a small box of the resulting compost.

Another option is Herland Forest, a nonprofit cemetery in rural Washington, which charges $3,000. It has no plans for expanding to California but accepts bodies from other states with an extra fee for transport.

Call around and compare prices and methods. See what kind of vibe you get.

If the idea of human composting leaves you cold, whether for religious, personal, or family reasons, don’t worry. No one is forcing you to nourish a tree. “I’m not taking anything away,” Garcia says. “I’m just expanding the options that we have.”

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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We all have pandemic fatigue. Even people who should know better have let precautionary measures slide. If you are sensing a mea culpa on the way, I won’t disappoint.

I confess I have been far less cautious over the past couple of months than I was early on. I have left home without a mask on a trip to the grocery or pharmacy, and instead of returning to get one, I’ve walked in unmasked, telling myself I’d be there for only a short time.

In June, I took a 12-hour trans-Atlantic flight on which virtually no passengers or crew members were masked. I wore my mask initially, a snug-fitting KN95. But after eating, I kinda sorta forgot to put it back on. In July, with covid clearly surging, I hosted a birthday party for my daughter without asking guests to test themselves before coming to the house.

And there’s more where that came from.

Whether through luck or booster-bolstered immunity, I have managed to evade the virus. But worrisome reports about the BA.5 omicron subvariant — which has spread like a California wildfire, in part because it can circumvent some defenses afforded by vaccines and prior infections — have provided the head-butt I needed to shore up my behavior.

I didn’t actually violate any rules in the situations I described above, because none were in place. Public mandates — such as masking and requiring that people be vaccinated to enter restaurants, gyms, and other indoor venues — have been so bitterly politicized that returning to them now, especially in an election year, would be like trying to cram a genie back in the bottle. I think many of us are coming to terms with a future in which keeping covid at bay will hinge on personal responsibility.

Most of California is in the high-risk covid transmission category, as determined by the Centers for Disease Control and Prevention. Yet even in pandemic-smacked L.A. County, reporting thousands of new infections a day and a double-digit rate of positive tests that is well into the danger zone, serious resistance emerged as health officials recently discussed — and ultimately shelved — a plan to reinstate a mask mandate. Multiple cities in the county, including Beverly Hills, Long Beach, and Pasadena, said they would not enforce it. Business owners openly questioned whether they would ask their employees to impose such a rule on unwilling and sometimes hostile patrons.

Kathryn Barger, a member of the county Board of Supervisors, wrote in an open letter to constituents that “masking mandates are polarizing and are unenforceable.” A better way to go, she said, would be “trusting the public to make personal COVID-19 prevention decisions to keep themselves and their loved ones safe, promoting the efficacy of vaccines and boosters, and investing in equitable access to COVID-19 treatments.”

Let’s face it: Covid is with us for the foreseeable future, and we can only speculate about other variants that might blindside us down the road or how many times we can chance reinfection without risking lasting damage to our health. Given this inconvenient truth, now is an excellent time to adopt everyday habits that reduce our risk of contagion — and not just from covid.

“There will continue to be cases of covid-19 for decades and centuries, the same way there have been for influenza,” says Dr. Saahir Khan, an infectious disease specialist at Keck Medicine of USC. In many Asian countries, he notes, there’s a culture “where every winter when these viruses are circulating at a high level, people wear masks in public places. And I think that has to become part of the culture here.”

The covid complacency that has overtaken so many of us is in large ways a credit to the vaccines and treatments that have sharply reduced the severity of illness from an infection. But the current vaccines have proved far less protective against infection itself, especially when faced with the evasive mechanisms exhibited by BA.5.

Shira Shafir, an associate professor of epidemiology at UCLA’s Fielding School of Public Health, experienced that disconcerting reality firsthand. When I called to interview her for this column, she was at home with covid. Shafir’s 70-year-old mother had been planning to visit from Arizona, so she and her husband opted to test themselves and their young son. Their son tested positive, and they told her mom not to come.

“My son had no symptoms,” Shafir says. “We only tested him because my mother was coming to visit — and thank goodness we did, because otherwise my mother would have been exposed and in all certainty would have gotten infected.”

The next day, Shafir tested positive, and the day after that, her husband did. Both she and her husband are boosted, and their son, who participated in a Pfizer vaccine trial for children under 5, has received three shots.

A starting point for developing your covid defensive strategy is determining how much transmission is happening in your community. If you are in an area of high prevalence, as more than 45% of U.S. counties were in late July, significant caution is warranted. An easy way to find out is by consulting this CDC webpage, which will show you which category your county is in. You can also follow your local health department on social media.

Another good measure is purely anecdotal: “If you know a lot of people right now who have covid, it means there’s a lot of covid,” Shafir says.

I know of at least 10 people, both friends and professional contacts, who have been infected in the past few weeks, all vaccinated and boosted. And that has set off the alarm bells I needed to reacquaint myself with basic safety measures.

Among them: Wear a mask in indoor public spaces and crowded outdoor ones. If you are at high risk of serious illness, avoid those places, and find alternatives such as curbside pickup and home delivery.

If you want to host a dinner party, ask guests to take a rapid home test before they come over. If you are taking an airplane, put on a mask the moment you enter the airport, and at a minimum keep it on until the plane is in the air and then again when you land.

If you test positive, follow these guidelines: Isolate from people for at least five days after your first symptoms or a positive test result. You can end isolation after the fifth day if you have a negative test, no fever, and your symptoms are improving.

If you are one of those people who don’t worry about covid because you don’t believe it will make you terribly sick, remember this: The course of the illness can still be highly unpredictable and includes some chance of ending up with long covid, which can leave you with brain fog, shortness of breath, and heart damage.

If you’re not convinced by any of that, then at least have some consideration for neighbors, co-workers, and relatives who may be older and sicker than you.

“That is what concerns me,” says USC’s Khan. “I want to make sure society is doing its best to protect those people.”

It goes like this: You find multiple providers in your plan’s directory, and you call them. All of them. Alas, the number is wrong; or the doctor has moved, or retired, or isn’t accepting new patients; or the next available appointment is three months away. Or perhaps the provider simply is not in your network.

Despite a spate of state and federal regulations that require more accurate health plan directories, they can still contain numerous errors and are often maddeningly outdated.

Flawed directories not only impede our ability to get care but also signal that health insurers aren’t meeting requirements to provide timely care — even if they tell regulators they are.

Worse, patients who rely on erroneous directory information can end up facing inflated bills from doctors or hospitals that turn out to be outside their network.

In 2016, California implemented a law to regulate the accuracy of provider directories. The state was trying to address long-standing problems, illustrated by an embarrassing debacle in 2014, when Covered California, the insurance marketplace that the state formed after the passage of the Affordable Care Act, was forced to pull its error-riddled directory within its first year.

Also in 2016, the federal Centers for Medicare & Medicaid Services demanded more accurate directories for Medicare Advantage health plans and policies sold through the federal ACA marketplace. And the federal No Surprises Act, which took effect this year, extends similar rules to employer-based and individual health plans.

California law and the federal No Surprises Act stipulate that patients who rely on information in their provider directories and end up unwittingly seeing doctors outside their networks cannot be required to pay more than they would have paid for an in-network provider.

Unfortunately, inaccurate directories continue to plague our health care system.

A study published in June in the Journal of Health Politics, Policy and Law analyzed data from the California Department of Managed Health Care on directory accuracy and timely access to care. It found that in the best case, consumers could get timely appointments in urgent cases with just 54% of the doctors listed in a directory. In the worst case: 28%. For general care appointments, the best case was 64% and the worst case 35%.

A key takeaway, the authors write, is that “even progressive and pro-consumer legislation and regulations have effectively failed to offer substantial protection for consumers.”

Few people know this better than Dan O’Neill. The San Francisco health care executive called local primary care doctors listed in the directory of his health plan, through a major national carrier, and could not get an appointment. Nobody he talked to could tell him whether UCSF Health, one of the city’s premier health systems, was in his network.

“I spent close to a week trying to solve this problem and eventually had to give up and pay the $75 copay to go to urgent care because it was the only option,” O’Neill says. “I now live a seven- or eight-minute walk from the main UCSF buildings, and to this day, I have no idea whether they are in my network or not, which is crazy because I do this professionally.”

Consumer health advocates say insurers are not taking directory accuracy seriously. “We have health plans with millions of enrollees and hundreds of millions in reserves,” says Beth Capell, a lobbyist for Sacramento-based Health Access California. “These people have the resources to do this if they thought it was a priority.”

Industry analysts and academic researchers say it’s more complicated than that.

Health plans contract with hundreds of thousands of providers and must constantly hound them to send updates. Are they still with the same practice? At the same address? Accepting new patients?

For doctors and other practitioners, responding to such surveys — sometimes from dozens of health plans — is hardly at the top of their to-do list. Insurers typically offer multiple health plans, each with a different constellation of providers, who don’t always know which ones they’re in.

The law gives insurers some leverage to induce providers to respond, and a whole industry has sprung up around collecting provider updates through a centralized portal and selling the information to health plans. The inaccuracy problem remains, however. Health plans and providers often have outdated data systems that don’t communicate with each other.

A significant improvement in health plan directories will require “more connectivity and interoperability,” says Simon Haeder, an associate professor at Texas A&M University’s School of Public Health and a co-author of the study on directory accuracy and timely access.

Until that day comes, you will need to fend for yourself. Be diligent when using your health plan’s provider directory. You should use it as your first stop — or to check whether a doctor recommended by a friend is in your network.

Remember the laws that say you can’t be charged out-of-network rates if the doctor you visit was listed in your health plan’s directory? You’ll have to prove that was the case. So take a screenshot of the directory showing the provider’s name and save it. Then, call the doctor’s office to double-check. Take notes and get the name of the person you talked to. If there’s a discrepancy, call your health plan, too.

If you find an inaccurate entry, report it to your health plan. California law requires plans to provide instructions for consumers to do that. If you are in a commercial health plan, your policy is likely regulated by the Department of Managed Health Care. You can lodge a complaint through the department (888-466-2219 or www.healthhelp.ca.gov). Since California’s law on provider directories took effect, the department has helped resolve 279 complaints, said spokesperson Rachel Arrezola.

If your plan has a different regulator, the department can point you in the right direction.

If you are one of the roughly 6 million Californians in a federally regulated employer or union plan and you get a big out-of-network bill from a doctor who was listed in your health plan directory, you can file an appeal through the office set up for that purpose (800-985-3059 or www.cms.gov/nosurprises).

Ultimately, efforts to improve the accuracy of provider directories are part of a broader push for greater transparency of health care prices and easier access to patient records. All of that will require a more open information superhighway.

Small income changes can cause people’s eligibility to shift, but when bad information is typed into a computer system shared by the two programs — or accurate information is deleted from it — enrollees can get big headaches.

Long-standing tension between the state, which oversees Medi-Cal, and county officials who do the nitty-gritty work of determining eligibility and enrolling those who qualify doesn’t help. And, sometimes, people applying for coverage unwittingly answer questions in a way that causes eligibility officers to switch them from one program to the other.

Legal aid attorneys, patient advocates, and insurance agents say computer glitches are not as common today as they were in the several years after California’s 2013 launch of ACA coverage. The exchange was new and millions of people were newly eligible for Medi-Cal. State officials have tackled computer glitches and other problems as they’ve arisen.

But eliminating all human and computer errors isn’t possible.

Just ask Andrea Veltman, who received a notice in December that her subsidized Covered California health plan was being terminated. The letter directed the 57-year-old Oakland resident to apply for Medi-Cal. When she called the program, she learned that Medi-Cal coverage for her 25-year-old son, Merlin, was also being terminated. He needed to reapply.

Veltman, who owns a landscaping business, was confused. She made some calls and found out that a Medi-Cal eligibility officer had logged into both of their accounts and somehow the two accounts had been merged into one. All her husband’s information was deleted, her business was removed, her son’s income was zeroed out, and some of his income was attributed to her.

No one contacted her to verify the changes.

Veltman doesn’t know whether human or computer error was to blame. She suspects that a review of the accounts was triggered when her son applied for food assistance and listed her as a contact person.

“Even if something triggers them to look at it, they still have to verify it is accurate information — and it was so incredibly wrong,” she says. “And that’s just not OK. Why don’t they just ask me?”

Veltman’s son didn’t regain his Medi-Cal coverage until mid-May. Her Covered California coverage was quickly restored in late December, but then the same thing happened in late April. She learned last week that her Covered California coverage was set to be reinstated this month, but she doesn’t know yet whether she will be retroactively covered for treatments in May.

Kevin Knauss, an insurance agent in Granite Bay, says he has heard of similar complaints in recent months from residents in Alameda, Los Angeles, Orange, San Diego, and Santa Barbara counties. “These are calls about information getting messed up in the computer that affects their eligibility,” he says.

Perhaps the most egregious aspect of Veltman’s case is that her son’s Medi-Cal termination violated a rule that prevents people from being disenrolled from Medicaid during the federal public health emergency that was declared at the start of the covid-19 pandemic.

“This shouldn’t be happening. It’s against the rules during the pandemic,” says Jack Dailey, an attorney at the Legal Aid Society of San Diego. “We tell people to push back immediately, and they will get reinstated immediately.”

The rule, which suspends the annual reviews normally conducted to determine enrollees’ eligibility, has enabled many Californians to maintain their Medi-Cal coverage during the pandemic. Those reviews will resume after the public health emergency ends, and millions of people could lose Medi-Cal coverage. The public health emergency is scheduled to expire July 15, but it is almost certain to be extended.

Medi-Cal took months to effectively implement the procedures required to comply with the rule. During several months in 2020, 131,000 enrollees were mistakenly dropped from coverage but were ultimately reinstated, according to the state Department of Health Care Services, which administers Medi-Cal. And such incidents have slowed sharply since.

They have “definitely been less of a problem in the last year or so,” says Skyler Rosellini, a senior attorney at the National Health Law Program. “But they still pop up.”

In the unlikely event this kind of mistake happens to you, a quick call to your county eligibility office might sort things out. You can find a list of county offices on the Department of Health Care Services website (www.dhcs.ca.gov).

If that doesn’t work, or if your patience wears thin, you can get advice and legal help from the Health Consumer Alliance (888‑804‑3536 or www.healthconsumer.org). Insurance agents can also bring lots of expertise to help resolve your problem. You can find agents through the California Agents and Health Insurance Professionals group (www.cahu.org/find-a-member).

If you still don’t get satisfaction, you can request a “fair hearing” before an administrative law judge through the state Department of Social Services (call 855-795-0634 or fill out a request online).

You can also ask for a fair hearing to resolve a dispute over eligibility for a subsidized Covered California health plan or to contest the amount of tax credits you are granted to help pay your premium.

But before you do that, call the marketplace’s customer service line (800-300-1506) to try to fix your problem. Covered California also has an ombudsperson (888-726-0840 or ombuds@covered.ca.gov).

Finally, Veltman has some practical advice: Keep the income information that you submit, or take a screenshot of it — otherwise, you’ll have to calculate everything again if it is erased.

“Also, just keep calling,” she says, “because they sometimes tell you, ‘We’re going to call you back,’ and that almost never happens.”