SEP Not Valid...got Plan from HC.gov

[AgentStone]

A prospect called me early in Nov stating that what she bought for 2015 wasn’t a good individual insurance plan and it didn’t cover much for hospital stays. She needed knee surgery soon and wanted an ACA plan. I went over the SEP qualifying events. She said she was going to lose her current insurance when she cancels it. I informed her that canceling her plan because she didn't like it didn’t constitute a SEP. She was not eligible and would have to wait until Jan1 for an ACA plan to start.

She then informed me that she was just on the phone with HC.gov and signed up for a plan that would start on Dec 1.…WHAT!?!? I was scratching my head…how was that possible!

What am I missing here?

Questions
1. Will the gov’t/ins company ask her for any documentation to prove this loss is valid?
2. Can the ins company deny paying the claim because she shouldn’t of been eligible?

 

[russelltw]

Welcome to the unfair playing field that is ACA. HC.gov can do what they want. I have to follow the rules and obey SEP situations. I have had several people call me needing insurance mid year. I could not help since there was no true sep. I sent all of them to hc.gov where each got a plan the next month....

This was one of the issues UHC cited for why they may pull out of the marketplace in 2017. The claims from SEP business have been incredible. Since the carrier has no real way to confirm the SEP, they are stuck with the bills. One of my carriers has started asking for proof of the SEP. Looks like people have figured out a way to game the system.

They need a 3 month waiting period on all plans to prevent this abuse.

 

[AgentStone]

Unreal!!

Just googled this...

POINT 1:
New Final Rule Eliminates Certificates of Creditable Coverage

New final regulations on Exchange and Insurance Market Standards for 2015 and Beyond published by the U.S. Department of Health and Human Services (HHS) on May 16, 2014 confirm the end of the requirement to issue certificates of creditable coverage. Certificates of creditable coverage are no longer required after December 31, 2014.

Read More New Final Rule Eliminates Certificates of Creditable Coveragehttp://www.healthcarereformdigest.com/new-final-rule-eliminates-certificates-creditable-coverage


POINT 2:
Special Enrollment Periods for complex issues

Misinformation or misrepresentation

Misconduct by a non-Marketplace enrollment assister (like an insurance company, navigator, certified application counselor, or agent or broker) resulted in you:
•Not getting enrolled in a plan
•Being enrolled in the wrong plan
•Not getting the premium tax credit or cost-sharing reduction you were eligible for

https://www.healthcare.gov/sep-list/


I guess the ins companies hands are tied either way! Unreal...

I agree, waiting period would be helpful.

 

[russelltw]

•Being enrolled in the wrong plan

Love this one...what determines if you were enrolled in the wrong plan?!?!?