ACA Plan Mess, Not Sure what to Do

beachbum2012

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So I helped enroll a husband and wife in an ACA plan effective April 1st. He's in his mid-50's, she's turns 65 next month. They were on his COBRA but were paying over $1,100/mo. in premiums. He recently hurt his back bad enough to where he's had surgery and can no longer work. He had a manual labor job. His short-term disability ended in January of this year, and his initial request to get SSD has been denied. At this point, they've started working with a law firm to hopefully get their disability case accepted. If it is, they say they're get SSD income retroactively to when their short-term disability ended (January 2014).

When we filled out the app thru the Exchange, we put in their estimated income for this year assuming he was going to get SSD. So their only incomes would be their 2 Social Security income payments which would total ~$30k for the year. This gave them a decent subsidy, but over the amount to qualify for Medicaid.

Fast forward to today, I do a 3-way call with the wife and healthcare.gov to notify them of a "life change" that she needs to drop off the plan at the end of the month since she's starting Medicare on 6/1. They haven't gotten any updates from the law firm regarding his SSD, so their only 2014 income has been her small SS income. As we talk to the rep, she asks the wife about her income, she tells her the small amount, then the rep checks her status and says his app has been sent to Medicaid and he no longer will have coverage thru his ACA plan. I would imagine though that he'll at least have coverage thru the end of May since they've already paid their premiums, but I'm not positive.

The ACA rep says it'll probably take a month for Medicaid to make their determination. So here are some of my questions:

- Does this mean he won't have any health insurance starting June 1st (possibly even as of today) until they do? He has a doctor appointment June 9th and doesn't know if he'll have any coverage then.

- If he's temporarily without insurance, what are his options? COBRA said he couldn't go back on. How about a short-term non-ACA major medical plan?

- Could Medicaid turn him down? If they do (for whatever reason), would he still be eligible for a subsidy for an ACA plan?

- Anyone have experience with legal action to get their SSD benefits after being declined? Just wondered about the success rate.

- Could they possibly be made to pay back the subsidy they've gotten for April and May if they don't end up with the SSD income because the income we input in the original ends up not to be accurate?

So the immediate need is to make sure he doesn't go without coverage since he's going thru some health issues. But in general I'd appreciate any guidance or advice you could give on his best course of action, or what to expect next.
 
So I helped enroll a husband and wife in an ACA plan effective April 1st. He's in his mid-50's, she's turns 65 next month. They were on his COBRA but were paying over $1,100/mo. in premiums. He recently hurt his back bad enough to where he's had surgery and can no longer work. He had a manual labor job. His short-term disability ended in January of this year, and his initial request to get SSD has been denied. At this point, they've started working with a law firm to hopefully get their disability case accepted. If it is, they say they're get SSD income retroactively to when their short-term disability ended (January 2014).

When we filled out the app thru the Exchange, we put in their estimated income for this year assuming he was going to get SSD. So their only incomes would be their 2 Social Security income payments which would total ~$30k for the year. This gave them a decent subsidy, but over the amount to qualify for Medicaid.

Fast forward to today, I do a 3-way call with the wife and healthcare.gov to notify them of a "life change" that she needs to drop off the plan at the end of the month since she's starting Medicare on 6/1. They haven't gotten any updates from the law firm regarding his SSD, so their only 2014 income has been her small SS income. As we talk to the rep, she asks the wife about her income, she tells her the small amount, then the rep checks her status and says his app has been sent to Medicaid and he no longer will have coverage thru his ACA plan. I would imagine though that he'll at least have coverage thru the end of May since they've already paid their premiums, but I'm not positive.

The ACA rep says it'll probably take a month for Medicaid to make their determination. So here are some of my questions:

- Does this mean he won't have any health insurance starting June 1st (possibly even as of today) until they do? He has a doctor appointment June 9th and doesn't know if he'll have any coverage then.

- If he's temporarily without insurance, what are his options? COBRA said he couldn't go back on. How about a short-term non-ACA major medical plan?

- Could Medicaid turn him down? If they do (for whatever reason), would he still be eligible for a subsidy for an ACA plan?

- Anyone have experience with legal action to get their SSD benefits after being declined? Just wondered about the success rate.

- Could they possibly be made to pay back the subsidy they've gotten for April and May if they don't end up with the SSD income because the income we input in the original ends up not to be accurate?

So the immediate need is to make sure he doesn't go without coverage since he's going thru some health issues. But in general I'd appreciate any guidance or advice you could give on his best course of action, or what to expect next.

Sorry not answer to your question, but is not health insurance guaranteed renewalable? If that is the case how does HC.gov rep have any right to end a persons coverage maybe said subsidy but their insurance policy?
 
I presume Beachbum did the correct thing and made the older spouse, aging into medicare first, the primary. They go to medicare, the other spouse has a QE due to no fault loss of coverage.

The younger spouse, the one in question, has a SEP, and doesn't qualify to go back on the plan they were formerly on. Exchange didn't term coverage, the primary did when they went to medicare.
 
This is happening repeatedly even with higher income. Happened to me yesterday with a client. See my other posts in other thread.

Best to re-do the app, change income by $10, and you'll get a new determination if their income is above medicaid levels. Did that, but still had problems as account is showing now inactive even though we submitted app with HC.gov rep.

Ray, what should happen, and what is happening, are two different things when dealing with the federal exchange.
 
1- Does this mean he won't have any health insurance starting June 1st (possibly even as of today) until they do? He has a doctor appointment June 9th and doesn't know if he'll have any coverage then.

2- If he's temporarily without insurance, what are his options? COBRA said he couldn't go back on. How about a short-term non-ACA major medical plan?

3- Could Medicaid turn him down? If they do (for whatever reason), would he still be eligible for a subsidy for an ACA plan?

4- Anyone have experience with legal action to get their SSD benefits after being declined? Just wondered about the success rate.

5- Could they possibly be made to pay back the subsidy they've gotten for April and May if they don't end up with the SSD income because the income we input in the original ends up not to be accurate?

So the immediate need is to make sure he doesn't go without coverage since he's going thru some health issues. But in general I'd appreciate any guidance or advice you could give on his best course of action, or what to expect next.
1-Probably. Most likely scenario is that the coverage will be retro to 6/1 and will reimburse him for costs incurred. He's likely paying out of pocket unless medicaid moves quickly.
2-STM is an option, but good luck finding a major medical plan for a month. You can always purchase an individual plan off exchange thanks to the SEP. You don't have a ton of options unfortunately.
3-Unlikely, but possible. More likely they drag it out a bit and approve him. If my memory serves, if you don't qualify for a subsidy, you don't qualify for a subsidy, even if you can't get medicaid.
4-Not personally, but luckily they report it all online: http://www.ssa.gov/policy/docs/statcomps/di_asr/2012/di_asr12.pdf for 2012, the most recent report. Chart 11 on page 143 (151 of the pdf) is what you're looking for. According to the chart, it was ~10% chance in 2010, and appears to be declining.
5-As far as we know, there is no clawback in place for those who have an income lower than estimated.

My advice? Get the guy in medicaid ASAP.
 
So I helped enroll a husband and wife in an ACA plan effective April 1st. He's in his mid-50's, she's turns 65 next month. They were on his COBRA but were paying over $1,100/mo. in premiums. He recently hurt his back bad enough to where he's had surgery and can no longer work. He had a manual labor job. His short-term disability ended in January of this year, and his initial request to get SSD has been denied. At this point, they've started working with a law firm to hopefully get their disability case accepted. If it is, they say they're get SSD income retroactively to when their short-term disability ended (January 2014).

When we filled out the app thru the Exchange, we put in their estimated income for this year assuming he was going to get SSD. So their only incomes would be their 2 Social Security income payments which would total ~$30k for the year. This gave them a decent subsidy, but over the amount to qualify for Medicaid.

Fast forward to today, I do a 3-way call with the wife and healthcare.gov to notify them of a "life change" that she needs to drop off the plan at the end of the month since she's starting Medicare on 6/1. They haven't gotten any updates from the law firm regarding his SSD, so their only 2014 income has been her small SS income. As we talk to the rep, she asks the wife about her income, she tells her the small amount, then the rep checks her status and says his app has been sent to Medicaid and he no longer will have coverage thru his ACA plan. I would imagine though that he'll at least have coverage thru the end of May since they've already paid their premiums, but I'm not positive.

The ACA rep says it'll probably take a month for Medicaid to make their determination. So here are some of my questions:

- Does this mean he won't have any health insurance starting June 1st (possibly even as of today) until they do? He has a doctor appointment June 9th and doesn't know if he'll have any coverage then.

- If he's temporarily without insurance, what are his options? COBRA said he couldn't go back on. How about a short-term non-ACA major medical plan?

- Could Medicaid turn him down? If they do (for whatever reason), would he still be eligible for a subsidy for an ACA plan?

- Anyone have experience with legal action to get their SSD benefits after being declined? Just wondered about the success rate.

- Could they possibly be made to pay back the subsidy they've gotten for April and May if they don't end up with the SSD income because the income we input in the original ends up not to be accurate?

So the immediate need is to make sure he doesn't go without coverage since he's going thru some health issues. But in general I'd appreciate any guidance or advice you could give on his best course of action, or what to expect next.

How much were they paying after subsidy? It might be easiest to go off-exchange. Depending on the Medicare plan you got her, it might even be about the same price.

It's definitely possible they will have to pay back the subsidy if he doesn't get the SSDI because the income was different than reported.
 
This is happening repeatedly even with higher income. Happened to me yesterday with a client. See my other posts in other thread.

Best to re-do the app, change income by $10, and you'll get a new determination if their income is above medicaid levels. Did that, but still had problems as account is showing now inactive even though we submitted app with HC.gov rep.

Ray, what should happen, and what is happening, are two different things when dealing with the federal exchange.

Yagents, as BeachBum said, due to a 50% drop in income (estimate) he is only eligible for medicaid. I know you're having a similar issue, but this is not one where he *should* be subsidy eligible. Unless BeachBum want's to assume that SSD comes through, and is comfortable doubling the estimate, they're going to be stuck.
 
Yup, medicaid expanded in MI, he is medicaid bound or paying full price off exchange. My explanation still stands if tax credit eligible.
 
I presume Beachbum did the correct thing and made the older spouse, aging into medicare first, the primary. They go to medicare, the other spouse has a QE due to no fault loss of coverage.

The younger spouse, the one in question, has a SEP, and doesn't qualify to go back on the plan they were formerly on. Exchange didn't term coverage, the primary did when they went to medicare.

I actually did the opposite, for 2 reasons (whether they were optimal, or not):

1) I was notified by one of the owners of my agency that we had to enter the applicants of a family plan on healthcare.gov in the same order as they are on their tax return. Otherwise, he said the app would be bounced. I assumed the husband was primary on the tax return because he's the primary wage earner.

2) So it would be easier to just drop the wife off the plan when the time came (now) and just have his plan transition smoother, rather than have to go thru another application process.
 
I actually did the opposite, for 2 reasons (whether they were optimal, or not):

1) I was notified by one of the owners of my agency that we had to enter the applicants of a family plan on healthcare.gov in the same order as they are on their tax return. Otherwise, he said the app would be bounced. I assumed the husband was primary on the tax return because he's the primary wage earner.

2) So it would be easier to just drop the wife off the plan when the time came (now) and just have his plan transition smoother, rather than have to go thru another application process.

In that case, he doesn't get an SEP unless they want to count his sudden "decrease in income"
 
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