ACA Scenario Help Needed

[yankee466]

Just need some thoughts to confirm my suspicions and guesses.

We put a 27 year single old female on an exchange plan in Jan with decent subsidies and cost sharing....as she is low enough income.

She now calls in to inform us she is pregnant. Based on her income, which she is now is also saying will be significantly lower than originally estimated for 2014, she technically qualifies for pregnancy medicaid here in Georgia. Based on the income change alone, she also qualifies for an immediate SEP due to the lower income level, giving her an even better cost sharing silver plan with full maternity coverage....and no stigma of Medicaid.

The question being.....since she was not eligible for pregnancy medicaid when she applied, is she really eligible for it now since she has full maternity coverage with subsidies. With her current income level, she can get an even better Humana Silver plan with a $750 deductible.

Also, technically, since she will ultimately be filling a 2015 tax return with one dependent, that gives her an even better deal with ACA subsidies.

I called the market place...spoke to a clueless person....who of course wanted all the client details so I could speak to one of these mysterious "specialists"....so I backed away, since I have not discussed this with the client yet.

Hate to lose the client's Humana plan to pregnancy Medicaid, but if that is the best deal for her, then that is what she should do. The GADOI just said it is based on income, but I always thought it had to do with not having maternity coverage....which would make sense, or every poor person on a group plan would qualify.

Also, when does she say that she now has a dependent? I would think she can not make that "life change" call until after she delivers....so she could now have two life changes in the same year. I'll assume she would have to name the dependent for them to process the change.

thanks

 

[yorkriver1]

Just used HC.gov search. got two relevant results:
https://www.healthcare.gov/how-do-i-report-life-changes-to-the-marketplace/
https://www.healthcare.gov/what-if-im-pregnant-or-plan-to-get-pregnant/
Just called Marketplace to see if they will make pregnant women apply for Medicaid after their subsidized coverage is active. Call rep says state by state the system will assign the proper place, just like at enrollment (note, if they don't report life changes, they are putting subsidy and coverage in jeopardy) the site says:
1. must report a list of life events asap, including getting pregnant. I may print and email/mail this list to clients...
2. 2nd link is a bit confusing, because does not include any mention of Medicaid: says that you can keep your coverage once child is born, or can switch, because the birth triggers a SEP to choose a different plan. That implies they stay on Marketplace, but could apply to people far enough above poverty level for subsidy, but not Medicaid.
So, maybe you know all this and just want to know if she will be required to apply for Medicaid if the pregnancy is reported.
It seems low likelihood that the person can choose whether to stay on Marketplace plan or go to Medicaid. Marketplace will follow the rules of each state for Medicaid eligibility. So, if eligible for Medicaid, probably will have to apply.
This is likely to come up for any of us, took the time to look, so I will know more what to expect for my clients.

 

[Quotebroker]

Another scenario I just came across and want to run by you all to make sure my thought process is correct.


64 year old single woman making 20k year signed up for Enhanced Silver plan, taking subsidies and CSRs. She's happy with her plan. July 1 she turns 65.

Is she no longer eligible for subsidies/CSRs because she has *access* to Medicare, or does one have to be *on* Medicare already to be denied subsidies?

Thanks in advance.

 

[unic.consulting]

Another scenario I just came across and want to run by you all to make sure my thought process is correct.


64 year old single woman making 20k year signed up for Enhanced Silver plan, taking subsidies and CSRs. She's happy with her plan. July 1 she turns 65.

Is she no longer eligible for subsidies/CSRs because she has *access* to Medicare, or does one have to be *on* Medicare already to be denied subsidies?

Thanks in advance.

From HC.gov: In most cases it’s to your advantage to sign up for Medicare when you’re first eligible.


So it doesn't look like it's required, just recommended.

 

[Quotebroker]

From HC.gov: In most cases it’s to your advantage to sign up for Medicare when you’re first eligible.


So it doesn't look like it's required, just recommended.

Thanks for the reply.

From the Medicare side, I understand that it usually makes sense to sign up for Medicare when eligible. But I know one of the knockout questions on the subsidy application involves being on/having access to Medicare. I'm in CA and our CoveredCA subsidy application wording has been in conflict with the law more than once so I can't trust the verbiage they use

 

[unic.consulting]

Thanks for the reply.

From the Medicare side, I understand that it usually makes sense to sign up for Medicare when eligible. But I know one of the knockout questions on the subsidy application involves being on/having access to Medicare. I'm in CA and our CoveredCA subsidy application wording has been in conflict with the law more than once so I can't trust the verbiage they use

Yeah, once again the state exchanges rear their ugly heads. I don't think the Feds would ask for the subsidy back for those months since they say it's not a requirement to go on Medicare, but who knows what the state will try to do.

 

[Quotebroker]

Yeah, once again the state exchanges rear their ugly heads. I don't think the Feds would ask for the subsidy back for those months since they say it's not a requirement to go on Medicare, but who knows what the state will try to do.

The divide between what the state and the feds tell you is always a nuisance.


https://www.healthcare.gov/what-if-i-have-a-marketplace-plan-but-will-be-eligible-for-medicare-soon/

Everything here says subsidy ends "when your Part A coverage starts" but makes no mention as to what happens if you just don't sign up for Part A. That implies you can just keep the subsidized plan as long as you don't sign up for Medicare, but I'm not about to give advice based on an implication from hc.gov.

 

[unic.consulting]

The divide between what the state and the feds tell you is always a nuisance.


https://www.healthcare.gov/what-if-i-have-a-marketplace-plan-but-will-be-eligible-for-medicare-soon/

Everything here says subsidy ends "when your Part A coverage starts" but makes no mention as to what happens if you just don't sign up for Part A. That implies you can just keep the subsidized plan as long as you don't sign up for Medicare, but I'm not about to give advice based on an implication from hc.gov.

Is she getting Social Security? If she is, then her Part A is automatically going to start. If not, then she might have some wiggle room. I definitely think going Medicare would be the best option for the long run, but these grey areas are horrible.

 

[houcoogster]

The divide between what the state and the feds tell you is always a nuisance.


https://www.healthcare.gov/what-if-i-have-a-marketplace-plan-but-will-be-eligible-for-medicare-soon/

Everything here says subsidy ends "when your Part A coverage starts" but makes no mention as to what happens if you just don't sign up for Part A. That implies you can just keep the subsidized plan as long as you don't sign up for Medicare, but I'm not about to give advice based on an implication from hc.gov.

Generally speaking you usually don't have to sign up for Part A... its automatic.

 

[Quotebroker]

Thanks all.


Another one for you, this one hypothetical:

Assume we are in open enrollment: Individual u-65 signs up on an exchange plan with subsidies and CSRs. They then find out this plan doesn't cover one of their two doctors. Exorbitant cost aside, can they sign up for a second, off exchange plan without affecting their initial exchange plan/subsidy to take advantage of two networks worth of physicians?