Lying About Not Having Employer Coverage.

G.Gordon

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Missouri
Last year I signed up a local business h/w owners. She is a tribe member. She of course has $0ded, 0% coinsurance, and $0 for all medications and $0 MOOP. Her daughter, married with a spouse that insures the family with his job, calls wanting her mother's deal. I inform her she can't due to having employer coverage.

This year she informed me that as of 12:01 they do not have employer coverage since they "didn't sign up for it" that action should make her eligible. I told her otherwise and she informs me later that night that she has signed the family up on her own. Glad my NPN is not on that app.

After the last email I sent her:

https://www.healthcare.gov/have-job-based-coverage/change-to-marketplace-plan/
 
Yeah, I had a weird one the other day.

The guy tells me that he is not offered coverage, then he says actually it is, but he can't afford it. I ask if it is a qualified plan, etc. He doesn't know. I ask how much coverage for just him is, he doesn't know.

He says it is different for everyone (that sounds strange to me). We call his employer together. The woman tells me it is a good plan with only a $1000 deductible and he is "#$#W" lucky she offers it at all. I ask how much it would cost my client to take the coverage. She flat out tells me she doesn't know, and she can't tell me because they do, in fact, charge employees more based on their age and she doesn't have the paperwork in front of her to know how much my client would be charged and she doesn't feel like looking it up.

She says they pay half of employee charge and the employee is charged the rest. This isn't leveled, so older employees do pay more than younger ones. She hasn't decided if she would even going to offer it next year and won't decide until the end of December.

Unbelievable. :twitchy:

I signed him up for subsidized coverage (at his age, based on what they described with the plan, half of a 60 year old man's rate will be well over 10% of his barely over poverty income). I have made copious notes about the situation. My client is aware he may have to repay the subsidy if his employer chooses to lie about how much they were charging him. They are a small business so there is no requirement for them to offer the coverage at all. I guess they have gotten away with this so far?

I have a clear conscience about it, there is not a qualified plan out there with a $1k deductible where 50% of a 60-year old man's premium (non-leveled) would be less than $100 a month. He said they wanted to charge him $250 a month two years ago (well over 10% of his income), and prices have gone up for all his coworkers the past couple of years. That is enough for me.

If an employer is not willing to cooperate and can't give me hard numbers about how much it would cost an employee to be on their plan, what can be done?

He said he went with a (different) agent last year and she did not ask him any of these questions at all about affordability of work-based coverage.
 
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Have had the marketplace tell me on several occasions that if the employee has missed the open enrollment with the group, that they can get subsidized coverage until the group has open enrollment again. At that point, they have to drop their ACA subsidy.

That's a big loop hole.
 
Read the link I posted. That does not mention that option. Missing a enrollment deadline by choice of accident is not an option, if it were anyone and everyone could just "miss" the deadline and get on-x coverage with tax credits.

Professionally I'm sticking by the rules I see in writing. If they want to call the marketplace and enroll via a rep they'll never hear from again and not be able to blame if the subsidy gets clawed back, that is on them. I'm not sticking my head in that loop hole.
 
Read the link I posted. That does not mention that option. Missing a enrollment deadline by choice of accident is not an option, if it were anyone and everyone could just "miss" the deadline and get on-x coverage with tax credits.

Professionally I'm sticking by the rules I see in writing. If they want to call the marketplace and enroll via a rep they'll never hear from again and not be able to blame if the subsidy gets clawed back, that is on them. I'm not sticking my head in that loop hole.

I agree, but the marketplace will tell them differently. I tell clients I have to follow the rules. But hc.gov does not, call them for help and they will make it work.
 
Exactly, my warning to someone on-x that is contrary to the rules: "When your sitting there with your tax guy and he says you owe a few thousand dollars back... that guy at the marketplace is not the one paying it."
 
What if the spouse that was offered employer group health, turned down and is over 65 and on Medicare and the other spouse has subsidy?
 
Blue, he is not required to take the group, because he has MEC (medicare) available and taken. She does not have access to group without him, therefore she is eligible for aptc. Same goes for pension retiree group plan extensions. Technically, these are not group, they are treated more like Cobra. Not the actual group plan(no longer an employee), but an extension of that group plan.

That's layman's terms. Group experts can chime in.
 
Blue, he is not required to take the group, because he has MEC (medicare) available and taken. She does not have access to group without him, therefore she is eligible for aptc. Same goes for pension retiree group plan extensions. Technically, these are not group, they are treated more like Cobra. Not the actual group plan(no longer an employee), but an extension of that group plan.

That's layman's terms. Group experts can chime in.

Thanks Y I thought that might be the case but was being told different by someone I work with.
 
Blue, he is not required to take the group, because he has MEC (medicare) available and taken. She does not have access to group without him, therefore she is eligible for aptc. Same goes for pension retiree group plan extensions. Technically, these are not group, they are treated more like Cobra. Not the actual group plan(no longer an employee), but an extension of that group plan.

That's layman's terms. Group experts can chime in.

In our state, the retired state employees can add a spouse at open enrollment. I would believe that there would be no subsidy since access to group is technically available.
 
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