Retroactive Subsidy for November 1st SEP?

[steph0216]

Client A loses group coverage on November 1st. Waits to enroll in a new plan, knows he has 60 days. Last week he has a stroke and lands in the hospital. Now he is currently unemployed and anticipates his 2015 income to be much less than it was in 2014. If he applies for coverage today-

1. Will the marketplace backdate any potential 2014 subsidy he may receive to 11/1? They have to, right?
2. Would he have to re-enroll or do a life change app when looking at plans for 2015 since his 2015 income will be lower and he'll be eligible for a bigger APTC?

Not sure what to do with this one, kinda wanting to just tell him to call HC.gov and be done with it...

 

[RayNY]

1. Yes, but it's based on estimated 2014 income, and he'll owe back due premium before claims are paid. Subsidy is only paid for months covered (nov/dec)
2. Yes, you'd have to manually process the change in income through the portal. This is subject to existing submission deadlines/effective dates/SEP.

 

[dgoldenz]

If he didn't enroll in a new plan, they're not going to backdate that plan to November 1...he needs to accept COBRA to get the stroke claim paid.

 

[RayNY]

10/31 SEP due to termination of existing group coverage results in replacement coverage effective the first day of the next month, or 11/1.

They should totally back date the plan to Nov 1.

45 CFR 155.420 - Special enrollment periods. | LII / Legal Information Institute Here's the important part of the law concerning SEP's and effectives, (b)(2)(ii) is the part that refers to this.

 

[dgoldenz]

10/31 SEP due to termination of existing group coverage results in replacement coverage effective the first day of the next month, or 11/1.

They should totally back date the plan to Nov 1.

45 CFR 155.420 - Special enrollment periods. | LII / Legal Information Institute Here's the important part of the law concerning SEP's and effectives, (b)(2)(ii) is the part that refers to this.

It's my understanding that coverage is the first of the following month from when the app is submitted, not when the event happened.

(ii) In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, as described in paragraph (d)(1) of this section, the Exchange must ensure coverage is effective on the first day of the following month.

Anyone know for sure?

 

[RayNY]

"In the case of marriage, or in the case where a qualified individual loses minimum essential coverage, the Exchange must ensure coverage is effective on the first day of the following month."

I'm very sure it's based on the event day, and not the submission day (I just took out the "as described in (d)(1)" part because it just says the same thing as the first line anyway and makes it confusing.) I've also submitted business and gotten the 1st following the SEP, even when it was a month+ retro, so I'm positive it's possible.

(b)(1):Regular Effective Dates, clearly goes by the submission date. (b)(2) is clearly a separate and distinct process. If they wanted those dates to apply to SEP's, they would have placed it in section (a) or (b), not as a subsection applying only to regular effective dates.

This is further reinforced by the fact that ONLY marriage/birth/adoption/loss of MEC have this "first of the next month" rule applied. Gaining citizenship, errors, contract violation, move of residence, and exceptional circumstances all have an effective based on submission date, not event date. The thinking was, they don't want a newly uncovered person, or newborn, to have a lapse.

 

[dgoldenz]

Just had client apply on Sherpa 12/30 for a SEP where the plan ended 12/31, HC.gov error causes app to not get processed until January. They told me today that effective date must be 2/1/15 since it's first of the month after plan selection, not the event. Double confirmed with supervisor.