5/16/14 CMS Final Rule-Almost 500 Pages

[Yagents]

Ok folks, here's the cliff notes from Jost' opinion (over zealous consumer advocate) in two separate blogs. A long, tedious and technical read, but well worth it as it breaks down 500 pages to 10. I'm worn out reading it.


Implementing Health Reform: Final 2015 Exchange And Insurance Market Standards Rule – Health Affairs Blog

Implementing Health Reform: Final 2015 Exchange And Insurance Market Standards Rule (Part 2) – Health Affairs Blog

 

[RayNY]

Yagents, we can both agree it's not ideal, and things are getting worse. To answer your question, no, you cannot sell it to someone with no insurance at all. The carrier is supposed to ask, and the client will be denied if they don't have pre-existing MEC.

Healthguy, see the above answer. No, not legal, and carrier shouldn't allow it unless you lie on the app. If you sneak it through, client is still getting a penalty.

dgoldenz, if your name is on an app, and it's wrong, you already know they won't care who put the info in. You're much better off being involved and making sure it's right if your name is tied to it.

xrac, that's not a half bad comparison. Honestly, I wouldn't be surprised to see $5,000 fines left and right. Quarter million? Maybe to make an example of someone prolific. I'd be shocked if we saw a 5-6 figure fine over a single app.

kstein, mostly Colonial's Group Medical Bridge, 3.0 to be specific. $2500 hospital admission takes a lot of pain away from the deductible on a silver/bronze plan. ER benefit is $150, $1000 available for diagnostic procedures, up to $3,000 for surgery. Depending on what happens, it can cover the entire deductible on bronze. A QHP with this plan is cheaper than a metal tier up from the same company, but thanks to the reimbursement, ends up having a similar AV.

 

[dgoldenz]

Yagents, we can both agree it's not ideal, and things are getting worse. To answer your question, no, you cannot sell it to someone with no insurance at all. The carrier is supposed to ask, and the client will be denied if they don't have pre-existing MEC.

Healthguy, see the above answer. No, not legal, and carrier shouldn't allow it unless you lie on the app. If you sneak it through, client is still getting a penalty.

dgoldenz, if your name is on an app, and it's wrong, you already know they won't care who put the info in. You're much better off being involved and making sure it's right if your name is tied to it.

xrac, that's not a half bad comparison. Honestly, I wouldn't be surprised to see $5,000 fines left and right. Quarter million? Maybe to make an example of someone prolific. I'd be shocked if we saw a 5-6 figure fine over a single app.

kstein, mostly Colonial's Group Medical Bridge, 3.0 to be specific. $2500 hospital admission takes a lot of pain away from the deductible on a silver/bronze plan. ER benefit is $150, $1000 available for diagnostic procedures, up to $3,000 for surgery. Depending on what happens, it can cover the entire deductible on bronze. A QHP with this plan is cheaper than a metal tier up from the same company, but thanks to the reimbursement, ends up having a similar AV.

There's still a difference between the agent entering the information and the client entering the information when someone submits an app. In DC the agent can complete the app for the client including the ability to state their income which determines the subsidy. I refuse to complete an app for someone requesting a subsidy for exactly that reason - if they do it themselves, I have no responsibility. If I did the app for them and the income was underreported, well guess who gets blamed...

 

[houcoogster]

There's still a difference between the agent entering the information and the client entering the information when someone submits an app. In DC the agent can complete the app for the client including the ability to state their income which determines the subsidy. I refuse to complete an app for someone requesting a subsidy for exactly that reason - if they do it themselves, I have no responsibility. If I did the app for them and the income was underreported, well guess who gets blamed...

If your name is on the app what defense do you have?

I simply tell everybody I write if your income goes up or down by more than $100 bucks a month call the marketplace so they can adjust your subsidy amount up or down.

What about people that work on commission in seasonal businesses like electronics/Christmas or pools/summer?? If they call the market place each month they will go from Medicaid to NO subsidy every other month

There are a lot of kinks to iron out with all this subsidy stuff. I'm just going to do the right thing for each person each time and hope for the best. What else can we do?

 

[dgoldenz]

If your name is on the app what defense do you have?

I simply tell everybody I write if your income goes up or down by more than $100 bucks a month call the marketplace so they can adjust your subsidy amount up or down.

What about people that work on commission in seasonal businesses like electronics/Christmas or pools/summer?? If they call the market place each month they will go from Medicaid to NO subsidy every other month

There are a lot of kinks to iron out with all this subsidy stuff. I'm just going to do the right thing for each person each time and hope for the best. What else can we do?

There is a record of the consumer submitting the application through the exchange themselves when they go through HC.gov. When the agent submits the app for a client through the DC exchange, there is a section the agent has to complete which specifically states that the agent completed the application on behalf of the client. I am not willing to sign that statement for a subsidy app, simple as that.

 

[Yagents]

You're asking for problems if you go in to change your income with HC.gov, it requires that you re-do the entire app, and the new determination is bound to be wrong.

Best to consider reconciling when they file their taxes, and save some extra money under the mattress.

But, I'm not a tax advisor.

 

[Norwayguy]

You're asking for problems if you go in to change your income with HC.gov, it requires that you re-do the entire app, and the new determination is bound to be wrong.

Best to consider reconciling when they file their taxes, and save some extra money under the mattress.

But, I'm not a tax advisor.

Yeah but did you stay at a Holiday Inn Express last night?

 

[russelltw]

My issues have been with income changes and adding new dependents. Each situation the website did something it was not supposed to do based on what the law says should happen. In the addition of a new born to a subsidized plan (family of 5 at 240% FPL), it sent the mother, father, second youngest, and new born to Medicaid; while saying the oldest two kids qualify for no subsidy and can buy their plan through the exchange.

In that case, the child should go on the plan and the premium should go down since the family is bigger (income is same) and the 4th child is no charge. Oh well, now we have to wait for Medicaid to decline the entire 4 of the family.

 

[Yagents]

So, you have 2 choices Russell.

1. let them go to medicaid, be rejected, and be without coverage until you get the answer that you know is going to come. Then, you may find their is no SEP, as no insurance was lost if it goes past 60 days.

2. Call up HC.gov with client, change the income by $10 up or down, and get a new determination, and fix the problem.

Then the 2nd game will begin, and that's banking on the fed to send the file with all people on the app, effective date, payment, APTC being sent, and agent info included. Ain't happenin' with my recent clients.

 

[kstein]

Does anyone know if a screw up by the company (they termed the EFT for some unknown reason) that caused cancelation 4/1 is a sep to get a different carrier off exchange?