ACA and Turning 26 Disabled

[WCMason]

I don't handle exchange cases but had a financial advisor asked me a question I thought I'd throw out here. Woman in question just turned 26 and has been on parent's IFP health plan. She recently got into a serious auto accident and with spinal injuries. Is there any provision for her to stay as a dependent on her current plan given the disability? Any advantage doing that over getting her own using the turning 26 SEP? At this point don't want to factor in any possible Medicaid eligibility.

 

[Newby]

I don't handle exchange cases but had a financial advisor asked me a question I thought I'd throw out here. Woman in question just turned 26 and has been on parent's IFP health plan. She recently got into a serious auto accident and with spinal injuries. Is there any provision for her to stay as a dependent on her current plan given the disability? Any advantage doing that over getting her own using the turning 26 SEP? At this point don't want to factor in any possible Medicaid eligibility.

After 24 months she will have Medicare and can get Medicare Advantage. Most people I see on disability have a disability attorney get them backdated for the disability, get Medicare immediately and get a little windfall from back payments which pays the attorney. It seems like a good ol boy system that some attorney dreamed up but it's how it always works.

 

[somarco]

Can't stay on parents plan past 26th birthday, healthy or not.

Aging off parents plan creates an SEP. She can buy her own plan. No underwriting, no pre-ex.

Old carrier responsible for claims incurred through the termination date. Keep in mind there is usually a time frame for submitting the claims. Providers must submit within 6 months to be eligible for payment, otherwise they are denied and provider has to eat the claim.

Parents must be diligent in tracking claims, making sure submitted claims are paid, etc. Match EOB's against patient bills. In situations like this claims often fall through the cracks and are not discovered until years later, even without the change in coverage.

New carrier picks up with claims incurred beginning with the eff date.

 

[kgmom219]

She can also do COBRA. And if she goes Medicare disabled in the first 18 months, she can extend it to 29 months.

Also, I think (someone else chime in here) that there is an AARP plan that will give her a Med Supp, even if she is disabled.

You need to get with someone in your state on the ACA indy plans. There will be several factors. If she is unable to work AND its a Medicaid Expansion state, then that might be an option. If its not a Medicaid Expansion state, and if she is unable to work, she won't get any financial help to pay the premium.

 

[somarco]

AARP plan that will give her a Med Supp, even if she is disabled.

Has to be age 50 and on SSDI before she can get approved for Medicare, and a gap plan.

MA is usually a better option for disabled, under 65.

 

[kgmom219]

Has to be age 50 and on SSDI before she can get approved for Medicare, and a gap plan.

MA is usually a better option for disabled, under 65.

I get the SSDI, then 2 years til Medicare part.

Where does the "over age 50" come into play? Is that just for the AARP plan?

(But I agree that MA is a better idea)

 

[somarco]

You must be an AARP member to buy their plan. Gotta be 50 or older to join the club.

Can still buy a Medigap from other carriers (depending on your state). The AARP/UHC plan is quite competitive for U65 disabled in GA.

YMMV

 

[WCMason]

Can't stay on parents plan past 26th birthday, healthy or not. Aging off parents plan creates an SEP. She can buy her own plan. No underwriting, no pre-ex. Old carrier responsible for claims incurred through the termination date. Keep in mind there is usually a time frame for submitting the claims. Providers must submit within 6 months to be eligible for payment, otherwise they are denied and provider has to eat the claim. Parents must be diligent in tracking claims, making sure submitted claims are paid, etc. Match EOB's against patient bills. In situations like this claims often fall through the cracks and are not discovered until years later, even without the change in coverage. New carrier picks up with claims incurred beginning with the eff date.

Thanks for clarifying the need for this person to use the SEP to get her own individual plan.

This is an interesting case, helping me get new insight into how Medicare works. The disability is due to an auto accident. Part of the settlement requires establishing a Medicare Set Aside account, a term I'd never heard of, to make sure the medical expenses related to the accident are paid as part of the settlement rather than by Medicare. I have some pretty general knowledge of the Medicare Second Payer Act, but was unfamiliar with this provision. Apparently if Medicare eligibility is expected within 30 months and the amount of the anticipated medical expense are above a certain threshold, Medicare requires this and requires the manager of the account to give an accounting of the expenses.

 

[somarco]

Part of the settlement requires establishing a Medicare Set Aside account, a term I'd never heard of, to make sure the medical expenses related to the accident are paid as part of the settlement rather than by Medicare.

Carriers (and Medicare) have subrogation rights which is always messy. Basically they don't want to pay anything that is supposed to be covered by the auto carrier. Presumably the set aside is established in such a way as to protect it from subrogation, otherwise the money may be gone in a few years.

Some additional reading might be in order here.

https://www.ohiobar.org/ForPublic/Resources/LawYouCanUse/Pages/LawYouCanUse-650.aspx

Congress has given the Medicare program specific collection powers with respect to its conditional payment recovery claims. The Center For Medicare Services (CMS) has both subrogation rights and the right to bring an independent action to recover its conditional payments from any entity that is "required or responsible . . . to make payment". [8] CMS is further authorized to bring actions against "any other entity that has received payment from a primary plan."

CMA ||  Medicare Secondary Payer Program


This article discusses the Medicare set aside.

 

[yorkriver1]

You must be an AARP member to buy their plan. Gotta be 50 or older to join the club.

Can still buy a Medigap from other carriers (depending on your state). The AARP/UHC plan is quite competitive for U65 disabled in GA.

YMMV

Now it seems the membership requirements are less strict. Must be glad to have more folks in their marketing base.
AARP will enroll an additional member of a household under age 50, including daughters/sons as members, providing someone age 50 or over joins as primary. Minimum age 18. Just checked with the membership dept. I recalled them telling me this while client was signing up during MedSupp appt a few months ago.
The underwriting rules for AARP/UHC MedSupp are another issue. How they handle eligibility for under 65 varies, as we know, by state/area. In my part of the state, no carriers offer MedSupp to under 65. There is one area in the state where one is offered by the BCBS organization, but so expensive that it's really irrelevant.