ACA Plan Mess, Not Sure what to Do

[beachbum2012]

2-STM is an option, but good luck finding a major medical plan for a month. You can always purchase an individual plan off exchange thanks to the SEP. You don't have a ton of options unfortunately.

My advice? Get the guy in medicaid ASAP.

Appreciate the answers, Ray.

2) Priority Health here in MI offers a health plan called "My Priority Short Term". You can get coverage from 1 to 6 months. It's not on Exchange, or considered meeting the ACA rules (e.g. 10 EHB's) as far as I know. It does have underwriting, but it looks like he'll pass all the questions. Premiums are about 25% of what they would be with a non-subsidized ACA plan, so it'd be a good deal for him.

The healthcare.gov rep said that his case got turned over to Medicaid today, and said it could take up to 30 days for a determination. I don't know if I (or my client) can do anything to expedite things.

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This is happening repeatedly even with higher income. Happened to me yesterday with a client. See my other posts in other thread.

Best to re-do the app, change income by $10, and you'll get a new determination if their income is above medicaid levels. Did that, but still had problems as account is showing now inactive even though we submitted app with HC.gov rep.

Ray, what should happen, and what is happening, are two different things when dealing with the federal exchange.

So, let me see if I understand this right. Income above 400% of FPL gets no subsidy. Income between 133% and 400% of FPL gets a subsidy, which increases the lower the income is...until income under 133% again gets no subsidy, but qualifies them for Medicaid. So it sounds like it's either Medicaid, or get their own off Exchange plan, right?

I'm very reluctant now to increase their income back to ~$30k or so on the app, because if they do qualify for Medicaid (almost certainly will with income currently under $10k) and they aren't enrolled because of overestimating their income and getting a subsidy as a result, I wouldn't want to risk them having to owe all that subsidy money back at the end of the year.

 

[AllenChicago]

So it sounds like it's either Medicaid, or get their own off Exchange plan, right?

If affordable, off-exchange is the way to go. Particularly since he has a June 9th doctor's appointment. Never know what they might find. Besides, statistically speaking, his doctor PROBABLY does not accept Medicaid, so retroactive Medicaid coverage is a moot point.

I wonder if you can have Medicaid and a Private plan? If so, Medicaid would cover 1st dollar up to the Private plan's deductible/coinsurance, assuming the provider (doctor/hospital/outpatient center, etc.) accepts Medicaid...would it not?

 

[Quotebroker]

I'm very reluctant now to increase their income back to ~$30k or so on the app, because if they do qualify for Medicaid (almost certainly will with income currently under $10k) and they aren't enrolled because of overestimating their income and getting a subsidy as a result, I wouldn't want to risk them having to owe all that subsidy money back at the end of the year.

From a retired lawyer on another forum. The following is not my research nor my advice.


"there is another regulation that effectively reduces the clawback for anyone whose income is less than the poverty line to -0-. You can find that here: 26 CFR 1.36B-2 - Eligibility for premium tax credit. | LII / Legal Information Institute
(6) Special rule for taxpayers with household income below 100 percent of the Federal poverty line for the taxable year. A taxpayer (other than a taxpayer described in paragraph (b)(5) of this section) whose household income for a taxable year is less than 100 percent of the Federal poverty line for the taxpayer’s family size is treated as an applicable taxpayer if— (i) The taxpayer or a family member enrolls in a qualified health plan through an Exchange; (ii) An Exchange estimates at the time of enrollment that the taxpayer’s household income will be between 100 and 400 percent of the Federal poverty line for the taxable year; (iii) Advance credit payments are authorized and paid for one or more months during the taxable year; and (iv) The taxpayer would be an applicable taxpayer if the taxpayer’s household income for the taxable year was between 100 and 400 percent of the Federal poverty line for the taxpayer’s family size. (7) Computation of premium assistance amounts for taxpayers with household income below 100 percent of the Federal poverty line. If a taxpayer is treated as an applicable taxpayer under paragraph (b)(5) or (b)(6) of this section, the taxpayer’s actual household income for the taxable year is used to compute the premium assistance amounts under § 1.36B-3(d).
I interpret this to mean that, come the time for reconciliation of the subsidy with the 2014 tax return, anyone whose income is below the 100% FPL mark will be treated as if their income was exactly 100% - unless there are other disqualifying factors, such as simultaneous eligibility for employer-provided health insurance.
Note: I’m a retired lawyer. I don’t have much experience with health insurance, but I do know how to look up the actual law and regulations."