Birth SEP Question for the Health Insurance Experts

[ohtobnaz]

I hope someone has the answer I want to hear. Haha.

My clients do not qualify for a subsidized premium due to income but have had a policy in place since Jan 1 I got throught the MP. They had a second child in March and this qualified them for a small subsidy. They also of course will have an SEP for birth plus they also are eligible for their group plan insurance through work.

If they are found not to be eligible for the marketplace plan because of the availability of the group plan which allows a retroactive issue date at birth, why would they not lose their marketplace coverage effective at the date of birth and have their premium refunded as well as paid claims rescinded?

Can they not use the SEP to change plans, even companies, retroactive to the date of birth? This was all I was originally planning to do ......change them to something that might save them some money like an HSA with a different company.

 

[Yagents]

1. They don't qualify for subsidy if group plan available.

2. Why would you want to change plans when all claims for birth under mom's deductible has been met, and kids claims since date of birth?

3. Don't know for sure if they can change plans even if wanted to change.

4. Anyone can buy a.c.a plan paying full price, not forced to take group plan.

U r asking for a world of hurt if you change plans on them

 

[ohtobnaz]

1. They don't qualify for subsidy if group plan available.

2. Why would you want to change plans when all claims for birth under mom's deductible has been met, and kids claims since date of birth?

3. Don't know for sure if they can change plans even if wanted to change.

4. Anyone can buy a.c.a plan paying full price, not forced to take group plan.

U r asking for a world of hurt if you change plans on them

_______________________________________________________________

1. If their group plan can start with the birth date, thereby paying the claims, and they are not eligible for the plan they had on the date of birth, why would the original plan not be termed as of the date of birth?

2. Statement above because of the smaller OOP with the group plan.

3. I thought getting an SEP retroactive with the date of birth qualified them to take whatever plan fit their birth claims the best, even with another company.

4. That's correct but would they be forced to?. What is the purpose of the SEP being retroactive to the birth date then?

....and thanks for the reply Yagents.

 

[traceyemoon]

I might be missing something here, but why would they lose their Marketplace plan? They can still continue it when employer coverage is offered, but they have to pay full price. How are they getting any subsidy since employer coverage is offered? I would double-check that first. Unless you are ok with the possibility that they may be asked to pay it back when they file 2017 taxes?

I get that the employer plan has lower out of pocket, but that is quite a bit of paperwork and money movement for the insurance companies and the clients if they have already paid all or a portion of the claims so far.

The marketplace is vague if they will let you change plans at this point. They typically will tell you only after you update the current application.

 

[ohtobnaz]

Thanks Tracey,

Vague is not the word for it. The premise I've been working with is that you can change your plan retroactive to the DOB within 60 days. I also thought since they can join their group plan they could take that option, again retroactive to the DOB and save a bundle.

Yes, the claims work would be involved but there are many other situations where the companies have to reverse claims payment.

Is this right?