Current ACA members--Wife's Medicare effective 7/1, husband now Medicaid eligible--how to proceed?

[Cenla Agent]

Here's the situation: A husband and wife are on a ACA plan together. The wife's Medicare is effective 7/1. So she needs to come off the application. The husband isn't 65 yet, so his coverage needs to continue. The monkey wrench is that his estimated income is below what they had estimated last year and it will now put him below 138%. Even if he reports no change in income, the number that was reported last fall is below 138% of the 2024 FPL. Last fall CMS was still using the 2023 FPL numbers but they are using 2024 now and there seems to be more of an increase than usual.

If we just put through the app on the Marketplace and it says it looks like he qualifies for Medicaid, what will happen? Doesn't he need to enroll in a new plan in order to continue coverage? You can't do that without APTC unless you want to pay full price, which obviously they can't do. Sometimes Medicaid automatically goes through and becomes effective almost immediately and sometimes it is held up and more information is requested. Plus, if he doesn't move forward and enroll in a plan by himself by 6/30, will it even end her coverage?

When you call the Marketplace, you get a lot of uncertain answers with scenarios like this. Even after all these years they will sometimes tell you to wait until the last day of the month to make changes like this to make sure that the spouse who is dropping coverage doesn't lose their coverage immediately rather than at the end of the month. That's the same kind of advice they were giving 10 years ago.

Is there a solution I'm missing?

 

[Yagents]

Yes, do last day of month.
Leave both on application as both incomes are included. If above 138%, then you're fine. If joint income is below, then send him to medicaid. There won't be a lapse in coverage as medicaid should be eff 7/1. If declined by medicaid, sep for aca

 

[DonP]

Hold up . Depends on the state . Many states have a donut whole were you got to be in absolute poverty to get Medicaid .

 

[Cenla Agent]

Yes, do last day of month.
Leave both on application as both incomes are included. If above 138%, then you're fine. If joint income is below, then send him to medicaid. There won't be a lapse in coverage as medicaid should be eff 7/1. If declined by medicaid, sep for aca

This close to the end of the month, can we be sure that it will be approved for Medicaid? Medicaid will pend if not auto-approved by the system.

Sure, there is a SEP if Medicaid is denied, but what about July's coverage? Once you get into July, ACA coverage generally won't begin until 8/1 unless there's an exception for Medicaid denial. (I think there is an exception for loss of group coverage in the middle of the month but I haven't done one of those in a while.)

 

[Cenla Agent]

Hold up . Depends on the state . Many states have a donut whole were you got to be in absolute poverty to get Medicaid .

The "donut hole" is for states that didn't expand Medicaid. This is in a state that expanded Medicaid.

In states that didn't expand Medicaid, even absolute poverty doesn't always cut it. Sometimes there has to be some sort of disability as well. Able-bodied adults getting free insurance is one of the main complaints that ACA opponents have when it comes to expanded Medicaid.

 

[Yagents]

If denied medicaid, the MP will backdate to loss of coverage date 7/1. Call MP to verify.

 

[Cenla Agent]

If denied medicaid, the MP will backdate to loss of coverage date 7/1. Call MP to verify.

That is basically what the MP said, but the rep went back and forth about a half dozen times trying to figure out what to do and he seemed more knowledgeable than a rep we spoke to several days ago.

IMHO it is ridiculous that there is still this much uncertainty about how to proceed after a decade of doing this. Ultimately the rep said the best thing to do was terminate the Marketplace coverage for both of them and hope he gets approved for Medicaid. He's reporting less income than he has made in previous years, so we'll see. Someone who is self-employed can't exactly send in W-2s and easily prove what he's making and write-offs aren't taken until taxes are filed. But he'd rather have no insurance than have to pay over 2k per month if they remove APTC. The rep said that even if he is denied for Medicaid he would get a SEP to get Marketplace coverage restored but that he may not get APTC since the income is too low.

 

[Yagents]

That is basically what the MP said, but the rep went back and forth about a half dozen times trying to figure out what to do and he seemed more knowledgeable than a rep we spoke to several days ago.

IMHO it is ridiculous that there is still this much uncertainty about how to proceed after a decade of doing this. Ultimately the rep said the best thing to do was terminate the Marketplace coverage for both of them and hope he gets approved for Medicaid. He's reporting less income than he has made in previous years, so we'll see. Someone who is self-employed can't exactly send in W-2s and easily prove what he's making and write-offs aren't taken until taxes are filed. But he'd rather have no insurance than have to pay over 2k per month if they remove APTC. The rep said that even if he is denied for Medicaid he would get a SEP to get Marketplace coverage restored but that he may not get APTC since the income is too low.

I would NOT terminate policy. Re-do the MP application with joint income below 138%, stating no coverage for her, but yes for him, and let MP send file to state medicaid to enroll.

Have client put together better proof of low income like self employed ledger showing income and expenses, and past tax year forms. If declined, it's because income above 138%, so either MP will still issue aptc (not sure), or move income to 139%+ since that's what medicaid shows w decline.

 

[Cenla Agent]

I would NOT terminate policy. Re-do the MP application with joint income below 138%, stating no coverage for her, but yes for him, and let MP send file to state medicaid to enroll.

Have client put together better proof of low income like self employed ledger showing income and expenses, and past tax year forms. If declined, it's because income above 138%, so either MP will still issue aptc (not sure), or move income to 139%+ since that's what medicaid shows w decline.

The problem is that there doesn’t seem to be a way to cancel her coverage without also canceling his. I’ll check again later but the Marketplace already put in that request. If he was above 138 you could just enroll him in a plan and it would term hers. I did it the way you said several days ago and he said it was not going to term hers. We were told that by a different rep last week as well.

 

[Yagents]

The problem is that there doesn’t seem to be a way to cancel her coverage without also canceling his. I’ll check again later but the Marketplace already put in that request. If he was above 138 you could just enroll him in a plan and it would term hers. I did it the way you said several days ago and he said it was not going to term hers. We were told that by a different rep last week as well.

When u re-do the app, the first questions are who needs coverage? Say no to hers, yes for him. It cancels the plan for her only on that day of app and next day eff date for him if above 138%