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?

The only way I can think of to definitely avoid a gap in coverage is to bump up his income on the app to get it over 138%, enroll him in his own Marketplace plan for July and then come back next month and report the change in income if it definitely looks like his income will be below the threshold. Has anyone dealt with this? What will happen if the lower income is reported now? (He's self-employed and thus income can be hard to predict. But his best guess is that it will end up being below 138%.)

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.