Never come across this situation before, maybe one of the experts here can help. Just wasted two hours on the phone with HC.gov and got nowhere, which is about what I expected. Here’s the situation:
-Employer has 50+ full-time equivalents
-Business based in Virginia where group health plan was established with two options, one HMO and one PPO (employee-only cost of HMO $160/mo, PPO $240/mo).
-New branch opened in Florida. Insurance company requires new PPO plan to be established for all Florida employees, but it is under the same policy. Employee-only cost $250/mo. This is the only plan that FL employees can enroll in, they cannot enroll in the VA HMO or PPO.
-Employee makes $23k annually, which is “affordable” under the VA HMO plan, but is not affordable under the FL PPO plan.
-Said employee applies through HC.gov and gets a subsidy claiming that plan is not affordable. There is nowhere on HC.gov’s application that asks what the employee is paying for coverage, or what the employer cost is, so there is no “test” on the app to determine affordability.
Employer responsibility provision requires that the employee’s share of the plan offered does not exceed 9.66% of employee income, but that is usually based on the lowest-priced plan they offer and the employee can decide whether to “buy up” to the better plans. However, if the employee is not able to enroll in the lowest-priced plan that is normally used as the benchmark, does the FL PPO (most expensive) plan then become the benchmark, or is it still based on the cheaper HMO since the employer offers it, even though they can’t enroll in it?
If the employer is not offering “affordable” coverage, they could be on the hook for some very expensive penalties, yet it is impossible to find any kind of statement about this situation in writing, and I have not seen it before. Should the employee be subsidy-eligible, or no?
-Employer has 50+ full-time equivalents
-Business based in Virginia where group health plan was established with two options, one HMO and one PPO (employee-only cost of HMO $160/mo, PPO $240/mo).
-New branch opened in Florida. Insurance company requires new PPO plan to be established for all Florida employees, but it is under the same policy. Employee-only cost $250/mo. This is the only plan that FL employees can enroll in, they cannot enroll in the VA HMO or PPO.
-Employee makes $23k annually, which is “affordable” under the VA HMO plan, but is not affordable under the FL PPO plan.
-Said employee applies through HC.gov and gets a subsidy claiming that plan is not affordable. There is nowhere on HC.gov’s application that asks what the employee is paying for coverage, or what the employer cost is, so there is no “test” on the app to determine affordability.
Employer responsibility provision requires that the employee’s share of the plan offered does not exceed 9.66% of employee income, but that is usually based on the lowest-priced plan they offer and the employee can decide whether to “buy up” to the better plans. However, if the employee is not able to enroll in the lowest-priced plan that is normally used as the benchmark, does the FL PPO (most expensive) plan then become the benchmark, or is it still based on the cheaper HMO since the employer offers it, even though they can’t enroll in it?
If the employer is not offering “affordable” coverage, they could be on the hook for some very expensive penalties, yet it is impossible to find any kind of statement about this situation in writing, and I have not seen it before. Should the employee be subsidy-eligible, or no?
