SEP's - Must Have "loss" of Coverage

[unic.consulting]

This confused me. I thought, "What? Yagents thinks birth, adoption, and marriage require prior coverage?" Then, I realized we have a miscommunication and that is what RayNY was trying to clarify.

What you are saying is that the baby who is born or adopted doesn't need to have prior coverage, to be added to an in-force policy. But if the family didn't have any insurance in force, and then a baby was born or adopted, the family can't use that as an SEP.

So it'd really suck for someone who finds out they're 3 months pregnant in April weeks. No coverage during the pregnancy and no coverage for the child for several months. Well, it'd really suck for the child at least.

 

[Yagents]

The baby can get a child only policy using SEP. But the family cannot if no current coverage.

This is from what I'm reading from various sources. This SEP stuff is all new to everyone, hence the discussion necessity.

 

[unic.consulting]

The baby can get a child only policy using SEP. But the family cannot if no current coverage.

This is from what I'm reading from various sources. This SEP stuff is all new to everyone, hence the discussion necessity.

Okay. That makes more sense to me.

 

[somarco]

Only if it's involuntary lapse (plan termination). Non payment won't fly.

So what if they say they paid their premium but the carrier can't find it?

I have a client with Cigna. Jan 1 eff date. He finally got a bill from Cigna which he paid before the end of January.

Cigna cashed his check.

In February he sent payment #2 (he refuses to use bank draft). Cigna returned his Feb check with a letter saying his policy was cancelled do to non-payment of his Jan premium.

 

[RayNY]

Yagents hit the nail on the head. Ann, you did too.

Child-only policy is available for a birth or adoption where the parents are not currently covered, regardless of the child's current coverage status.

If the parents are covered, a birth or adoption creates an SEP for the whole family-they can add the dependent, or even switch plans/carriers, as dictated by law.

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So what if they say they paid their premium but the carrier can't find it?

I have a client with Cigna. Jan 1 eff date. He finally got a bill from Cigna which he paid before the end of January.

Cigna cashed his check.

In February he sent payment #2 (he refuses to use bank draft). Cigna returned his Feb check with a letter saying his policy was cancelled do to non-payment of his Jan premium.

If you ask me, that's SEP reason #1 "A qualified Individual or dependent loses minimum essential coverage (not due to their own failure to pay or contract breach allowing rescission)".

45 CFR 155.420 (d)(1)

You will likely have to prove 1) the checks were submitted on time, 2) the check was cashed to bind his coverage, and 3) it was the company's screw up.

If the carrier admits it, you're golden. If they deny it, you have an uphill battle. Either way, you're already in uncharted territory.

 

[Yagents]

So what if they say they paid their premium but the carrier can't find it?

I have a client with Cigna. Jan 1 eff date. He finally got a bill from Cigna which he paid before the end of January.

Cigna cashed his check.

In February he sent payment #2 (he refuses to use bank draft). Cigna returned his Feb check with a letter saying his policy was cancelled do to non-payment of his Jan premium.

This plan was never "effectuated", meaning never placed. I would just remove current health plan and financial app off HC.gov, and resubmit for May 1st effective date.

If OFF exchange, just reapply for May 1st.

This assumes no claims have been made or necessary.

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Yagents hit the nail on the head. Ann, you did too.

Child-only policy is available for a birth or adoption where the parents are not currently covered, regardless of the child's current coverage status.

If the parents are covered, a birth or adoption creates an SEP for the whole family-they can add the dependent, or even switch plans/carriers, as dictated by law.

I'll add another one............If fiance' has coverage, and you get married, the non covered new spouse can join the fiance's plan by adding a dependent. If both uninsured, marriage does not create an SEP.

Moral of the story.........marry someone who is insured. I guess we will still see the old world scenario of "people getting married just to get insurance" outside of OEP

 

[somarco]

This plan was never "effectuated", meaning never placed. I would just remove current health plan and financial app off HC.gov, and resubmit for May 1st effective date.

If OFF exchange, just reapply for May 1st.

This assumes no claims have been made or necessary.

Original app was off exchange.

And yes, they have had claims.

I probably get at least 1 email a week from this client, bi***ing about Cigna.