Silver Cost Sharing Reductions in Practice

TN_agent

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Hypothetical situation, anyone encountered this in real life, if so what was the outcome?


Client at 140% of poverty (94% CSR level). Client gets another job/increased income to 160% of poverty (if income stays the same for the rest of the year now eligible for 87% CSR level)

Plan originally enrolled in had $0 deductible, MOOP $600. (I am making these numbers up). We will call it Plan X-94.

Identical plan at 87% CSR has $0 deductible, MOOP $1800. We will call it Plan X-87.

Plan X with no CSR is $2500 ded/$5000 MOOP, 35% coinsurance, no copays.

Assume the client has met the $600 MOOP for the year already.

When client is placed on Plan X-87 mid-year, will the carrier acknowledge the $600 already paid this year, or will they start it over as if they had been placed on a brand new plan?

Anyone had any real-life experience with this?
 
The $600 is required to be put towards the new OOP on the new CSR plan.

Whether the carrier gets it right on the first claims is another story.
 
Thanks yagents . I thought that is how it should work, but I have never seen where exactly that is spelled out in guidelines or training, only seen mentions of how people who fall out of CSR range mid-year don't have to pay it back.
 
Yes, I have someone I'm waiting to see how it turns out on the original plan at -0- deductible; $500 maximum OOP. This person had a knee surgery and then changed jobs for more money. He is now at $500 deductible; $1500 maximum OOP. I am wondering as well if they will apply the original claim to the original plan?

These people had overpaid as BC/BS is having a hard time recognizing the subsidized out of pocket as well. They even told the doctor's office/hospital that his maximum out of pocket was $6350. I had to call them and ask them to 'look further' as they told me $6350 as well. Evidently, there is another screen the benefits people are not seeing when they verify benefits.
 
Government forcing insurers to accept lower OOP has to be one of the most hated ACA mandates in the eyes of health insurance companies. You can't even find the CSR Summary of Benefits at bcbsil.com this year. HHS must not be keeping their end of the bargain by paying it's share of the CSR at claims time.
 
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