The Universal SEP

[FLM2]

But what's weird is that the "newly eligible for an APTC or CSR" reason for an SEP is supposed to be only given to those who already are insured through on a QHP, isn't it? (admission, I made this mistake earlier this week).

It is weird because all I did was answer the questions honestly, once we said her income was changing the application went right through.

I posted this thread because it seems like the Marketplace is circumventing the law as most of us interpret it (and most of the Off Exchange companies do as well) but since it creates the SEP why not use it?

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Sometimes it's multiple choice

I have noticed that the CA Exchange also often does not require any actual proof of the SEP, just the attestation by the applicant that there is a SEP.

Dave, the prior plan is not group coverage so this did not create a SEP with the company providing the Off Exchange policy.

It's clear from this (at least to me) that the Marketplace has a much wider tolerance for creating SEP's, just like Cigna allows you to go from a 1 month STM to a SEP for an Off Exchange policy.

I'm guessing the administration will do anything possible to add new subscribers to the rolls, this is just one way to do it-had the applicant gone straight tot he Marketplace knowing nothing it would have also gone right through, there must be thousands of these that have gone through in the same manner recently.

 

[taterpeeler]

Question.... was this the old app or the new streamlined app we have been hearing about?

 

[FLM2]

Question.... was this the old app or the new streamlined app we have been hearing about?

This was started on September 25th, I would assume this is the new streamlined application.

 

[kgmom219]

I had to do one yesterday over the phone with them and when she said "hold on, I have to go back" I asked if she was on the old app and was told "yes". Its still not 100% live. You can't assume its the streamlined based on date.

 

[Dave020]

Dave, the prior plan is not group coverage so this did not create a SEP with the company providing the Off Exchange policy.

Sorry, thought it was group.

 

[houcoogster]

I had a client yesterday who just lost her job (her employer pays the premium for an individual plan for her as a reimbursement, after tax, of course) and can no longer afford the premium.

We went to healthcare.gov and, as soon as we clicked 'my income has changed' (which it has) as a reason for requesting the SEP it was approved with no further questions or documentation requested in the eligibility letter.

She was very happy, of course, to get a plan for $150 a month (Silver with cost sharing help) instead of the $425 per month for the Platinum plan.

I've read that insurers can't turn down an applicant after the Marketplace approves the SEP so this seems like a universal way to create an SEP for anyone who is self employed without any consideration as to whether the change in income affects the eligibility for a premium subsidy (in addition to those who leave a job or start working less hours). Am I missing something here?

The reason for this SEP is Loss of Coverage. Not change in income.

Losing other health coverage (for example due to a job loss, divorce, loss of eligibility for Medicaid or CHIP, expiration of COBRA coverage, or a health plan being decertified). Note: Voluntarily quitting other health coverage or being terminated for not paying your premiums are not considered loss of coverage. Losing coverage that is not minimum essential coverage is also not considered loss of coverage.)

ObamaCare Open Enrollment

If the person did not have QHP coverage it wouldn't or at least "shouldn't" work.

 

[Yagents]

her employer pays the premium for an individual plan for her as a reimbursement, after tax, of course) and can no longer afford the premium.

as soon as we clicked 'my income has changed' (which it has) as a reason for requesting the SEP

How is this an involuntary loss of coverage?

 

[bluediamond]

It isn't involuntary loss of coverage, it was an individual and she could have taken over the premium's. Just because the employer quit paying doesn't mean she can't.

Well now I am questioning myself, she did have a loss of income, but then again she did voluntarily drop her individual plan mmmmmmm.

 

[taterpeeler]

First off this is NOT loss of employer coverage, period. The consumer has a current individual plan that meets MEC stds, it is a current off market ACA plan. The plan is neither renewing or terminating and never, ever had anything to do with the employer... the "special" deal was between her and the former employer. The employer did not purchase nor apply for this plan.

Of course any agent could state that to the HC.GOV rep and due to how stupid they are they will grant it but this should be noted, the FFM does have a history of what plan you currently have.... how do I know this? Simple, I was messing around with a client one day and for whatever reason I clicked a box incorrectly and up poped her current ACA plan... freeked the crap out of me.... Trust me they know.

Again, an ACA paid for by either the client, the boogy man or the cookie monster is still a ACA plan and if the cookie monster decided to stop paying the premium its still voluntary loss of coverage.... A real group plan that meets group law and standards is an entirely different story which Ann can more that speak about.

Lastly, anyone agent or client that goes into this situation attempting to state loss of group coverage is not following the rules as pursuant to federal law. Now, how do you get caught? well, that's another story in and of itself. Im sure when the end of the year happens and the marketplace sees an old ACA plan then another subsidzed plan will raise red flags me as and agent would not want to submit

 

[FLM2]

How is this an involuntary loss of coverage?

It's not but the Marketplace only asked if her income had changed. I understand this isn't a SEP per the definition of the law but pointing out where the marketplace apparently doesn't care about what the law says, isn't that consistent with Obama-think?

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First off this is NOT loss of employer coverage, period. The consumer has a current individual plan that meets MEC stds, it is a current off market ACA plan. The plan is neither renewing or terminating and never, ever had anything to do with the employer... the "special" deal was between her and the former employer. The employer did not purchase nor apply for this plan.

Of course any agent could state that to the HC.GOV rep and due to how stupid they are they will grant it but this should be noted, the FFM does have a history of what plan you currently have.... how do I know this? Simple, I was messing around with a client one day and for whatever reason I clicked a box incorrectly and up poped her current ACA plan... freeked the crap out of me.... Trust me they know.

Again, an ACA paid for by either the client, the boogy man or the cookie monster is still a ACA plan and if the cookie monster decided to stop paying the premium its still voluntary loss of coverage.... A real group plan that meets group law and standards is an entirely different story which Ann can more that speak about.

Lastly, anyone agent or client that goes into this situation attempting to state loss of group coverage is not following the rules as pursuant to federal law. Now, how do you get caught? well, that's another story in and of itself. Im sure when the end of the year happens and the marketplace sees an old ACA plan then another subsidzed plan will raise red flags me as and agent would not want to submit

The original plan was Off Exchange.

I did not do anything to encourage or discourage the applicant from applying, I said we could answer the questions as they were asked and see what the response was-in this case they granted the SEP and issued the policy. Nowhere did we state she lost group coverage because she hadn't.