What if the person is self-employed and has estimated their income wrong? Do they get an SEP?
We Are Closed !!!
- Thread starter Yagents
- Start date
Depends on the mis-estimation.
Estimated they were not going to be subsidy eligible, but Q1 income extrapolated out implies they are? SEP! (Strongly implied must apply on-exchange with a subsidy)
Estimated they are subsidy eligible, but had a raise and are not anymore? SEP! (Strongly implied they must apply off-exchange)
The key there is "newly eligible or ineligible". No, you can't say you "estimated" you'd make a whole lot more than last year, but now realize you actually are making the same as last year. That's going to be their check for "newly" in cases where no application was made.
If the client did apply, the check will be today's estimated income vs. the income stated in the initial application. Keep in mind, it has to either be new eligiblility or ineligibility, or a change in CSR level. A simple change does not count (but still must be reported as a life change event to keep APTC's correct and avoid a tax penalty at the end of the year!)
Estimated they were not going to be subsidy eligible, but Q1 income extrapolated out implies they are? SEP! (Strongly implied must apply on-exchange with a subsidy)
Estimated they are subsidy eligible, but had a raise and are not anymore? SEP! (Strongly implied they must apply off-exchange)
The key there is "newly eligible or ineligible". No, you can't say you "estimated" you'd make a whole lot more than last year, but now realize you actually are making the same as last year. That's going to be their check for "newly" in cases where no application was made.
If the client did apply, the check will be today's estimated income vs. the income stated in the initial application. Keep in mind, it has to either be new eligiblility or ineligibility, or a change in CSR level. A simple change does not count (but still must be reported as a life change event to keep APTC's correct and avoid a tax penalty at the end of the year!)
- 2,172
Yes, the process and what qualify's as an event are a tad strange. I would have not agreed that just because a mother is giving a birth this opens up a whole SEP for family. I would think just the newborn would qualify, but it seems FB just keeps adding to the list, well maybe it's stopped, haven't heard anything new in the past couple of days.
Thanks Ray
How many of you considering writing business as a SEP have thought about the possibility of an insurance company issuing the policy and then, after claims are filed in excess of expectations, suddenly deciding to investigate the validity of the SEP and possibly cancel the policy based on the lack of a true qualifying event?
If you don't think that will happen particularly with a company like Florida Blue, then you are proceeding blindly-every insurance company will do whatever possible to keep from paying claims out in this new era of healthcare and health insurance.
If you don't think that will happen particularly with a company like Florida Blue, then you are proceeding blindly-every insurance company will do whatever possible to keep from paying claims out in this new era of healthcare and health insurance.
I don't doubt the carriers trying something like you describe, we've all heard horror stories with claims.
I do, however, think it's far less likely considering that proof is provided and required up front. It's like a carrier requiring proof of residency at application, and then trying to deny claims because you don't reside in the service area.
I think they are far more likely to not approve a questionable SEP with shaky proof, than accept it and try to discredit the approved proof when the contract has poor experience.
Not to mention, by the time they actually have experience, and track down your client, it will be OEP again. Turnover is going to be obscene moving forward.
I do, however, think it's far less likely considering that proof is provided and required up front. It's like a carrier requiring proof of residency at application, and then trying to deny claims because you don't reside in the service area.
I think they are far more likely to not approve a questionable SEP with shaky proof, than accept it and try to discredit the approved proof when the contract has poor experience.
Not to mention, by the time they actually have experience, and track down your client, it will be OEP again. Turnover is going to be obscene moving forward.
- Thread starter
- #16
Everyone needs to differentiate between what the FFM will consider a SEP for ON exchane, and what the carrier deems as an SEP for OFF exchange. They are different. And states exchanges, like NY, will also be different.
If the FFM declares SEP, the carrier won't be able to contest it, nor do they have the guts to contest it.
Carriers will want proof of QLE, before approving. Once approved, they won't deny claims unless fraudulent QLE.
If the FFM declares SEP, the carrier won't be able to contest it, nor do they have the guts to contest it.
Carriers will want proof of QLE, before approving. Once approved, they won't deny claims unless fraudulent QLE.
- 599
Does that count for state run exchanges too or just the federal?
- Thread starter
- #20
