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II. Grab Bag FAQ: Potential impact of a life change on health plans’ deductibles
Q1: If someone reports a life change to the Marketplace but stays with the same issuer, does the issuer have the option to reset the deductible and/or accumulators?
A1: It depends what effect the life change has on the enrollment group. If the change results in the subscriber remaining as part of the enrollment group and the group remains in the same plan, CMS requires issuers to continue accumulators such as amounts paid towards deductibles and out-of-pocket maximum amounts. However, if the subscriber is removed from the enrollment group, the issuer has discretion, subject to state law, to reset deductibles and/or accumulators. Furthermore, the issuer has the discretion, subject to state law, to reset deductibles and/or accumulators when the enrollment group changes plans, with the same or a different issuer.
Example 1: A mother who is also a subscriber has a baby and adds the child to the same plan with the same issuer. In this case the issuers must continue accumulators such as amounts paid towards deductibles and out-of-pocket maximum amounts.
Example 2: The enrollment group includes a husband, wife, and two dependent children. The subscriber is the husband, and he is removed from the plan. Since the subscriber was removed from the enrollment group, the issuer has discretion, subject to state law, to reset deductibles and/or accumulators.
* The subscriber is the person who has elected benefits or for whom benefits have been elected in the event that the application filer is not choosing health coverage. There is always only one subscriber per enrollment group and each member of the enrollment group will be associated with the subscriber. The subscriber may also be referred to as the anchor for the group. The Marketplace indicates which family member is the subscriber on the enrollment transaction to an issuer. Consumers can contact the issuer if they would like to know who the subscriber is in the enrollment group.
How do I know who the subscriber is in the enrollment group?
Determining who the subscriber is can be done using these rules:
1. The subscriber is the application filer AND is an insured member in the enrollment group; or
2. If the enrollment group consists of children only, then the subscriber is the youngest child (to avoid the enrollment group dissolving when the oldest child ages off); or
3. If neither of the two rules above applies, then the subscriber is the oldest insured member in the enrollment group.
http://www.icontact-archive.com/NRCTqX2Wssc73lgTvoTJUt_rH03u8tFW?w=7
Q1: If someone reports a life change to the Marketplace but stays with the same issuer, does the issuer have the option to reset the deductible and/or accumulators?
A1: It depends what effect the life change has on the enrollment group. If the change results in the subscriber remaining as part of the enrollment group and the group remains in the same plan, CMS requires issuers to continue accumulators such as amounts paid towards deductibles and out-of-pocket maximum amounts. However, if the subscriber is removed from the enrollment group, the issuer has discretion, subject to state law, to reset deductibles and/or accumulators. Furthermore, the issuer has the discretion, subject to state law, to reset deductibles and/or accumulators when the enrollment group changes plans, with the same or a different issuer.
Example 1: A mother who is also a subscriber has a baby and adds the child to the same plan with the same issuer. In this case the issuers must continue accumulators such as amounts paid towards deductibles and out-of-pocket maximum amounts.
Example 2: The enrollment group includes a husband, wife, and two dependent children. The subscriber is the husband, and he is removed from the plan. Since the subscriber was removed from the enrollment group, the issuer has discretion, subject to state law, to reset deductibles and/or accumulators.
* The subscriber is the person who has elected benefits or for whom benefits have been elected in the event that the application filer is not choosing health coverage. There is always only one subscriber per enrollment group and each member of the enrollment group will be associated with the subscriber. The subscriber may also be referred to as the anchor for the group. The Marketplace indicates which family member is the subscriber on the enrollment transaction to an issuer. Consumers can contact the issuer if they would like to know who the subscriber is in the enrollment group.
How do I know who the subscriber is in the enrollment group?
Determining who the subscriber is can be done using these rules:
1. The subscriber is the application filer AND is an insured member in the enrollment group; or
2. If the enrollment group consists of children only, then the subscriber is the youngest child (to avoid the enrollment group dissolving when the oldest child ages off); or
3. If neither of the two rules above applies, then the subscriber is the oldest insured member in the enrollment group.
http://www.icontact-archive.com/NRCTqX2Wssc73lgTvoTJUt_rH03u8tFW?w=7
