The Universal SEP

[FLM2]

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?

 

[Yagents]

It's only because she already had an account set up at HC.gov

 

[FLM2]

It's only because she already had an account set up at HC.gov

Nope, we set up the account yesterday...

 

[Yagents]

She owned the platinum plan off exchange??

 

[AllenChicago]

Lost job=no income=medicaid??

 

[FLM2]

She owned the platinum plan off exchange??

Yes, that is correct...

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Lost job=no income=medicaid??

No Medicaid expansion in Florida-her income for the year will be about 250% FPL, subsidies are based on whole year income, not monthly.

 

[Dave020]

SEP Code #6 is the winner:

6. Newly eligible or ineligible for the Advanced Premium Tax Credit (APTC)

 

[Ann H]

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).

 

[FLM2]

SEP Code #6 is the winner:

She was actually eligible for a premium subsidy before leaving her job but the Marketplace doesn't make that distinction, if it had I would not have submitted the application under my broker ID.

I posted this because if I was really surprised this went through-we answered the questions honestly and provided all of the requested information. There was no question as to what her previous income was and what it will be now, just questions asking 'Yes' or 'No'.

 

[Dave020]

She was actually eligible for a premium subsidy before leaving her job but the Marketplace doesn't make that distinction, if it had I would not have submitted the application under my broker ID.

I posted this because if I was really surprised this went through-we answered the questions honestly and provided all of the requested information. There was no question as to what her previous income was and what it will be now, just questions asking 'Yes' or 'No'.

4. Employee or dependents no longer eligible for prior health insurance plan because of:
- termination of employment.
- reduction in number of hours of employment.
- loss of employer contribution toward premiums.
- have exhausted COBRA benefits.

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.