Transitions AVOIDING COVERAGE GAPS 1

Help Consumers Think Ahead Will you be turning 65? Will you be eligible for Medicare? If you are receiving SSDI, when did it begin? Will your child on Medicaid/FAMIS be turning 19? Will you be losing Medicaid for any other reason? End of post-partum coverage? Are you planning to start a new job? Child turning 26? Will the immigration status of anyone in your family change during the next year? 2

Basics: Ending coverage and coverage effective dates 3

Ending Coverage for Members of a Household In most cases, coverage and changes to APTS and CSRs will be effective immediately. To terminate online: Use “Report a Life Change” function, then “Add or remove member of household” Clicking “Save & Continue” until the “You’re applying for health coverage for these people” page Select the “Remove” button for the person you’re removing from Marketplace coverage and continue through the application. On the household information screen, add the removed spouse or dependent’s information if they are still a member of the household Click the green “Continue to Enrollment.” If consumer is on autopay make sure they contact the insurance company to cancel the payments and set up new ones for the new amount. 4

Tip The household contact is usually the person who created the Marketplace account. If you end coverage for the household contact, he or she will remain the contact for everyone staying on the plan. To update the household contact, you must contact the Marketplace Call Center. Don’t try to do this online. It is easier if the household member who will remain on the Marketplace plan is the household contact. Ex. If husband is going to turn 65 before the wife, the wife should be the household contact. 5

Ending coverage for household Cancellation can take effect as soon as 14 days from the day you cancel, but no earlier How to end coverage for everyone on your application Select “Visit the Marketplace for Individuals and Families.” Select the application you want to end coverage. On the far left side of the screen, select “My Plans & Programs.” Select the red button that says “End (Terminate) All Coverage.” Select an effective date to end your coverage that’s at least 14 days from the current date and click the attestation. Select the red “Terminate Coverage” button. A red “Cancelled” or “Terminated” status should appear above the plan you ended. If the consumer does not terminate the coverage 14 days prior to a different form of coverage beginning, he/she could be liable for repayment of excess APTCs and will likely pay double premiums. 6 45CFR § (b)(2)(ii)(d)

Special SEP Effective Coverage Dates Coverage begins on the date of event Gain a dependent through birth, adoption, placement of a foster child, or court order Enrollee may have the option to begin coverage on the first day of the following month 1 st day of the following month Marriage Move, if plan selected before the date of the move Loss of minimum essential coverage, if plan selected before or after loss of coverage date Expiration of non-calendar year plan, even if consumer has the option to renew Current Enrollees only Loss of dependent Newly eligible for APTCs 7

Cont’d Effective date appropriate to circumstances (decided by the Marketplace) Exceptional circumstances Natural disaster or serious medical condition prevented enrollment during Open Enrollment Survivor of domestic abuse or spousal abandonment Medicaid/Marketplace transfers that prevented enrollment during Open Enrollment System errors related to immigration status Unresolved casework that prevented enrollment during Open Enrollment Error, misconduct or inaction by the Marketplace, HHS or entities providing enrollment assistance Demonstrates that QHP violated contract May need appeal 8 45CFR § (b)

Medicare Basics Original Medicare (Part A and Part B) Medicare Advantage (Part C) Prescription Drug Coverage (Part D) Medigap or Supplemental Policies Only work with Original Medicare Marketplace plan CANNOT be used to supplement a Medicare plan Many not available to those under 65 who are Medicare eligible due to disability Open Enrollment October 15 – December 7 Work with your local VICAP offices – they are the experts! 9

Marketplace to Medicare Once a consumer becomes eligible for premium free Medicare, they are no longer eligible for APTCs or CSRs Can keep marketplace plan for the remainder of the year without APTCs or CSRs It is important the consumer does not miss their initial enrollment period (usually the 3 months before and the 3 months after their 65 th birthday) Avoid penalty Avoid a gap in coverage Consumer may face “upselling” by insurance company when calling to cancel their plan Consumers may complain about having to pay more for Medicare v. Marketplace 10

Marketplace to Medicaid Children, parents, and individuals with disabilities newly eligible for Medicaid due to drop in income Application can take up to 45 days, 90 for individual with disabilities If individual has medical needs, make plan with providers first (full prescriptions, check-ups complete, etc.) Retroactive coverage available for 3 months prior to application date if requested (?) and eligible during those months. Otherwise coverage is retroactive to application date. Effects of retroactive coverage and APTC reconciliation is still a question (new 1095B form) Fight the stigma! Medicaid is comprehensive coverage. Medicaid for Pregnant Women and FAMIS MOMS Application must be processed in 10 days Can now get FAMIS/FAMIS Moms even though there is access to subsidized state-employee health coverage Counts as MEC & now includes dental services Newborn will automatically be enrolled in Medicaid/FAMIS for a year 11

Medicaid to Marketplace Medicaid for children and FAMIS end at the end of the month that the child turns age 19 Children who age out of foster care can maintain Medicaid coverage until age 26 Children in the Adoption Assistance program or with disabilities maintain coverage until age 21 Medicaid for Pregnant Women and FAMIS ends 60 days post-partum Income increase Medicaid enrollees are entitled to 10-day advanced notice of any changes/terminations of coverage. And if they appeal at any time BEFORE the date of action, they can keep coverage pending the outcome of the appeal. If loss of coverage is due to consumer error, such as failure to submit renewal materials, they are not eligible for Marketplace coverage Marketplace coverage will begin on 1 st day of the month following the plan selection 12

Other Issues With Income Changes Newly eligible for CSRs, or a difference level of CSRs If already enrolled in a silver plan, it is important to stay in same silver plan so the deductible is not reset Falling into the gap Use Gap script Plan First 13

Newly Eligible for Employer Coverage Remind consumers to update application or terminate coverage to avoid repaying APTCs Some may be resistant to do this because the employer coverage may be more expensive or have a lower actuarial value. Make sure the consumer knows that if the coverage is adequate (60% AV) and affordable (˂ 9.5% household income for employee alone), they must: Accept the offer and drop the Marketplace plan; pay full cost for the marketplace plan (without APTCS or CSRs); or drop both and pay the penalty. Consumers with families should be aware of potential family glitch If cost to insure employee alone is ˂ 9.5% of household income, entire household is ineligible for APTCs Consumers can get an exemption if the cost of insurance is unaffordable (˃8% household income) Two or more family members' aggregate cost of self-only employer-sponsored coverage exceeds 8 percent of household income, as does the cost of any available employer-sponsored coverage for the entire family. ( Consumer can still purchase Marketplace plan at full cost 14

COBRA & retiree plans If the consumer enrolls in COBRA they cannot enroll in a Marketplace plan unless they have an SEP, their COBRA expires, or it is Open Enrollment. Loss of COBRA due to non-payment does not qualify the consumer for an SEP. Scenario A: Consumer loses her job and accepts COBRA, she then contacts you hoping to enroll in a Marketplace plan. Scenario B: Consumer has been on COBRA for 3 months, and it is Open Enrollment. He would like to know what his options are. Scenario C: Consumer is on COBRA and just got married. Her spouse is not enrolled in any health coverage. 15

New 1095 forms 1095 A ( Marketplace Coverage Used to reconcile APTCs (Form 8962) 1095 B ( Proof of coverage Small Business Health Options Program (SHOP) Employer-sponsored coverage Government-sponsored program Individual market insurance Multiemployer plan Other designated minimum essential coverage 1095 C ( Includes information on coverage offer made by an applicable large employer subject to the employer shared responsibility provision in the Affordable Care Act. Proof of coverage for those enrolled in an employer based self-insured plan 16

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Questions? 20