If you apply late, last minute for coverage, when does it start?
Medi Cal Conditional Eligibility?

Realistic Drop Dead Deadline Date?

• Question What if you apply on March 30th for an April 1st effective date and you don’t get ID cards till April 24th,
  do you have to pay April premium?
  • What about trying to collect on claims paid out of pocket?

• Answer – See the letter of understanding below.  Yes, you have to pay for April, you had coverage.  Apply at least two weeks before the date you want coverage to start. 

Letter of Understanding for Late Applications 

Some Insurance Companies ^#kaiserform for example have a form that must be signed when
applications are sent in late to avoid any misunderstanding.

In order for your group, ___________to be considered for late enrollment for a/an _________effective date, both customer and broker will need to  sign this letter of understanding.

Complete group eligibility and enrollment documentation must be submitted. This letter and/or group submission do not guarantee approval, but rather consideration for a/an _____effective date.

Please note the following potential liabilities of a late enrollment:

 Customer is responsible for the full month’s premium – no proration or refunds

 Effective date of coverage will not be changed to a future date

Potential impacts to members:

 Members will not have member ID cards, nor be active in systems, including medical facilities, until enrollment is complete and processed, which could take 7- 10 business days beyond submission

 Members may be billed or asked to pay at point of service. ^{Kaiser Form} *

Jump to section on:

• Can parents of a competent adult get coverage for them? 
  • Who can sign an application?
• Covered CA Conditional Eligibility 
• Late Applications – ID Cards, Effective Dates 

FAQ’s

• Question  I asked you a simple “quick” yes or no question.
  • Why can’t you just give me a yes or no!!!
• Answer I’d love to, but as you know President Trump said Insurance was very complicated and no one knew (except me).My mandatory annual training for Medicare Advantage also knew and an agent can get in BIG TROUBLE for giving simple answers which may mislead or misrepresent the coverage or how it works.
  • We are not even allowed to answer the question:
    • Is this the best plan?40.4 – Prohibited Terminology/Statements You can’t Use absolute superlatives (e.g., “the best,” “highest ranked,” “rated number 1”) and/or qualified superlatives (e.g., “one of the best,” “among the highest rank”) unless they are substantiated with supporting dataThe superlatives used and the data provided must be in context and may not mislead consumers CMS.gov 2015 * 42 CFR 422.2262, 422.2264, 423.2262, 423.2264, 422.2268(e), 423.2268(e)
• Question  How do I visit the doctor, if I don’t have my Insurance Card?
• Answer You do have Insurance Information!
  • Here is where your application is shown as pending in my broker portal. We also sent this to you on the 23rd. There is no requirement to have Insurance to visit a doctor or hospital. If nothing else, put the bill on your credit card and then file a claim.   Check our Insurance Company webpages Employer Group  * Individual & Family * for the forms or email us and we can get it for you.
  • Here’s a form that one Insurance Company requires when applications are submitted late.

  • I recall when I studied at San Diego State and received a BS in Insurance (see our biography page) one of my professors Mr. Charles Muse, CLU explained that there is no requirement to have coverage to get treated. He just paid and then let the provider send a bill, he would file a claim form.

    • We also learned that Insurance is for the BIG things that can cause economic disaster that one can’t plan for. Sure, Insurance has changed and now includes preventative care
    • When you ask the Insurance Company to pay every little thing, it only jacks up your costs. Insurance Companies keep 20% of every premium dollar they take for expenses and profits. It was that way before ACA/Health Care Reform and the ACA made it law. See our page on MLR Medical Loss Ratio.
    • Under the ACA everything is guaranteed issue. Pre ACA you would have had to fill out complete details of your medical history and then you might have been denied or had your heart condition excluded as a pre existing condition.
    • That is why, one can normally only buy coverage at Open Enrollment or Special Enrollment, not while you are being admitted to the hospital.
    • So, in your case, where you lost employer coverage, one needs to PROVE that!
    • While you applied for coverage on the 10th, you didn’t comply with the requirement to send proof of loss of coverage till the 23rd. Who moves that fast? It took you two weeks to comply, you expect the Insurance Company to finish up everything in a week?

    • What is your doctor’s email address? I’ll email them and explain the situation.