cost.sharing.reductions
Enhanced Silver – Benefits – Income – Use our Complementary Quote Engine at the right for the most current FPL – Federal Poverty Level Calculations
Report Changes as they happen
Report Changes as they happen – within 30 days
Covered CA - List of Special Enrollment Periods
Covered CA – List of Special Enrollment Periods – They have more than direct with Insurance Company

One way to qualify for a NEW enrollment in Covered CA when it’s not Annual Open Enrollment is if your income changes, so that you qualify for a new or different level of Enhanced Silver Subsidies or income change makes you newly eligible for subsidies.  However, Covered CA’s interpretation of the law is that you must already have coverage through Covered CA. FN 1

CA CCR Code of Regulations (7) An enrollee Definition, or his or her dependent enrolled in the same QHP – Qualified Health Plan, is determined newly eligible or ineligible for APTC (Subsidies) or has a change in eligibility for CSR. [Cost Sharing Reductions – Enhanced Silver]

See more detail and discussion in footnotes below.

It just doesn’t seem “Fair” that if someone makes $100k as a single and then loses his job, can’t enroll when that happens.

Yes, I’ve been told that if you want Fair, you have to go to Pomona.

CFR §156.425 Changes in eligibility for cost-sharing reductions. (Enhanced Silver)

Please start your research into Special Enrollment Periods by reviewing our main page of California Code of Regulations on Qualifying Events

 See Full FPL Federal Poverty Level Chart – Income vs Plan and Program you and your family qualify for

(a) Effective date of change in assignment. If the Exchange notifies a QHP issuer of a change in an enrollee’s def eligibility for cost-sharing reductions (including a change in the individual’s eligibility under the special rule for family policies set forth in §155.305(g)(3) of this subchapter due to a change in eligibility of another individual on the same policy), then the QHP issuer must change the individual’s assignment such that the individual is assigned to the applicable standard plan or plan variation of the QHP as required under §156.410(b) as of the effective date of eligibility required by the Exchange.

(b) Continuity of deductible and out-of-pocket amounts. In the case of a change in assignment to a different plan variation (or standard plan without cost-sharing reductions) of the same QHP in the course of a benefit year under this section, the QHP issuer must ensure that any cost sharing paid by the applicable individual under previous plan variations (or standard plan without cost-sharing reductions) for that benefit year is taken into account in the new plan variation (or standard plan without cost-sharing reductions) for purposes of calculating cost sharing based on aggregate spending by the individual, such as for deductibles or for the annual limitations on cost sharing ECFR.Gov

(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions.

(i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; [Enhanced-Silver]

advance payments of the premium tax credit (subsidies) or is experiencing a change in eligibility for Enhanced Silver – cost-sharing reductions CA Agent Training Page 9  or premiums become unaffordable 155.420  156.425   156.410

premium tax credit

determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions [enhanced silver],

Special enrollment periods no longer will be available for:

Consumers who had signed up for exchange plans with too much in advance payments of tax credits because of redundant or duplicate coverage;

Consumers who were affected by Social Security income tax errors;    (Counihan, CMS blog, 1/19).  Learn More ⇒CA Health Line – Health Affairs.org 1.20.2016

(ii) The enrollee’s dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; or

(iii) A qualified individual or his or her dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.

affordable or provide minimum value [bronze plan] for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan;  Learn More⇒Change Enhanced Silver

(iv) A qualified individual in a non-Medicaid expansion State who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100 percent of the FPL, who was ineligible for Medicaid during that same timeframe, and who has experienced a change in household income that makes the qualified individual newly eligible for advance payments of the premium tax credit.

Related Pages in Open and Special Enrollment Section

 

Footnotes

1.  Covered CA cites their webpage and says change in income is only if you are already enrolled in a Covered CA plan. Email dated 11.14.2016 3:35 PM

45 CFR §155.420(d)(6); 10 CCR – CA Code of Regulations – Special Enrollment Periods  § 6504(a)(6). Note that Covered California interprets this to only allow for changes in plan, not to newly enroll based on language in the state and federal regulations referring to the enrollee rather than the individual as in other sections. Thus, if you are already in a plan you can change to a new plan but you can’t newly enroll in a plan when your income decreases. Western Poverty Page 5.215

45 CFR §155.420(d)(6) Newly eligible or ineligible for advance payments of the premium tax credit, or change in eligibility for cost-sharing reductions.

(i) The enrollee is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions;

(ii) The enrollee‘s dependent enrolled in the same QHP is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions; or

(iii) A qualified individual or his or her dependent who is enrolled in an eligible employer-sponsored plan is determined newly eligible for advance payments of the premium tax credit based in part on a finding that such individual is ineligible for qualifying coverage in an eligible-employer sponsored plan in accordance with 26 CFR 1.36B-2(c)(3), including as a result of his or her employer discontinuing or changing available coverage within the next 60 days, provided that such individual is allowed to terminate existing coverage.

(iv) A qualified individual who was previously ineligible for advance payments of the premium tax credit solely because of a household income below 100 percent of the FPL and who, during the same timeframe, was ineligible for Medicaid because he or she was living in a non-Medicaid expansion State, who either experiences a change in household income or moves to a different State resulting in the qualified individual becoming newly eligible for advance payments of the premium tax credit;

 

Enrollee means a qualified individual or qualified employee enrolled in a QHP. Enrollee also means the dependent of a qualified employee enrolled in a QHP through the SHOP, and any other person who is enrolled in a QHP through the SHOP, consistent with applicable law and the terms of the group health plan. Provided that at least one employee enrolls in a QHP through the SHOP, enrollee also means a business owner enrolled in a QHP through the SHOP, or the dependent of a business owner enrolled in a QHP through the SHOP.

Qualified individual means, with respect to an Exchange, an individual who has been determined eligible to enroll through the Exchange in a QHP in the individual market.    Definitions  155.20

 

You can completely forget about what federal law has to say when it comes to Covered CA.  Since Day 1, they have been making up their own rules without regard to the law when it suits their fancy.  So, to Covered CA, decrease in income only allows a change of health plan if already enrolled through Covered CA despite the fact that in just about any other state, it triggers an SEP.  MAX Herr

 

Response from Covered CA   Income changes so much that a current Covered California enrollee becomes newly eligible or ineligible for help paying for their insurance. For example, if a consumer is already getting help paying for their insurance premium, and their income goes down, they may be able to get extra help.  coveredca.com/special-enrollment

This is what it states in Healthcare.gov.

If you’re enrolled in a Marketplace plan and your income or household change, you should report the changes as soon as possible.

These changes — like higher or lower income, adding or losing household members, or getting offers of other health coverage — may affect the coverage or savings you’re eligible for.

Why it’s important to update your application immediately

If your income estimate goes up or you lose a household member:

You may qualify for less savings than you’re getting now. If you don’t report the change, you could have to pay money back when you file your federal tax return.

If your income estimate goes down or you gain a household member:

You could qualify for more savings than you’re getting now. This could lower what you pay in monthly premiums.

You could qualify for free or low-cost coverage through Medicaid or the Children’s Health Insurance Program (CHIP). healthcare.gov/why-report-changes/

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