Health insurance for our sons - "potentially CHIP / medicaid eligible"

[EnjoyTheJourney]

I'm checking in to better understand the application process and timing for health insurance enrollment under different scenarios for our sons. The origin of this inquiry is that when applying for ACA coverage our sons were flagged as eligible for CHIP / medicaid (details further down, each son was flagged as eligible for a different program) for the upcoming year. Our key question is as  follows:

If one or both of our sons were to be found ineligible for coverage under New Jersey's CHIP / medicaid programs, then would we have a chance to purchase ACA health care coverage starting March 1st, or would we need to wait until April 1st to organize health insurance coverage for them? This could mean a need to potential backdate of coverage through the ACA to get coverage as of March 1st for one or both of our sons, as application processing times seem likely to run well past March 1st.

As a bit more background information, we completed the application process for ACA coverage earlier today, seeking coverage March 1st. By default, applying today seems to meet the deadline for March 1st coverage. We mentioned annual income for the family coming in at 140% of the federal poverty level. This meant my spouse and I were eligible for ACA coverage and we have purchased health care coverage for ourselves.

Regarding our twin sons, they are currently both in elementary school. One of our sons is on the autism spectrum, is attending a school for children on the spectrum, and is listed as "potentially medicaid eligible" on NJGetCovered.com due to being classified in a different category than our other son. We could purchase health insurance for our son who is on the spectrum. Our other son is listed as "potentially CHIP eligible" and we cannot purchase ACA health insurance for him.

I phoned the state of NJ number given on the NJGetCovered website and was told that they haven't yet received any application materials. I was told that if our son is rejected for CHIP eligibility then the representative with whom I spoke doesn't know whether we would be able to organize health insurance from March 1st forward, or not. The representative reassured me that we would be contacted if there were questions that needed to be addressed (ie: proof of income, if they can't verify on their own) rather than just having the application denied. They apparently have a 30-45 day turnaround on applications, so we won't know if our son has been rejected until about the middle or end of March.

I'm currently trying to get through to the County level to inquire about medicaid application process questions.

Our son on the spectrum is currently receiving in-home ABA therapy several days each week. Because we have health insurance for him, that is (currently) very affordable with a low daily charge for services. If we lost health insurance coverage for him, though, it would be best to stop therapy until coverage resumed because the bills would otherwise be *very* large.

Any insights provided about the application process would be helpful and most appreciated. Thank you in advance.

[mavendrill]

I can't answer all of your questions, because each state's Medicaid program is somewhat unique.

However:
1) at 140% FPL both of your kids will be Medicaid eligible, barring bizarre circumstances.
2) 140% is very close to the nj threshold for parents to be Medicaid eligibile (138%).  A bit of retirement savings could put you into that bucket.
3). There is a dirty secret about state benefit programs - they are almost hilariously impossible to navigate and understand, and customer support is generally terrible.  There are federal grants available to nonprofits to provide assistance with understanding and navigating social services.  I recommend checking at three following 3 places : libraries, churches, and united Way community Resource centers.  Odds are there are some very nice people near you who can help give appropriate answers, and help you apply correctly (these services should never charge you a fee).   Talented social workers at your son's school may be able to help, but they are probably so overworked they will only be able to answer very specific questions if at all.

[EnjoyTheJourney]

Thank you for an illuminating response and for the suggestions about how to navigate what may be a challenging process.

At this point, having looked carefully through what's OK and what's needed, it's likely that we'll be fine once we prove our income will be what we say it will be. This is simple in practice because we create income when we want by withdrawing money from deferred tax accounts and we have full control over how much we withdraw. But, it may or may not be simple to get three different institutions (those overseeing the ACA, those overseeing NJ CHIP, and those overseeing NJ medicaid) to agree that whatever explanation we provide of why we will earn what we say we will earn "proves" we will earn that amount of income.

In the end, showing that we have full discretion over how much income to declare may not be enough. So, our initial thought is to set up automatic withdrawals from our tax deferred accounts so the AGI we gave online for the ACA ends up being the AGI we end up earning in 2022 and to share evidence of those automatic withdrawals having been set up to everybody concerned.

In case somebody here has been in a similar situation, then it would be most helpful to hear whether this plan makes sense. Thank you in advance for any insights provided.

[EnjoyTheJourney]

Postscript ...

At least in New Jersey there are two parts to the medicaid coverage each child receives. One part is emergency care, urgent care, and primary care from a pediatrician. The other part seems to be ... everything else, which is managed by an HMO in New Jersey.

Basically, it seems to be the case in New Jersey that coverage for emergency room visits, perhaps some urgent care, and perhaps some primary care from a pediatrician can receive backdated coverage. However, all other portions of health care insurance are handled through an HMO, such as Blue Cross Blue Shield. No backdating of coverage happens for any part of a child's heath insurance covered through an HMO, at least in New Jersey and perhaps in some other states. In fact, in New Jersey coverage can only begin at the beginning of the next month after a child's application has been approved for anything other than a very narrow (although, to be fair, potentially ruinously expensive) range of health care services, such as emergency room services.

A KEY POINT TO REMEMBER, AND THE REASON FOR THIS REPLY:

If you ask a NJ medicaid customer service representative "Is health insurance coverage backdated to the beginning of the month in which a child applies?", then my experience was that they will answer by saying "yes", with no qualifications mentioned or exceptions noted. None, zip, zero. I asked this question several times and always got a simple "yes" as the answer. Also, materials that we found about HMOs on the NJ medicaid website focused on how to apply and who is eligible. The "backdate coverage or not" question didn't seem to be addressed anywhere in their discussion about HMOs, or at least nowhere obvious.

Nonetheless, any bills from health care services that would have been coordinated through the HMO will not receive backdated coverage, regardless of how poorly that fact is communicated by those charged with looking after medicaid in New Jersey.