Author Topic: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid  (Read 1900 times)

redrocker

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I need a little help getting my head around what just happened with my health insurance.

For a little background, I signed up on the Marketplace late last year to start coverage on Jan 1. So I'm a little new to this but thought I'd figured it out mostly. We worked through some early kinks with a subpar insurance provider and are currently on an affordable plan that we like, that has the doctor we want in network. Seemed pretty hunky dory.

My wife is pregnant, but we didn't know until February (after I had enrolled). I can't remember if I'd ever disclosed this to the Marketplace but as far as I knew, I wasn't supposed to add a dependent or report a life change until after birth.

The hospital called to ask us to make our payment for her delivery costs (basically the entire deductible) ahead of time. They told us what our coinsurance would be after the deductible, and it was higher than I thought it would be.

I reviewed our finances and discovered that if we were to double our IRA contribution, we'd qualify for significant cost sharing that would both lower our deductible and reduce our coinsurance afterward significantly. Seemed like a slam dunk.

SO I go online to the Marketplace and report a "life change" --- since a change income of only $2000 is considered a "life change." I didn't realize it'd basically be resubmitting the entire application again but I chugged through it.

I get to the end and I see that my premium tax credit has been reduced by almost 2/3s. No clear explanation WTF is going on. Panic ensues. I called the Marketplace and was told that my wife qualifies for Medicaid, so she can't be on the same plan anymore. Profanity ensues.

I said that I liked our current plan, our preferred doctor is on the plan, my wife is due in a GD month is there anyway around this? (no.) I asked if I hadn't tried to change anything (I was working towards a "let's just delete that recent change" approach) would I have been penalized after the fact? (answer wasn't really clear.) I wasn't told explicitly that the pregnancy should have been reported but that seemed to be implied. I was told that I could appeal the decision. I was also told that after the birth I'd need to submit another application to get coverage for the child and that he may end up back on my plan. So if I understand correctly, my wife qualifies for Medicaid for the next ~40 days that she's pregnant, after which she might be transferring back to the same plan I'm on. Unless I appeal, which could take so long that by the time that's resolved, she's no longer pregnant and the ridiculous situation is moot. When I tried to get confirmation of this I was simply told that the Medicaid rules differ state to state. Holy ____ ____.

I was told that Medicaid would contact us to confirm my wife's eligibility. I *think* I was told that until she's on Medicaid she'd still be on my plan.

I don't understand any of this. I thought as my spouse, on a joint return, that our income would exceed Medicaid eligibility. Apparently when someone's pregnant that is not the case? This might be further complicated because Louisiana inaugurated a new governor who reversed the previous governor's decision not to take the Medicaid expansion. That would have taken place after we were enrolled. Not sure if that's playing a factor, but bottomline, I don't like being denied a choice to keep the insurance that we spent months getting settled into and want to understand if I have any option other than some (likely hopeless) appeal.

Now before the flame throwers get pulled out, I completely understand that this will probably *save us money.* That's not the point. Pregnant ladies don't like the rug pulled out from under them a GD month before the due date. I'm learning this very emphatically. A precursory check indicates that she wouldn't be able to keep her current doctor or even use the same hospital we'd settled on.

Has anyone run into a situation remotely close to this? Looking for suggestions on how to steady this rocking boat.

Axecleaver

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #1 on: September 14, 2016, 12:44:53 PM »
LA Medicaid covers pregnant women using different (expanded) eligibility rules, which is why you got the surprise you did. You are not required to disclose this information, so don't worry about subsidies being clawed back. The problem is that the ACA was written in such a way, that if you qualify for Medicaid, you must accept it and you do not qualify for subsidies or cost sharing any longer. So now that you've changed your eligibility information, you have to accept the new determination, or pay full price for the plan.

When you changed your application on the federal marketplace, they would have sent your application to LA Medicaid. You can also call your local Medicaid office to inquire about the status of your application. She will typically get retro eligibility back to the date of her application. They may also pay for services 90 days prior to her eligibility date. But it could take up to 45 days for the application to be processed. Here's a link to LA Medicaid's site for more information. This links to an application, wouldn't hurt to apply again directly to the Medicaid site or to speak to a member services representative to ask after your status. http://dhh.louisiana.gov/index.cfm/faq/category/22

SKL-HOU

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #2 on: September 14, 2016, 01:40:46 PM »
Can you resubmit again with the same original numbers and get qualified for the same previous plan again?

redrocker

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #3 on: September 14, 2016, 01:42:06 PM »
Can you resubmit again with the same original numbers and get qualified for the same previous plan again?

Perhaps. I've thought about that too. But Id have to lie on the question regarding pregnancy. If it doesn't have to be disclosed...

redrocker

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #4 on: September 14, 2016, 01:47:42 PM »
She will typically get retro eligibility back to the date of her application. They may also pay for services 90 days prior to her eligibility date. But it could take up to 45 days for the application to be processed.

Your whole post was wonderfully informative, especially for someone out of state. Thanks.

My next question (although probably for a Medicaid rep) is what kind of proof or documentation we would provide for care if we have applied for Medicaid but have not been entered into the system. Maybe I'm being over-reactive to this abrupt change but it seems like if it takes up to 45 days for processing and the baby will likely be born in the next 30 days then maybe I should pay out of pocket for the insurance plan we currently have in case Medicaid falls through.

You are not required to disclose this information, so don't worry about subsidies being clawed back. The problem is that the ACA was written in such a way, that if you qualify for Medicaid, you must accept it and you do not qualify for subsidies or cost sharing any longer. So now that you've changed your eligibility information, you have to accept the new determination, or pay full price for the plan.

That's good to know about the previous subsidies not being rescinded. However, if I'm not required to disclose a pregnancy, I wonder if it would be a bad idea to resubmit an application and say "no" to the pregnancy question. This wouldn't be such a big deal if this had happened a few months ago and we'd had time to transition. But now it feels risky.

Axecleaver

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #5 on: September 14, 2016, 02:12:26 PM »
I'd call Medicaid member services today and explain to them your situation. I used to manage a team that did the technical work on the Louisiana Medicaid program, many moons ago. Although they have up to 45 days to make an eligibility determination, they may complete it in less time. There are also procedures they can execute to make an immediate determination. Call them and find out. You can also submit a new application directly with a member services rep.

Documentation is typically composed of pay stubs to show your income, and a statement from you about how many people live in your home. Assets are no longer part of the determination process. "Churn" is a particular problem in Medicaid, as people get and lose jobs they often come on and off the Medicaid plan. States have different ways to manage churn, and I don't know what Louisiana does today. They may have a simple solution to your problem.

The "pro" of being on Medicaid, is that it's completely free (to you, anyway). Typically it extends out from the date of pregnancy until 2-3 months after birth. No copays, Rx, cost sharing, or premiums.

The "con" is that you may have less choices in terms of your providers. Medicaid tends to pay providers less than private plans do, so the very best doctors don't need to accept it. If you're particularly concerned about keeping your obstetrician, call her office today to find out if she accepts Medicaid. Then you can figure out your next steps.


redrocker

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Re: Healthcare Marketplace confusion, now spouse is being pushed to Medicaid
« Reply #6 on: September 14, 2016, 04:31:36 PM »
Just finished applying over the phone with a Medicaid rep.

After submitting the application and when she asked if I had any questions I asked what I should do with my wife's current insurance. She said to keep it active until Medicare made a determination but also said they don't give timelines on how long that takes. When I mentioned that we'd be paying out of pocket for the policy next month since the subsidy has been rescinded going forward, she sounded confused. When I explained further that I'd been told since my wife qualified for Medicaid she therefore didn't qualify for a Marketplace plan, the rep was surprised by that. Not very reassuring. Even worse is that she gave me the exact same number I'd dialed to reach her and suggested I speak to someone with Medicaid.

So at this point, I intend to call tomorrow about the status (and repeatedly call until I get an answer) and I guess pay in full for the next month of coverage.