Vava fa'alavelave fa'afuase'i fa'aola, alalaupapa 90 aso Medicaid, ma COBRA¶

O le mafatia i se fa'alavelave fa'afuase'i fa'afoma'i, ulufale i le falema'i, po'o se taotoga fa'anatinati i le va o fuafuaga tau inisiua soifua maloloina, po'o le iloaina ua e misia lau 60-aso Affordable Care Act (ACA) Special Enrollment Period (SEP) e gata mai ai po'o lou fa'aauauina o le COBRA ua le toe totogiina, e mafai ona tu'u atu lou aiga i le fiasefulu afe tala ile falema'i e le'i inisiua. O le tele o tagata gasegase e manatu o le taimi lava e pasi ai le taimi e lesitala ai poʻo le ulufale atu i potu faʻafuaseʻi e aunoa ma se pepa inisiua malosi, e leai se auala faaletulafono e maua ai se inisiua e totogi ai togafitiga faafomaʻi ua uma ona tupu.

O le mea moni, o tulafono a le feterale i le Iunaite Setete ua fausia i ni auala malosi se tolu retroactive health coverage mechanisms na fuafuaina faapitoa e tapeina ai pili faafoma'i e le'i inisiua i le taimi o se va: (1) **Mandatory 90-Day Retroactive Medicaid Coverage (42 U.S.C. § 1396a(a)(34) ma le 42 C.F.R.id. lala sooupu e toe o'o atu i le 3 masina fa'akalena atoa a'o le'i o'o i le masina na e talosaga ai ma totogi so'o se pili ile falema'i na fa'atupu ile masina na pa'u ai lau tupe maua; (2) O le 105-Day COBRA Retroactive Bridge Strategy (29 U.S.C. § 1165 ma § 1162(2)(C)), lea e mafai ai ona e “opeopea” mo le oo atu i le 60 aso e filifili ai le COBRA ma le isi 45 aso e totogi ai le tau muamua a o tumau pea le 100 o lau galuega i le aso ua leiloa ma le (3) ACA Maketi "Tulaga Tulaga Fa'apitoa" Toe Iloilo Fa'apitoa Fa'aulu (45 C.F.R. § 155.420(d)(9)), lea e fa'atagaina ai le toe fa'afo'isia o le inisiua pe a fa'ama'i i le falema'i, le malosi, po'o se fa'aletonu o le falefaigaluega/inisiua na mafua ai ona e misia lau fa'amalama o le lesitalaina o le 60 aso.

Fai nei loa¶

1. Aua ne'i faatuai le tausiga faafoma'i mo faalavelave faafuasei ona o loo e i ai i se va o le inisiua: I lalo o le tulafono a le feterale Emergency Medical Treatment and Labor Act (EMTALA, 42 U.S.C. § 1395dd), e mana'omia faaletulafono uma matagaluega a le falema'i e auai i le Metikea i le Iunaite Setete e faia se su'ega faafoma'i ma togafitiga atoatoa (e aofia ai taotoga fa'afuase'i, tausiga o le ICU), ma le malosi o le totogi o se tagatanu'u, tausiga o le ICU, ma le gafatia o le totogi o sitiseni, ICU, ma le gafatia ma ua fa'asa le fa'atuai o le fa'amautu o togafitiga e fesili ai e uiga i inisiua pe mana'omia se tupe fa'aalu muamua, pe o le falema'i e 1 kilomita (0.6 maila) po'o le 50 kilomita (31 maila) le mamao. Afai o oe poʻo se tasi e pele ia te oe o loʻo feagai ma le tiga o le fatafata, faʻamaʻi o le stroke, tigaina le toto, faigata ona manava, poʻo soʻo se faʻalavelave faʻafuaseʻi e lamatia ai le ola, valaʻau lau numera faʻafuaseʻi i le lotoifale (911 i le US ma Kanata, 112 i le EU, 999 i Peretania) pe siaki matou numera fa'afuase'i fa'atonuga vave.
2. Talosaga mo Medicaid a'o le'i o'o i le aso mulimuli o le masina e loka ai le 3-Month Retroactive Lookback (42 C.F.R. § 435.915): E le pei o fuafuaga a le ACA Marketplace (e na'o le fa'amoemoe e fa'amanaia i le aso 1 o le masina e soso'o ai), O le agava'a Medicaid e fa'atatau i se tupe maua fa'aletausaga-e le'o le 0 masina o lo'o iai nei Ufiufi**. Afai na e mafatia i se falema'i fa'afuase'i e le'i inisiua ia Iulai ma leiloa lau galuega po'o le leai o se tupe maua ia Iulai, o le talosaga mo Medicaid i le aso po'o le Oketopa 31 e fa'amalosia ai le polokalame Medicaid a le setete (i setete e aunoa ma se fa'amavaega o le Vaega 1115) e toe fa'afo'i lau pili fa'afoma'i Iulai, Aokuso, ma Setema i le aso 1 o Iulai.
3. Fa'aoga le 60-Day COBRA Election + 45-Day Initial Premium Window e fa'ailoa ai se fa'alavelave fa'afuase'i i le taimi o le suiga o galuega: Afai na e tu'ua lau galuega i totonu o le 60 aso ua tuana'i ma e iai se avanoa a'o le'i amataina le fuafuaga fa'alesoifua maloloina a lou fale faigaluega fou (pe a'o le'i fa'amanaia lau fuafuaga a le ACA Marketplace), 'aua le totogia muamua COBRA taugata se'i vagana ua e mana'omia moni le tausiga fa'afoma'i taugata. I lalo o le ERISA (29 U.S.C. § 1165), e iai sau 60 aso faakalena mai le aso mulimuli ane o le aso na faamuta ai lau inisiua po o le aso na auina atu ai le COBRA Palota Faasilasilaga ia te oe e filifili ai le COBRA, faaopoopo i ai ma le 45 aso faakalena pe a uma le aso na e filifilia ai COBRA e totogi ai lau totogi tuai i tua **15 aso e toe maua ai le puipuiga o le 15 aso e toe maua ai le tulaga lamatia leiloa.
4. Aua ne'i tu'u fua le COBRA i le ogatotonu o le tausaga ma fa'apea e mafai ona e sui i se fuafuaga a le ACA Maketi: Ole mailei fa'alesoifua maloloina e tasi e sili ona mata'utia ile Iunaite Setete. I lalo o le 45 C.F.R. § 155.420(e), fa'amuta vave lau inisiua COBRA (po'o le tu'u lau COBRA e fa'aleaogaina ona ua e taofia le totogiina o le pili fa'alemasina) E LE'O se Mea Fa'apitoa i le Olaga Fa'apitoa ma e LE fa'aosoina ai le 60-aso Fa'apitoa o le Fa'ailoga Fa'ailoga ile HealthCare.gov. O le taimi lava e te filifilia ma totogi ai le COBRA, ua lokaina oe mai le fesuia'i i se fuafuaga a le ACA Maketi a le maketi se'ia o'o i le tausaga Tatala Tatala Vaitaimi (Novema 1), se'i vagana ua mae'a atoa lau vaitaimi COBRA e 18 masina pe fa'amuta fo'i le fesoasoani a le COBRA.
5. Ia e iloa o le leiloa o le COBRA Subsidy a le Employer E Afua ai le 60-Day ACA Special Enrollment Period: A o lafoa'i le COBRA e le'i fesoasoani i le ogatotonu o le tausaga e le agavaa mo se SEP, tulafono a le feterale (45 C.F.R. § 155.420(d)(15)) pe afai o lau vaega muamua o le COBRA o lo'o tu'uina atu i ai lau totogi muamua o le COBRA pe afai na tu'uina atu e lau kamupanī lau totogi muamua o le COBRA. e avea o se vaega o le paketi fa'ate'a, o le mutaaga o lena galuega fesoasoani COBRA Ose Agava'a i le Soifuaga Fa'apitoa e tu'uina atu ia te oe 60 aso fa'akalena a'o le'i o'o i le aso mulimuli po'o le mae'a fo'i o le aso mulimuli o le fesoasoani a le falefaigaluega e lafoa'i le COBRA ma lesitala i se fuafuaga fa'asoa a le ACA Marketplace.
6. Fai se Talosaga SEP "Tulaga Fa'apitoa" i lalo ole 45 C.F.R. § 155.420(d)(9) pe afai na e misia lau 60 aso ACA faamalama: Afai na e misia lau 60-aso Faapitoa Fa'autala Vaitaimi ina ua leiloa galuega-fa'avae inisiua (silasila i le matou leiloa o le taiala inisiua soifua maloloina) ona o oe na taofia i le falema'i, e le'i malosi lou soifua maloloina, na a'afia i se fa'alavelave fa'alenatura a le FEMA, po'o le tuai/sese o pepa na tu'uina atu e lou kamupanī po'o le tagata fai inisiua, vala'au le Marketplace Call Center (1-800-318-2596) vave e talosagaina se Taimi Fa'apitoa Fa'aigoaina Fa'apitoa mo Tulaga Fa'apitoa Fa'atasi ma le Aso Fa'amālōlōina Fa'aola.

Laau fa'ai'uga: Fa'asaoina se pili fa'afoma'i e le'i inisiua po'o le va'a o le inisiua¶

Fa'aoga le siata fa'ata'ita'i lenei e iloa ai po'o fea le upega fa'aletulafono e mafai ona toe tapeina se fa'alavelave fa'afuase'i fa'afoma'i e le'i inisiua pe toe tatala se faamalama tapuni e lesitala ai.

flowchart TD
    A["Fa'alavelave Fa'afuase'i Fa'afoma'i e le'i Inisiua PO'O le Fa'amalama ole Fa'ailoga Inisiua Soifua Maloloina"] --> B{"E fia Aso talu ona fa'ai'u le fa'asalalauga fa'avae a Iopu?"}
    B -->|"I totonu o le 60 Aso o le leiloa o le inisiua (po'o le mauaina o le COBRA Fa'asilasilaga)"| C["Totonu Fa'amalama 60-Aso: Fa'atusatusa le COBRA Retroactive Election vs. ACA SEP"]
    C -->|"Ua uma ona i ai Pili Tele ER/ Falema'i A'o Gap"| D["Filifili loa COBRA (Toe fa'agaoioi ile Aso 1) + Fa'aaogā le Fa'amalama o Totogi Muamua e 45 Aso"]
    C -->|"Leai ni pili tetele ae mana'omia le taugofie o le fuafuaga faifaipea"| E["Fa'aulu ile ACA Maketi Fuafuaga e ala ile 60-Aso SEP + Fa'aaoga COBRA e leai se totogi 60-Aso Fa'alavelave Fa'afuase'i"]
    B -->|"60 aso ua tuana'i PO'O COBRA ua uma"| F{"Siaki 4 Faʻalavelave Faʻafuaseʻi Retroactive Lifelines"}
    F -->|"Tupe Maua Fa'alemasina i le taimi nei i lalo ole Fa'agata a le Setete Medicaid (fa'ata'ita'iga, 138% FPL / -$1,732/mo Nofofua)"| G["Talosaga mo Medicaid Vave + Talosaga mo le 90-Aso Toe Fa'ailo (42 C.F.R. 435.915)"]
    F -->|"Fa'ato'a Fa'ato'a Fa'amavaega Fesoasoani a le COBRA"| H["Talosaga 60-Aso COBRA Fesoasoani Fesoasoani SEP i lalo ole 45 C.F.R. 155.420(d)(15) ile HealthCare.gov"]
    F -->|"Ua misia le 60-Aso SEP ona o le Falema'i, Fa'alavelave, po'o le Faigaluega/Fa'aaliga Sese"| I["Fa'aulu Tulaga Fa'apitoa SEP Talosaga i lalo ole 45 C.F.R. 155.420(d)(9) mo le Fa'asa'o"]
    F -->|"COBRA na le toe totogiina i totonu ole 30 aso ua te'a mo le le totogiina"| J["Fa'afofoga COBRA i totonu ole Vaitaimi Fa'ato'a 30-Aso Fa'atonu (29 U.S.C. 1162(2)(C)) po'o le Tulafono Fa'aletonu Fa'aletonu"]

Fuafuaga 1: O le 105-Day COBRA Retroactive Bridge (Fa'afefea ona maua fua avanoa puipui)¶

A e tuua se galuega i le aso 31 o Mati ma e le amata le inisiua soifua maloloina a lou fale faigaluega fou ia Me 1 po o Iuni 1, e te feagai ma se va mata'utia 30 i le 60 aso e le'i inisiua. Totogiina le $900 i le $2,400 i le masina i luma mo le COBRA (lea e totogia ai le 102% o le tupe atoa a le vaega) na'o le fa'amalieina o le va o le 45 aso pe a e soifua maloloina e fa'aumatia tupe e te mana'omia mo le lisi. Nai lo lena, fa'aaoga le tulafono COBRA Retroactive Bridge i lalo o le ERISA §§ 602 ma le 605 (29 U.S.C. §§ 1162, 1165) ma le 26 C.F.R. § 54.4980B-6:

Fa'afefea ona galue le uati fa'aletulafono e 60-Aso + 45-Aso¶

1. O le 60-Day Palota Window (29 U.S.C. § 1165(a)(1)): A uma ona fa'amutaina lau vaega faigaluega, e i ai le itiiti ifo o le 60 aso fa'akalena mai le mulimuli o le (a) le aso na faamuta ai lau inisiua malosi, po'o le (e) le aso na auina atu ai e le pule o le fuafuaga lau pepa aloaia COBRA Fa'aaliga Fa'apalota,
2. ** Toe Fa'afo'i I tua i le Aso 1:** E le pei o fuafuaga fa'alesoifua maloloina ta'ito'atasi uma i luga o le maketi, afai e te sainia ma fa'ailoga lau Pepa Palota COBRA i le Aso 59, e mana'omia e le tulafono a le feterale le fuafuaga e toe fa'afo'i lau inisiua soifua maloloina ** toe fo'i i tua i le Aso 1** (le minute tonu na muta ai lau inisiua fa'avae), ma le seai se avanoa i le inisiua.
3. O le 45-Day Initial Premium Payment Window (29 U.S.C. § 1162(2)(C)): Ua faasaina oe mai le manaomia e lafo atu se tupe ma lau Pepa Palota COBRA. I lalo o le tulafono a le feterale, o le taimi lava e te faia ai le palota, e tatau i le fuafuaga ona tu'uina atu ia te oe 45 aso fa'alekalena pe a uma le aso o lau palota COBRA e totogi ai le ulua'i totogi tuai.
4. E faʻafefea ona faʻatino le "COBRA Float" ma le saogalemu:
5. Faatumu lau Pepa Palota COBRA i le Aso 1, saini, ma tuu i totonu o se teutusi faʻailoga e tuʻuina atu i le pule COBRA i luga o lau laulau umukuka (tuu se kopi i lou toʻalua poʻo faʻafesoʻotaʻi faʻafuaseʻi).
6. Afai e te sao i lau vaeluaga ole 30-i-60-aso ile fuafuaga ole soifua maloloina a lou fale faigaluega fou (po'o lau fuafuaga fou ole ACA Marketplace) e aunoa ma le gau o se ponaivi pe alu i le falema'i, e na'o oe e te le meli atu lava le pepa COBRA, ma na e totogiina le $0 mo le 60 aso o le puipuiga mata'utia.
7. Afai e te mafatia i se appendicitis osofaʻi poʻo se faʻalavelave taʻavale i le Aso 42 (se $18,000 ER pili) aʻo e totogiina le \(1,400 COBRA premium, e te meli atu lau COBRA Faʻailoga Palota ua sainia e ala ile Meli Faʻamaonia aʻo leʻi oʻo i le Aso 60, totogi le lua masina o le toe faʻafoʻisia COBRA premium (\)2,800) i totonu o le 45 aso, ma le $000 le kamupani inisiua e tatau ona totogi atoa.

Fuafuaga 2: Fa'atonu 90-Aso Retroactive Medicaid & Fa'atonu Falema'i Agava'a¶

Afai e te le'i inisiua pe a o'o mai se fa'alavelave fa'afuase'i fa'afoma'i, 'aua ne'i manatu e tele naua tupe e te maua mo Medicaid e fa'atatau i mea na e maua muamua i le tausaga fa'alekalena.

Aisea e agavaa ai tagata maualuluga e leiloa a latou galuega mo Medicaid vave¶

I lalo ole Affordable Care Act's Modified Adjusted Gross Income (MAGI) Medicaid count rules (42 C.F.R. § 435.603(h)), a'o fesoasoani a le ACA Marketplace e va'ava'ai i lau fa'ata'ita'iga le tausaga atoa tupe maua fa'aletausaga, O le agavaa mo Medicaid e fa'atatau tonu lava i lau tupe maua fa'alemasina i le taimi nei nisi fa'amanuiaga e le fa'atatauina). E tusa lava pe na e mauaina le $85,000 i le va o Ianuari ma Iulai, afai na e faamalolo i le aso 31 o Iulai ma o lau tupe maua i le masina o Aukuso e \(0 (pe i lalo ifo o le 138% o le Feterale Poverty Level i le 40+ Medicaid Expansion states, e tusa ma le **\)1,732/masina mo se tagata matua nofofua** po o le \(3,588 mo le aiga atoa, e tusa ma le **\)1,732/masina mo se tagata matua nofofua po o le $3,588 mo le aiga atoa i le fa tausaga. Medicaid ia Aokuso.

Fa'amalosia le 3-Masina Retroactive Medicaid Statute (42 U.S.C. § 1396a(a)(34))¶

I lalo ole tulafono a le feterale Medicaid (42 U.S.C. § 1396a(a)(34) ma le 42 C.F.R. § 435.915), e tatau i ofisa a le Setete Medicaid ona faaavanoaina le fesoasoani faafomai mo le tausiga ma auaunaga ua tuuina atu i totonu po o le maea ai o le masina lona tolu a o lumanai le masina lea e faia ai e le tagata le talosaga, pe afai e ausia aiaiga e lua:

1. Na e mauaina au'aunaga fa'afoma'i i lena masina ua te'a (e pei o le asiasiga a le ER, nofo i le falema'i, ta'otoga, felauaiga a le falema'i, po'o le talavai), tusa lava pe ua uma ona e totogiina le pili pe leai; MA
2. ** Semanu e te agavaa mo Medicaid i le taimi na tuuina atu ai auaunaga** pe ana e talosaga i lena taimi (o lona uiga o lau tupe maua faalemasina i lena masina na muamua atu sa i totonu o le tapulaa Medicaid, po o au pili faafomai matautia ua sili atu i lau tupe maua i lalo o se setete Foma'i Manaomia Spend-Down / Share of Cost program).

** Laasaga Fa'atino i le Falema'i Moega (Hospital Presumptive Eligibility, 42 C.F.R. § 435.1110):** A'o e fa'ataga pea i le falema'i, fai atu e te talanoa ma le falema'i Medicaid Financial Counselor po'o Patient Advocate ma talosaga Hospital Presumptive Eligibility (HPE)- ma se talosaga mo le Falema'i Presumptive Eligibility (HPE)-** ma se Fa'atonuga Fa'apitoa mo Falema'i. Faaopoopo)**. I lalo ole 42 C.F.R. § 435.1110, e mafai e falema'i agava'a ona tu'uina atu ia te oe le inisiua Medicaid le tumau i le aso lava e tasi e fa'atatau i au tupe maua fa'alemasina o lo'o iai nei ina ia mafai ai ona e fa'atumu talavai pe a fa'ate'a a'o fa'agasolo lau talosaga toe fa'afo'i atoa le 90 aso.

Fa'atusatusaga o alalaupapa fa'alavelave fa'afuase'i ma tulafono toe fa'afouina¶

Fa'amaloloina o se faiga fa'avae COBRA ua le'i maua: Le 30-Aso Fa'amalie Vaitaimi & Tulafono "Fa'atauva'a Fa'aletonu"¶

Afai e lafo atu e lau pule COBRA se fa'asilasilaga fa'amuta e fa'apea ua fa'aleaogaina tumau lau inisiua COBRA ona ua tuai ona o'o mai le totogi fa'alemasina po'o le itiiti ifo i ni nai tala, siaki vave nei puipuiga fa'aletulafono e tolu:

1. O le Vaitaimi Fa'ameaalofa Fa'alemasina e 30-Aso (29 U.S.C. § 1162(2)(C) ma le 26 C.F.R. § 54.4980B-8, Q&A-5): Mo totogi COBRA ta'i masina uma pe a uma lau ulua'i totogi e 45-aso, e fa'atulafonoina e le tulafono feterale le itiiti ifo o le 30-aso kalena. E tusa lava pe fai mai lau pili o le COBRA "E tatau ona totogi i le aso 1 o le masina," o se totogi ua fa'ailoga (po'o tu'uina atu i luga ole laiga) i luga po'o le i luma o le 30 aso talu ona mae'a le aso e tatau ona fa'atulafonoina, ma e tatau i le tagata fai inisiua ona toe fa'afo'i le inisiua i le aso 1 o le masina.
2. O le IRS "Insignificant Shortfall" Rule (26 C.F.R. § 54.4980B-8, Q&A-5(d)): E masani ona faalēaogāina e le pulega o le COBRA faiga faavae pe a suia e le siitaga faaletausaga lau tupe totogi masina mai le $812 i le $845 ae lafo atu e lau auto-pay le $812. I lalo o le Tulafono a le Ofisa o Tupe § 54.4980B-8, Q&A-5(d), afai e te totogia se tau COBRA i le taimi tatau e faapuupuu i se "le taua tele", e faauigaina e le feterale saogalemu uafu o le itiiti ifo i le $50 po o le 10 pasene o le totogi manaomia, o le fuafuaga e faasa mai le faamutaina o lau COBR muamua sei vagana ua tuuina atu ia te oe se faaaliga tusitusia sei vagana ua tuuina atu muamua ia oe le COBRA** faaopoopo 30 aso faakalena mai lena faaaliga e totogi ai le eseesega o loo misi.
3. Faasilasilaga Faiga Palota COBRA ua le atoatoa (ERISA § 502©(1), 29 U.S.C. § 1132©(1)): I lalo ole 29 U.S.C. § 1166, o lou fale faigaluega ma le pule o le fuafuaga e iai taimi fa'atulafonoina fa'atulafonoina (e masani lava e o'o atu i le 44 aso tu'ufa'atasi) e lafo atu ai lau Fa'asilasilaga Fa'apalota COBRA i lou tuatusi mulimuli na iloa (e aofia ai fa'aaliga fa'alagolago pe a mana'omia). Afai latou te le'i lafoina le COBRA Fa'aaliga Palota i le taimi, e le'i amata fa'aletulafono lau uati palota 60 aso, ma e feagai le Pule Fa'atonu ma fa'asalaga fa'aletulafono e o'o atu i le $110+ i le aso fa'atasi ai ma le noataga mo au tagi fa'afoma'i e le'i fa'aalia.

Kopi ma faapipii fa'ata'ita'iga: Retroactive Coverage Demand & COBRA / SEP Apili¶

Fa'aoga le Vaega 1 e mana'omia ai se ACA Exceptional Circumstances Retroactive SEP, Vaega 2 e talosaga ai mo 90-Day Retroactive Medicaid, po'o le Vaega 3 e toe fa'afo'i ai le COBRA Termination.

SECTION 1: REQUEST FOR ACA MARKETPLACE "EXCEPTIONAL CIRCUMSTANCES" RETROACTIVE SEP
(PURSUANT TO 45 C.F.R. § 155.420(d)(9), § 155.420(d)(4), AND § 155.420(b)(2)(iii))

Date: [Insert Date]
TO: Health Insurance Marketplace Appeals Center / State-Based Exchange Appeals Unit
    [Mail to: Health Insurance Marketplace, Attn: Appeals, 465 Industrial Blvd, London, KY 40750-0061]
RE: Marketplace Application ID: [Insert ID] | Applicant: [Your Full Name & DOB]

Dear Marketplace Eligibility & Appeals Specialist:

I hereby request an immediate Special Enrollment Period (SEP) with a RETROACTIVE EFFECTIVE DATE of [Insert Date Coverage Should Have Started] pursuant to 45 C.F.R. § 155.420(d)(9) (Exceptional Circumstances) and/or 45 C.F.R. § 155.420(d)(4) (Misconduct or Error of Non-Exchange Entity / Employer / Issuer).

1. QUALIFYING LIFE EVENT & REASON FOR DELAY:
   My prior Minimum Minimum Coverage terminated on [Date]. I was prevented from completing my Marketplace plan selection within the standard 60-day window due to:
   [ ] Serious medical incapacitation / emergency hospitalization from [Date] to [Date] (hospital admission records attached).
   [ ] Failure of my former employer / health plan administrator to provide timely written notice of my coverage termination date or COBRA subsidy expiration until [Date] (late notice attached).
   [ ] A technical error / misrepresentation by the Marketplace, insurance carrier, or enrollment assister on [Date].

2. DEMAND FOR RETROACTIVE EFFECTIVE DATE:
   Pursuant to 45 C.F.R. § 155.420(b)(2)(iii), I request that my Marketplace coverage be made retroactively effective to [Insert Date] upon my payment of the corresponding binder premiums so that emergency medical claims incurred during the involuntary gap are covered.

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SECTION 2: NOTICE TO COBRA ADMINISTRATOR OF UNLAWFUL TERMINATION / INSIGNIFICANT SHORTFALL

TO: [Name of COBRA Third-Party Administrator & Employer Plan Administrator]
RE: Participant: [Your Full Name] | COBRA Account No.: [Insert Number]

PLEASE TAKE NOTICE that your purported termination of my COBRA continuation coverage effective [Date] violates ERISA §§ 602 and 605 (29 U.S.C. §§ 1162, 1165) and Treasury Regulation 26 C.F.R. § 54.4980B-8:
[ ] My premium payment was postmarked / transmitted on [Date], within the mandatory 45-day initial payment window or 30-day monthly grace period under 29 U.S.C. § 1162(2)(C) and 26 C.F.R. § 54.4980B-8, Q&A-5.
[ ] Any alleged underpayment of $[Amount] was less than the lesser of $50 or 10% of the required premium, triggering the mandatory 30-day written cure notice requirement under 26 C.F.R. § 54.4980B-8, Q&A-5(d). Enclosed is immediate payment of $[Amount].

Demand is hereby made for immediate reinstatement of my COBRA coverage with zero gap.

Sincerely,

____________________________________
[Your Signature, Printed Name, Address, Phone, and Email]

Fa'ava-o-malo fa'alavelave fa'alesoifua maloloina fa'alavelave & alalaupapa tau o talavai¶

Afai e leiloa lau fuafuaga fa'aopoopo o vaila'au/soifua maloloina po'o ua e feagai ma se pili fa'afoma'i tu'i i le taimi o le suiga o le inisiua i fafo atu o le Iunaite Setete, fa'agaoioi loa nei polokalame fa'aletulafono lautele:

• Kanata (Provincial Public Pharmacare & Trillium / Fair PharmaCare Income Reassessment): E ui o auaunaga autu a le falemaʻi ma fomaʻi o loʻo aofia uma i lalo o inisiua faʻale-soifua maloloina a le itumalo (OHIP, MSP, AHCIP, RAMQ), o le leiloa o lau galuega e faʻaumatia ai le Fuafuaga Faʻalauteleina o le Soifua Maloloina ma Fuafuaga Faʻasaienisi a lou fale faigaluega. Afai fa'afuase'i ona e feagai ma vaila'au fa'apitoa taugatā (e pei o le inisalini, vaila'au fa'aola, po'o vaila'au o le fatu), talosaga vave mo le polokalame o vaila'au fa'ama'i fa'alavelave fa'alaua'itele a lau itumalo, e pei o le Ontario Trillium Drug Program (lea e fa'apipi'i ai lau talavai i fafo o le taga i le pe tusa o le 4% o tupe maua a lou aiga), BC Fair PharmaCare, po o le **Albertaage Non-Group. Faiga Fa'atauva'a: Talosaga le polokalame mo se Su'esu'ega o Tupe Maua i le Tausaga / Toe Iloiloga Fa'apitoa ina ia fa'atatau lau toesea i lau tupe maua fa'aitiitiga i le taimi nei ina ua mae'a galuega, ae le o le fa'afo'i lafoga o le tausaga talu ai. Ia maitauina foi e iai lau 60 aso mai le leiloa o lau fuafuaga a le vaega o le fale faigaluega e liliu atu ai i se fuafuaga fa'alesoifua maloloina "FollowMe / Assured Access" e aunoa ma le leai se tusi fa'afoma'i.
• United Kingdom (NHS Low Income Scheme, HC1 Form & 3-Month Retroactive HC5 Refund): E ui e leai se totogi o togafitiga faʻafuaseʻi a le falemaʻi a le NHS i le tulaga o le faʻaaogaina mo tagata Peretania, o le leiloa o au tupe maua e mafai ona e le mafai ai ona totogi ** NHS talavai ** (i Egelani), togafitiga o nifo, poʻo le tausiga o mata. Afai e te le'i mauaina le Fa'aaitalafu Fa'ale-aganu'u, tu'u mai se Talosaga Fa'asoa a le NHS Low Income Scheme (Form HC1) i luga ole laiga po'o le meli e maua ai se HC2 Certificate (100% free talavai ma tausiga nifo) po'o le HC3 Certificate (fesoasoani vaega). Tulafono Toe Fa'afo'i Fa'afoi: Afai e tatau ona e totogia se talavai po'o se fa'alavelave fa'afuase'i NHS tausiga nifo i aso nei a'o fa'atali mo lau HC1 po'o le Universal Credit e fa'amaonia, fesili i le falema'i mo se pepa aloaia NHS Resit Form FP57 i le taimi tonu e te totogia ai (e le mafai ona e mauaina se FP57 mulimuli ane) ma tu'u mai le Refund Claim Form HC5 e maua ai i totonu o le 3 masina.
• Ausetalia (Medicare Safety Net, Low Income Health Care Card & Private Health 60-Day Suspension): O tagata nofomau uma e agavaa e taofia le falemaʻi lautele ma le PBS pharmaceutical avanoa e ala i Medicare, e tusa lava po o le a le leiloa o galuega. Afai e pa'ū tele lau tupe maua ina ua leai sau galuega, talosaga i le Services Australia (Centrelink) mo se Low Income Health Care Card (e fuafua i luga o le 8-week rolling income window, ae le o le lafoga o tupe maua faaletausaga), e faaitiitia ai lau Pharmaceutical Benefits Scheme (PBS) talavai e totogi faatasi i le tau maualalo o le Saogalemu ($70. (EMSN)** paepae. Afai e te le toe gafatia lau Inisiua Soifua Maloloina mo le falema'i (pe e te mana'o e 'alo'ese mai le Medicare Levy Surcharge ma le Lifetime Health Cover e utaina ai sala), fesili i lau inisiua soifua maloloina mo se fa'alilolilo aloaia Financial Hardship/Unemployment Policy Suspension (o le tele o tupe e mafai ai ona taofia le totogi mo le 2 masina i le 2 tausaga e aunoa ma le leiloa o lou taimi fa'atali mo le Soifua Maloloina).

Fesili e fai soo¶

Punavai ua siaki¶

• U.S. Matagaluega o Soifua Maloloina ma Auaunaga Tau Tagata (HHS) ma Nofoaga Autu mo Auaunaga Fa'aMedia & Medicaid (CMS, Iunaite Setete): Mandatory 90-Day Retroactive Medicaid Eligibility Statute (42 U.S.C. § 1396a(a)(34)) and Regulations (42 C.F.R. § 2.2000) Monthly Inc. C.F.R. § 435.603), Tagata Fa'atonu a le Falema'i (42 C.F.R. § 435.1110), ma le Tulafono o Togafitiga Fa'afuase'i Fa'afoma'i ma Leipa (EMTALA, 42 U.S.C. § 1395dd)*.
• Centers for Medicare & Medicaid Services (CMS / HealthCare.gov, United States): ACA Exchange Special Enrollment Periods (45 C.F.R. § 155.420), Expiration of Employer COBRA Contributions SEP (45 C.F.R. § 155.420)(d), 155.420(d), 155.420(d), 155.420(d) Aso Fa'agata (45 C.F.R. § 155.420(d)(9) ma le § 155.420(b)(2)(iii))*, ma le Tulafono Fa'ai'u Inisiua Pu'upu'u, Fa'atapula'a (45 C.F.R. § 144.103).
• U.S. Matagaluega o Leipa (EBSA) ma Auaunaga Lautele (United States): Consolidated Omnibus Budget Reconciliation Act (COBRA, ERISA §§ 601 i le 608, 29 U.S.C. §§ 1161 i le 1168) ma * Treasury COBRA Regulation Continuation Coverage6. 54.4980B-6 i Vaitaimi Faiga Palota ma § 54.4980B-8 ile 45-Aso/30-Aso Totogi Pupuni ma Fa'aletonu Laiti)*.
• Matagaluega o le Soifua Maloloina o Ontario ma BC Matagaluega o le Soifua Maloloina (Kanata): Trillium Drug Programme Ta'iala Toe Iloiloga o Tupe Maua ile Tausaga ma Tulafono Iloiloga o Tupe Maua a le BC Fair PharmaCare.
• NHS Business Services Authority (NHSBSA, United Kingdom): NHS Low Income Scheme (HC1/HC2/HC3) ma Retroactive Prescription/Dental Return Rules (Forms FP57 ma HC5).
• Auaunaga a Ausetalia ma le Komesina o Sulufaiga a le Soifua Maloloina Tuma'oti (Ausetalia): *Kati mo le tausiga o le soifua maloloina e maualalo tupe maua 8-vaiaso su'ega o tupe maua, *fa'alautele le upega o le Saogalemu a le Medicare, ma le *Ta'iala mo le Fa'amaloloina o Fa'afitauli Fa'aletupe Fa'alesoifua maloloina Tuma'oti.

Taiala fa'atatau¶

• Ma'imau inisiua soifua maloloina, COBRA, ma Fa'ailoga Fa'apitoa
• Aoina o pili faafomai, fesoasoani tau tupe a le falemai, ma le tausiga alofa
• Tete'eina o tagi inisiua mo taimi pupuu ma taimi umi (Apili ERISA)
• Fa'afuase'i le leai o se galuega ma ola fa'aletupe
• Vala'au mai ma'i ma ave livi fa'afoma'i puipuia (FMLA)
• Numera o fa'alavelave fa'afuase'i ile atunu'u