Diphatlha tsa tshireletso ya boitekanelo ya tshoganyetso, Medicaid ya malatsi a le 90 e e boelang morago, le maborogo a COBRA¶

Go nna le maemo a tshoganyetso a magolo a kalafi, go amogelwa kwa bookelong, kgotsa go ariwa ka bonako ka nako ya phatlha fa gare ga dithulaganyo tsa inšorense ya boitekanelo, kgotsa go lemoga gore o fositse letlha la gago la bofelo la malatsi a le 60 la Molao wa Tlhokomelo e e ka Duelesegang (ACA) Special Enrollment Period (SEP) kgotsa gore tshireletso ya gago ya tsweletso ya COBRA e fedile ka ntlha ya go sa duele didolara tsa bookelo, go ka senola dibili. Bontsi jwa balwetse ba tsaya gore fa letlha la bofelo la go ikwadisa le sena go feta kgotsa go amogelwa kwa phaposing ya maemo a tshoganyetso go diragala kwantle ga karata ya inshorense e e dirang, ga go na tsela ya semolao ya go bona thulaganyo ya inshorense ya go duelela tlhokomelo ya kalafi e e setseng e diragetse.

Tota e bile, molao wa puso kwa United States o aga mo mekgweng e meraro e e maatla ya tshireletso ya boitekanelo e e boelang morago e e diretsweng go phimola dikoloto tsa kalafi tse di sa inšorilweng ka nako ya phatlha: (1) Tshireletso ya Medicaid ya Malatsi a le 90 e e Boelang Morago e e Patelediwang (42 U.S.C. § 1396a)C.R.24(3). 435.915), e e pateletsang dikemedi tsa puso tsa Medicaid go fitlhelela morago go fitlha go dikgwedi di le 3 tse di tletseng tsa khalentara pele ga kgwedi e o dirang kopo ka yone le go duelela dikoloto dipe tsa bookelo tse di dirilweng mo kgweding fa lotseno lwa gago lo wetse tlase; (2) Leano la Borogo la COBRA la Malatsi a le 105 la go Boela Morago (29 U.S.C. § 1165 le § 1162(2)(C)), le le go letlang go "phaphamala" go fitlha go malatsi a le 60 go tlhopha COBRA le malatsi a mangwe a le 45 go duela phesente ya ntlha ya go boela morago ya o latlhegetswe ke tiro; le (3) ACA Marketplace "Maemo a a Kgethegileng" Boikuelo jo bo Kgethegileng jwa Kwadiso jo bo Boelang Morago (45 C.F.R. § 155.420(d)(9)), jo bo nayang tshireletso e e boelang morago fa go robadiwa kwa bookelong, go tlhoka bokgoni, kgotsa phoso ya mothapi/moinšorense e go dirile gore o ikwadise.

Dira se jaanong¶

1. O se ka wa diega tlhokomelo ya kalafi ya tshoganyetso ka gonne o le mo phatlheng ya tshireletso: Ka fa tlase ga Molao wa puso wa Kalafi ya Tshoganyetso le Badiri (EMTALA, 42 U.S.C. § 1395dd), lefapha lengwe le lengwe la tshoganyetso la bookelo le le tsayang karolo mo Medicare kwa United States le tlhokega semolao go tlamela ka tlhatlhobo e e feletseng ya kalafi le karo, tlhokomelo ya ICU, le go belega ka matlhagatlhaga) go sa kgathalesege gore o boemo bofe jwa inšorense, boagi, kgotsa bokgoni jwa gago jwa go duela, mme batlelereke ba kwadiso ya bookelo ba thibetswe go diegisa kalafi e e tlhomamisang go botsa ka inshorense kgotsa go batla madi a a kwa pele, e ka tswa bookelo bo le dikilometara di le 1 (dimaele di le 0.6) kgotsa dimaele di le 50. Fa wena kgotsa moratiwa wa gago a itemogela botlhoko jwa sehuba, matshwao a seterouku, go dutla madi thata, go hema ka bothata, kgotsa maemo ape a tshoganyetso a a tshosetsang botshelo, leletsa nomoro ya tshoganyetso ya lefelo la lona (911 kwa US le Canada, 112 kwa EU, 999 kwa UK) kgotsa tlhola nomoro ya rona ya . dinomoro tsa tshoganyetso lenaanethalo ka bonako.
2. Dira kopo ya Medicaid pele ga letsatsi la bofelo la kgwedi go lotlela mo Tebegomorago ya Dikgwedi di le 3 (42 C.F.R. § 435.915): Go farologana le dithulaganyo tsa Mmaraka wa ACA (tse di tsenang tirisong fela ka nako e e solofetsweng ka la bo 1 la kgwedi e e latelang), **Medicaid e balelwa mo kgweding e e latelang (eseng lotseno lwa ngwaga le ngwaga) mme e akaretsa Tshireletso ya Malatsi a le 90 e e Boelang Morago. Fa o ne wa robadiwa kwa bookelong ka tshoganyetso jo bo sa inšorilweng ka Phukwi mme wa latlhegelwa ke tiro kgotsa wa nna le letseno le le gaufi le lefela ka Phukwi, go dira kopo ya Medicaid ka kgotsa pele ga Diphalane 31 go pateletsa lenaneo la Medicaid la puso (mo dinageng tse di senang kgololo e e tshesane ya Karolo 1115) go akaretsa dibili tsa gago tsa kalafi ka Phukwi, Phatwe1, le Phukwi1.
3. Dirisa Ditlhopho tsa COBRA tsa Malatsi a le 60 + Fesetere ya Premiamo ya Ntlha ya Malatsi a le 45 go akaretsa maemo a tshoganyetso ka nako ya phetogo ya tiro: Fa o tlogetse tiro ya gago mo malatsing a le 60 a a fetileng mme o na le phatlha pele ga leano la boitekanelo la mothapi wa gago yo mošwa le simolola (kgotsa pele ga leano la gago la ACA Marketplace la go duela pele le sa tlhoke go duela), tlhokomelo e e turang ya kalafi**. Ka fa tlase ga ERISA (29 U.S.C. § 1165), o na le malatsi a khalentara a le 60 go tloga ka letlha le tshireletso ya mothapi wa gago e fedileng ka lone kgotsa letlha le Kitsiso ya Ditlhopho tsa COBRA e go rometsweng kwa go wena go tlhopha COBRA, mmogo le tuelo e nngwe ya tlaleletso ya malatsi a le 45 a khalentara go fitlha ka letlha le o tla duelang ka lone CORA go ya go malatsi a le 105 a tshireletso e e boelang morago e e senang kotsi go boela kwa Letsatsing la 1 la go latlhegelwa ke tiro ya gago.
4. O se ka wa ithaopela go latlhela COBRA mo bogareng jwa ngwaga o tsaya gore o ka fetogela kwa thulaganyong ya ACA Marketplace: Seno ke serai se le sengwe se se bolayang thata sa inšorense ya boitekanelo kwa United States. Ka fa tlase ga 45 C.F.R. § 155.420(e), go ithaopela go fedisa tshireletso ya gago ya COBRA go sa le gale (kgotsa go letlelela COBRA ya gago go khanselwa ka gonne o emisitse go duela sekoloto sa kgwedi le kgwedi) GA SE Tiragalo ya Botshelo e e Tshwanelegang mme GA E tlhotlheletse Paka e e Kgethegileng ya Kwadiso ya malatsi a le 60 ka 155.420. HealthCare.gov. Fa o sena go tlhopha le go duelela COBRA, o notletswe kwa ntle ga go fetogela kwa thulaganyong ya ACA Marketplace e e thusiwang ka matlole go fitlha ka ngwaga le ngwaga Paka ya Kwadiso e e Buletsweng (Ngwanatsele 1), ntle le fa paka ya gago e e tletseng ya COBRA ya dikgwedi di le 18 e fela gotlhelele kgotsa thuso ya matlole ya mothapi ya COBRA e fela.
5. Itse gore go latlhegelwa ke Thuso ya Mothapi ya COBRA GO TLHOLA Paka e e Kgethegileng ya Ikwadiso ya ACA ya Malatsi a le 60: Le fa go tlogela COBRA e e sa thusiweng mo bogareng jwa ngwaga go sa tshwanelegele SEP, melawana ya puso (**45 C.F.R. § 155.420)t tsotlhe kgotsa karolo ya dipremiamo tsa gago tsa COBRA jaaka karolo ya sephuthelwana sa go kgaotsa tiro, go fela ga nako ga ketleetso eo ya COBRA ya mothapi KE Tiragalo ya Botshelo e e Tshwanelegang e e go nayang malatsi a le 60 a khalentara pele kgotsa morago ga letsatsi la bofelo la ketleetso ya mothapi go tlogela COBRA le go ikwadisa mo Mmarakeng wa ACA o o tshegediwang ka matlole.
6. Faela Boikuelo jwa SEP jwa "Maemo a a Kgethegileng" ka fa tlase ga 45 C.F.R. § 155.420(d)(9) fa o fositse fensetere ya gago ya ACA ya malatsi a le 60: Fa o fositse Paka ya gago e e Kgethegileng ya Ikwadiso ya malatsi a le 60 morago ga go latlhegelwa ke tshireletso e e theilweng mo tirong (bona kaedi ya tatlhegelo ya inšorense ya boitekanelo) ka gonne o robaditswe kwa bookelong, o sa kgone go dira tiro ya kalafi, o amilwe ke masetlapelo a tlholego a FEMA, kgotsa o neilwe dipampiri tse di thari/tse di sa siamang ke mothapi wa gago kgotsa moinšorense, leletsa Marketplace Call Center (1-800-318-2596) ka bonako go kopa Paka e e Kgethegileng ya Kwadiso ya Maemo a a Kgethegileng e e nang le Letlha la go Tsena Tirisong le le Boelang Morago.

Setlhare sa tshwetso: Go namola sekoloto sa kalafi se se sa inšorilweng kgotsa phatlha ya tshireletso¶

Dirisa tšhate eno ya go tlhaola go supa gore ke letlowa lefe la pabalesego la semolao le le ka phimolang maemo a tshoganyetso a kalafi a a sa inšorilweng kgotsa la bula gape fensetere e e tswetsweng ya ikwadiso.

flowchart TD
    A["Maemo a Tshoganyetso a Kalafi a a senang Inšorense KGOTSA Fesetere ya Ikwadiso ya Inšorense ya Boitekanelo e e Fositsweng"] --> B{"Ke Malatsi a le Kae Fa E Sa Le Tshireletso e e Theilweng mo Tirong e Fedile?"}
    B -->|"Mo malatsing a le 60 a go Latlhegelwa ke Tshireletso (kgotsa go Amogela Kitsiso ya COBRA)"| C["Mo teng ga Fesetere e e Dirang ya Malatsi a le 60: Bapisa Ditlhopho tsa COBRA tse di Boelang Morago kgatlhanong le ACA SEP"]
    C -->|"O Setse a Na le Molaotlhomo o Mogolo wa ER/Bookelo ka Nako ya Phatlha"| D["Tlhopha COBRA ka bonako (E boela morago go Letsatsi la 1) + Dirisa Lefensetere la Tuelo ya Ntlha ya Malatsi a le 45"]
    C -->|"Ga go ise go nne le Dibili tse dikgolo mme go tlhokega Thulaganyo e e Tswelelang e e Duelesegang"| E["Ikwadise mo Thulaganyong ya Mmaraka wa ACA ka SEP ya Malatsi a le 60 + Dirisa COBRA jaaka Bekapo ya Mahala ya Maemo a Tshoganyetso ya Malatsi a le 60"]
    B -->|"Malatsi a le 60 a a Fetileng KGOTSA COBRA e Setse e Fedile"| F{"Tlhola Dithapo tsa Botshelo tsa Tshoganyetso di le 4"}
    F -->|"Lotseno lwa ga jaana lwa Kgwedi le Kgwedi lo lo kwa tlase ga Tekanyetso ya Puso ya Medicaid (ka sekai, 138% FPL / -$1,732/kgwedi O sa nyalwa)"| G["Kopa Medicaid ka bonako + Kopa Tshireletso ya Malatsi a le 90 e e Boelang Morago (42 C.F.R. 435.915)"]
    F -->|"Thuso ya COBRA ya Kgaotso ya Mothapi e sa tswa go fela"| H["Bitsa go Felelwa ke nako ga Thuso ya Madi ya COBRA ya Malatsi a le 60 SEP ka fa tlase ga 45 C.F.R. 155.420(d)(15) mo go Tlhokomelo ya Boitekanelo.gov"]
    F -->|"SEP e e Fositsweng ya Malatsi a le 60 ka Ntlha ya go Robadiwa kwa Bookelong, Masetlapelo, kgotsa Phoso ya Mothapi/Kitsiso"| I["Faela Maemo a a Kgethegileng Boikuelo jwa SEP ka fa tlase ga 45 C.F.R. 155.420(d)(9) ya Tshireletso e e Boelang Morago"]
    F -->|"COBRA e fedile mo malatsing a le 30 a a fetileng ka ntlha ya go sa duelwe"| J["Alafa COBRA mo Pakeng e e Tlamang ya Malatsi a le 30 (29 U.S.C. 1162(2)(C)) kgotsa Molao wa Tlhaelo e e sa Botlhokwa"]

Leano 1: Borogo jwa COBRA jwa Malatsi a le 105 jo bo Boelang Morago (Kafa o ka bonang tshireletso ya mahala ya phatlha)¶

Fa o tlogela tiro ka March 31 mme inshorense ya botsogo ya mothapi wa gago yo mosha e sa simolole go fitlha ka May 1 kgotsa June 1, o lebane le phatlha e e tshosang ya malatsi a le 30 go ya go a le 60 a o sa inshorenwang. Go duela $900 go ya go $2,400 ka kgwedi pele ga nako ya COBRA (e e duedisang 102% ya premium e e tletseng ya setlhopha) fela go akaretsa phatlha ya malatsi a le 45 fa o itekanetse go senya madi a o a tlhokang go renta. Go na le moo, dirisa Borogo jwa COBRA jo bo Boelang Morago jo bo ka fa tlase ga ERISA §§ 602 le 605 (29 U.S.C. §§ 1162, 1165) le 26 C.F.R. § 54.4980B-6:

Kafa tshupanako ya semolao ya Malatsi a le 60 + a le 45 e dirang ka gone¶

1. Lefensetere la Ditlhopho la Malatsi a le 60 (29 U.S.C. § 1165(a)(1)): Morago ga gore tshireletso ya setlhopha sa mothapi wa gago e fele, o na le bonnye jwa malatsi a khalentara a le 60 go tloga ka moragonyana ya (a) letlha le tshireletso ya gago e e dirang e khutlisitsweng ka lone, kgotsa (b) letlha le motsamaisi wa gago wa semmuso wa E**ti CO mme o buse foromo ya ditlhopho.
2. Tshireletso e e Boelang Morago Go Boela kwa Letsatsing la 1: Go farologana le leano lengwe le lengwe la boitekanelo la poraefete mo mmarakeng, fa o saena le go tshwaya Foromo ya gago ya Ditlhopho ya COBRA ka Letsatsi la 59, molao wa puso o tlhoka gore leano le busetse inšorense ya gago ya boitekanelo ka tshireletso e e boelang morago kwa Letsatsing la 1 (motsotso o o tlhomameng o tshireletso ya gago e e theilweng mo tirong ga**p e fedileng ka yone).
3. Fensetere ya Tuelo ya Ntlha ya Premiamo ya Malatsi a le 45 (29 U.S.C. § 1162(2)(C)): O thibetswe go tlhoka go romela madi ka Foromo ya gago ya Ditlhopho ya COBRA. Ka fa tlase ga molao wa puso, fa o sena go dira ditlhopho, leano le tshwanetse go go naya malatsi a le 45 a khalentara morago ga letlha la ditlhopho tsa gago tsa COBRA go duela dipremiamo tsa ntlha tse di boelang morago.
4. Kafa o ka dirang "COBRA Float" ka gone ka pabalesego:
5. Tlatsa Foromo ya gago ya Ditlhopho ya COBRA ka Letsatsi la 1, o e saene, mme o e beye mo enfelopong e e nang le setempe e e lebisitsweng kwa motsamaisi wa COBRA mo tafoleng ya gago ya boapeelo (o tlogele khopi le molekane wa gago kgotsa motho yo o ka ikgolaganyang le ene ka nako ya tshoganyetso).
6. Fa o ka kgona go feta mo phatlheng ya gago ya phetogo ya malatsi a le 30 go ya go a le 60 go tsena mo thulaganyong ya gago e ntšhwa ya boitekanelo ya mothapi wa gago (kgotsa thulaganyo ya gago e ntšhwa ya ACA Marketplace) kwantle ga go roba lerapo kgotsa go ya kwa bookelong, o ga o ke o romela foromo ya COBRA ka poso, mme o duetse $0 ya malatsi a le 60 a tshireletso ya masetlapelo.
7. Fa o ka tlhaselwa ke bolwetse jwa appendicitis kgotsa kotsi ya koloi ka Letsatsi la bo 42 (sekoloto sa ER sa $18,000) fa o ntse o duela tuelo ya COBRA ya $1,400, o romela Foromo ya gago ya Ditlhopho ya COBRA e e saennweng ka Poso e e Netefaditsweng pele ga Letsatsi la bo 60, duela dikgwedi tse pedi tsa inšorense ya go boela morago ya khamphani the days, $2. Tleleimi ya bookelo ya $18,000 ka botlalo.

Leano la 2: Medicaid e e Tlamang ya Malatsi a le 90 e e Boelang Morago le go Tshwanelega ga Bookelo¶

Fa o se na inšorense fa maemo a tshoganyetso a kalafi a tlhasela, o se ke wa tsaya gore o amogela madi a mantsi thata a Medicaid go ikaegilwe ka se o se amogetseng pelenyana mo ngwageng wa khalentara.

Goreng batho ba ba amogelang madi a mantsi ba ba latlhegelwang ke ditiro tsa bone ba tshwanelegela Medicaid ka bonako¶

Ka fa tlase ga melawana ya go bala ya Medicaid ya Molao wa Tlhokomelo e e ka Duelesegang ya Lotseno lotlhe lo lo Fetotsweng lo lo Fetotsweng (MAGI) (42 C.F.R. § 435.603(h)), fa dithuso tsa Mmaraka wa ACA di leba rente ya gago e e akanyediwang ya lotseno lwa gago lwa ngwaga le ngwaga lwa ngwaga otlhe, Medica lotseno (mme ga e akaretse madi a a duelwang ka nako e le nngwe mo kgweding e e fetileng kgotsa dipoelo dingwe tse di sa duedisiweng lekgetho). Le fa o amogetse $85,000 magareng ga Ferikgong le Phukwi, fa o ne o kobilwe mo tirong ka Phukwi 31 mme lotseno lwa gago lwa ga jaana lwa kgwedi le kgwedi ka Phatwe e le \(0 (kgotsa ka fa tlase ga 138% ya Maemo a Lehuma a Bosetšhaba mo dinageng tsa 40+ tsa Katoloso ya Medicaid, mo e ka nnang **\)1,732/kgwedi ya $8^th a for 500). ya nne), o tshwanelega semolao go bona Medicaid e e tletseng ka Phatwe.

Go diragatsa Molao wa Thuso ya Kalafi ya Dikgwedi di le 3 (42 U.S.C. § 1396a(a)(34))¶

Tlasa molao wa Medicaid wa mmuso (42 U.S.C. § 1396a(a)(34) le 42 C.F.R. § 435.915), dikemedi tsa mmuso tsa Medicaid di tlameha ho etsa hore thuso ya bongaka e be teng bakeng sa tlhokomelo le ditshebeletso tse fanweng ka kapa ka mora **kgwedi ya boraro pele ho kgwedi eo motho a fanang ka yona:

1. O amogetse ditirelo tsa kalafi tse di akareditsweng mo kgweding eo e e fetileng (jaaka ketelo ya ER, go nna kwa bookelong, karo, dipalangwa tsa ambulense, kgotsa taelo ya ngaka), e ka tswa o setse o duetse sekoloto kgotsa nnyaa; LE
2. O ka bo o tshwanelegetse go bona Medicaid ka nako e ditirelo di neng di neelwa ka yona fa o ne o dirile kopo ka nako eo (se se rayang gore lotseno lwa gago lwa kgwedi le kgwedi mo kgweding eo e e fetileng lo ne lo le mo teng ga selekanyo sa Medicaid, kgotsa dikoloto tsa gago tsa kalafi tse di bakang masetlapelo di ne di feta lotseno lwa gago lo lo feteletseng ka fa tlase ga lenaneo la puso la Medically Needy Spend / Don Cost).

Kgato ya Tiro kwa Bookelong (Go Tshwanelega ga Bookelo, 42 C.F.R. § 435.1110): Fa o sa ntse o amogetswe kwa bookelong, kopa go bua le Mogakolodi wa Ditšhelete wa Medicaid wa bookelo kgotsa Mmueledi wa Bookelo jwa Molwetse le go Tshwanelega (HP) a Kopo ya Medicaid e e Boelang Morago (Tlaleletso ya Tshireletso ya Pele ga Dikgwedi di le 3). Ka fa tlase ga 42 C.F.R. § 435.1110, dikokelo tse di tshwanelegang di ka go naya tshireletso ya nakwana ya Medicaid ya mo lefelong ka lone letsatsi leo go ikaegilwe ka lotseno lwa gago lwa ga jaana lwa kgwedi le kgwedi gore o kgone go tlatsa ditaelo tsa ngaka fa o gololwa fa kopo ya gago e e tletseng ya malatsi a le 90 e e boelang morago e ntse e dirwa.

Papiso ya maborogo a tshireletso ya tshoganyetso le melao e e boelang morago¶

Go alafa pholisi ya COBRA e e fedileng nako: Paka ya Mohau ya Malatsi a le 30 le Molao wa "Tlhaelo e e sa Botlhokwang"¶

Fa motsamaisi wa gago wa COBRA a go romela kitsiso ya go fedisa tiro a bolela gore tshireletso ya gago ya COBRA e phimotswe ruri ka gonne tuelo ya porimiamo ya kgwedi le kgwedi e gorogile thari kgotsa e ne e le khutshwane ka didolara di le mmalwa, tlhola diphemelo tse tharo tseno tsa semolao ka bonako:

1. Paka ya Mohau ya Kgwedi le Kgwedi ya Malatsi a le 30 e e Tlamang (29 U.S.C. § 1162(2)(C) le 26 C.F.R. § 54.4980B-8, Q&A-5): Mo tuelong nngwe le nngwe ya kgwedi le kgwedi ya COBRA **paka ya gago ya ntlha ya malatsi a le 45 a molao. Le fa bili ya gago ya COBRA e re "E tshwanetse go duelwa ka la 1 la Kgwedi," tuelo e e tshwailweng ka poso (kgotsa e e rometsweng ka eleketeroniki) ka kgotsa pele ga letsatsi la bo 30 morago ga letlha le le tshwanetseng go duelwa e mo nakong semolao, mme moinšorense o tshwanetse go busetsa tshireletso morago go la 1 la kgwedi.
2. Molao wa IRS wa "Tlhaelo e e sa Botlhokwa" (26 C.F.R. § 54.4980B-8, Q&A-5(d)): Batsamaisi ba COBRA gantsi ba phimola dipholisi fa koketsego ya seelo sa ngwaga le ngwaga e fetola karolotuelo ya gago ya kgwedi le kgwedi go tswa go $812 go ya go $845 le tuelo ya gago ya go itirisa ya $812. Ka fa tlase ga Molawana wa Lefapha la Matlotlo § 54.4980B-8, Q&A-5(d), fa o duela karolelano ya COBRA ka nako e e khutshwane ka "madi a a sa reng sepe", e e tlhalosiwang ke boemakepe jo bo babalesegileng jwa puso jaaka **e e kwa tlase ga $50 kgotsa diperesente di le 10 tsa karolelano e e tlhokegang e e sa **a thibelwe go tswa go **a CO motsamaisi o go romela pele kitsiso e e kwadilweng ya tlhaelo mme a go neye malatsi a khalentara a le 30 a mangwe go tswa mo kitsisong eo go duela pharologano e e tlhaelang.
3. **Kitsiso ya Ditlhopho ya COBRA e e nang le bogole kgotsa e e tlhaelang (ERISA § 502©(1), 29 U.S.C. § 1166, mothapi wa gago le motsamaisi wa leano ba na le matlha a a gagametseng a semolao (ka tlwaelo go fitlha go malatsi a le 44 a kopantswe) go romela Kitsiso ya gago ya Ditlhopho ya COBRA kwa atereseng ya gago ya bofelo e e itsiweng (go akaretsa dikitsiso tse di farologaneng tsa go ikaega fa go tlhokega). Fa ba paletswe ke go romela Kitsiso ya Ditlhopho tsa COBRA ka nako, tshupanako ya gago ya ditlhopho ya malatsi a le 60 ga e ise e ko e simolole go dira semolao, mme Motsamaisi wa Leano o lebane le dikotlhao tsa semolao tsa go fitlha go $110+ ka letsatsi mmogo le maikarabelo a ditleleimi tsa gago tsa kalafi tse di sa akarediwang.

Thempoleite ya go kopolola le go kgomaretsa: Tlhokego ya Tshireletso e e Boelang Morago le Boikuelo jwa COBRA / SEP¶

Dirisa Karolo 1 go batla SEP e e Boelang Morago ya Maemo a a Kgethegileng a ACA, Karolo 2 go dira kopo ya Medicaid e e Boelang Morago ya Malatsi a le 90, kgotsa Karolo 3 go busetsa morago Phediso ya COBRA e e seng ka fa molaong.

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]

Tshireletso ya boditšhabatšhaba ya tshoganyetso ya boitekanelo le maborogo a ditshenyegelo tsa taelo ya ngaka¶

Fa o latlhegelwa ke thulaganyo ya gago ya tlaleletso ya melemo/boitekanelo kwa tirong kgotsa o lebane le sekoloto se se masisi sa kalafi ka nako ya phetogo ya tshireletso kwa ntle ga United States, dira gore mananeo ano a semolao a setšhaba a dire ka bonako:

• Canada (Tlhokomelo ya Melemo ya Setšhaba ya Porofense & Trillium / Tshekatsheko ya Lotseno lwa Tlhokomelo ya Melemo e e Siameng): Le fa ditirelo tsa konokono tsa bookelo le tsa ngaka di akarediwa lefatshe ka bophara ka fa tlase ga inšorense ya boitekanelo ya porofense (OHIP, MSP, AHCIP, RAMQ), go latlhegelwa ke tiro ya gago go fedisa Leano le le Atolositsweng la Boitekanelo le Taelo ya Ngaka ya mothapi wa gago. Fa ka tshoganetso o lebane le melemo e e kgethegileng e e turang (e e jaaka insulin, di-biologics, kgotsa melemo ya pelo), dira kopo ka bonako ya lenaneo la melemo ya masetlapelo a setšhaba le le ikaegileng ka lotseno la porofense ya gago, le le jaaka Lenaneo la Melemo ya Ontario Trillium (le le fokotsang ditshenyegelo tsa gago tsa taelo ya ngaka e e tswang mo kgetsaneng ya gago ka bokana ka Fahocome inhouse ya gago), PharmaCare, kgotsa Tshireletso ya Alberta e e seng ya Setlhopha. Kgato e e Botlhokwa: Kopa lenaneo go Tlhatlhobo ya Lotseno lwa Ngwaga / Tlhatlhobo ya Phapogo gore madi a gago a a gogelwang a balelwa mo lotsenong lwa gago lwa ga jaana lo lo fokoditsweng morago ga go latlhegelwa ke tiro, e seng pusetso ya lekgetho ya ngwaga o o fetileng. Ela tlhoko gape gore o na le malatsi a le 60 go tswa mo go latlhegelweng ke thulaganyo ya gago ya setlhopha sa mothapi go fetogela kwa thulaganyong ya boitekanelo ya "FollowMe / Assured Access" ya motho ka bongwe e e nang le go se na kwadiso ya kalafi.
• United Kingdom (Sekema sa Lotseno lo lo kwa Tlase lwa NHS, Foromo ya HC1 & Pusetso ya HC5 ya Dikgwedi di le 3): Le fa kalafi ya tshoganyetso ya bookelo jwa NHS e le mahala kwa lefelong la tiriso mo baaging ba UK, go latlhegelwa ke lotseno lwa gago go ka go tlogela o sa kgone go duelela Ditaelo tsa ngaka tsa NHS (kwa Engelane), kalafi ya meno kgotsa kalafi ya meno. Fa o ise o amogele Universal Credit e e tshwanelegang, romela Kopo ya Sekema sa Lotseno lo lo kwa Tlase lwa NHS (Foromo HC1) mo inthaneteng kgotsa ka poso go bona Setifikeiti sa HC2 (100% ya ditaelo tsa ngaka tsa mahala le tlhokomelo ya meno) kgotsa Setifikeiti sa HC3 (thuso e e sa felelang). Molao wa Pusetso ya Madi o o Boelang Morago: Fa o tshwanetse go duelela taelo ya ngaka kgotsa tlhokomelo ya meno ya tshoganyetso ya NHS gompieno fa o ntse o letetse gore HC1 ya gago kgotsa Universal Credit e amogelwe, kopa rakhemisi gore a go neye Foromo ya Kamogelo ya NHS FP57 ya semmuso ka nako e e tshwanang le e o duelang ka yone (ga o ka ke wa bona laRefund and HC5** mo lobakeng lwa dikgwedi di le 3 go amogela pusetso ya madi ka botlalo.
• Australia (Medicare Safety Net, Karata ya Tlhokomelo ya Boitekanelo ya Lotseno lo lo kwa Tlase & Go Sekegwa ga Boitekanelo jwa Poraefete ga Malatsi a le 60): Baagi botlhe ba ba tshwanelegang ba boloka phitlhelelo ya bookelo jwa puso le melemo ya PBS ka Medicare, go sa kgathalesege gore ba latlhegetswe ke tiro. Fa lotseno lwa gago lo wela tlase thata morago ga go latlhegelwa ke tiro, dira kopo kwa Services Australia (Centrelink) ya Karata ya Tlhokomelo ya Boitekanelo ya Lotseno lo lo Kwa Tlase (e e tlhomamisiwang mo fensetereng ya lotseno lo lo tswelelang lwa dibeke di le 8, e seng lotseno lwa lekgetho lwa ngwaga le ngwaga), e e fokotsang sekema sa gago sa go duela **Dipoelo tsa Melemo ($7.70 AUD) mme e latlhela Nete ya Pabalesego ya Medicare e e Atolositsweng (EMSN) ya gago. Fa o sa tlhole o kgona go duelela Inšorense ya Boitekanelo ya Poraefete ya gago ya dipremiamo tsa bookelo (kgotsa o batla go tila kotlhao ya go laisa Medicare Levy Charge le Lifetime Health Cover), kopa moinšorense wa gago wa boitekanelo wa poraefete go go naya Go Sekega ga Pholisi ya Mathata a Madi / Botlhokatiro ka tsela e e tlhomameng (bontsi jwa matlole a letla dipremiamo tsa **dingwaga tsa **suspe dipaka tsa gago tsa go leta kgotsa seemo sa Tshireletso ya Boitekanelo ya Botshelo Jotlhe).

Dipotso tse di bodiwang kgapetsakgapetsa¶

Metswedi e tlhotlhomisitswe¶

• RONA. Lefapha la Boitekanelo le Ditirelo tsa Batho (HHS) le Disenthara tsa Ditirelo tsa Medicare le Medicaid (CMS, United States): Molao wa go Tshwanelegela go bona Thuso ya Kalafi ya Malatsi a le 90 (42 U.S.C. § 1396a(a)(34)) le Melawana (42 C Melao ya Lotseno (42 C.F.R. § 435.603), Go Tshwanelega ga Bookelo (42 C.F.R. § 435.1110), le *Molao wa Kalafi ya Tshoganyetso le Tiro (EMTALA, 42 U.S.C.) § 59.
• Disenthara tsa Ditirelo tsa Kalafi le Kalafi (CMS / HealthCare.gov, United States): Dipaka tse di Kgethegileng tsa go Ikwadisa tsa Kananyo ya ACA (45 C.F.R. § 155.420), Go Felelwa ke Nako ga Dikabelo tsa COBRA tsa Mothapi SEP (45 C.F.R. Maemo SEP le Matlha a go Tsena Tirisong a a Boelang Morago (45 C.F.R. § 155.420(d)(9) le § 155.420(b)(2)(iii)), le *Molao wa Bofelo wa Inšorense ya Nako e Khutshwane, ya Nako e e Lekanyeditsweng)
• RONA. Lefapha la Badiri (EBSA) le Tirelo ya Lekgetho la ka fa Gare (United States): Molao wa Poelano ya Tekanyetsokabo ya Omnibus e e Kopantsweng (COBRA, ERISA §§ 601 go ya go 608, 29 U.S.C. § 54.4980B-6 ka ga Dipaka tsa Ditlhopho le § 54.4980B-8 ka ga Difensetere tsa Tuelo tsa Malatsi a le 45/30 le Ditlhaelo tse di sa Botlhokwa).
• Lefapha la Boitekanelo la Ontario le Lefapha la Boitekanelo la BC (Canada): Dikaelo tsa Tshekatsheko ya Lotseno lwa Lenaneo la Diokobatsi la Trillium mo Ngwageng le Melao ya Tlhatlhobo ya Lotseno lwa BC Fair PharmaCare.
• Bothati jwa Ditirelo tsa Kgwebo tsa NHS (NHSBSA, United Kingdom): Sekema sa Lotseno lo lo kwa Tlase lwa NHS (HC1/HC2/HC3) le Melao ya Pusetso ya Madi a Ditaelo tsa Ngaka/Meno a a Boelang Morago (Diforomo FP57 le HC5).
• Ditirelo tsa Australia le Motsereganyi wa Inšorense ya Boitekanelo ya Poraefete (Australia): Teko ya Lotseno lwa Dibeke di le 8 tsa Karata ya Tlhokomelo ya Boitekanelo ya Lotseno lo lo Kwa Tlase, Letlowa la Pabalesego la Medicare le le Atolositsweng, le Dikaelo tsa go Sekega ga Mathata a Madi a Inšorense ya Boitekanelo ya Poraefete.

Dikaedi tse di tsamaelanang¶

• Go latlhegelwa ke inshorense ya boitekanelo, COBRA, le Kwadiso e e Kgethegileng
• Dikokoanyo tsa dituelo tsa kalafi, thuso ya madi ya bookelo, le tlhokomelo ya bopelotshweu
• Go ganwa ga ditleleimi tsa inšorense ya bogole ya pakakhutshwane le ya pakatelele (boikuelo jwa ERISA)
• Go latlhegelwa ke tiro ka tshoganyetso le go nna le madi ka bonako
• Go bitsa balwetse le go tsaya khunologo ya kalafi e e sireleditsweng (FMLA)
• Dinomoro tsa tshoganyetso go ya ka dinaga