TN 7 (04-14)

A. Introduction

As a result of the Windsor and Obergefell decisions, we are able to process premium surcharge rollback request actions for individuals who enrolled in the General Enrollment Period, but had Group Health Plan (GHP) or Large Group Health Plan (LGHP) coverage based on current employment of a same-sex spouse.

B. Policy

Same-sex marriages are treated the same as opposite-sex marriages for purposes of the premium surcharge rollback. The gender of the married individuals, domicile and date of marriage are not factors in determining eligibility for the premium surcharge rollback. For instructions regarding premium surcharge rollback, see HI 00805.280 for SMI and HI 00805.285 for Premium-HI.

NOTE: Individuals age 65 and over who are, at the time of the premium surcharge rollback request, in non-marital legal same-sex relationships, such as civil unions and domestic partnerships are not considered spouses and do not meet eligibility requirements for the premium surcharge rollback.

C. Procedure

Follow instructions in HI 00805.280C.

D. Examples

1. Example of approval

Sarah refused SMI during her IEP, which ended January 2010. Sarah is the spouse of Liz. Sarah had GHP coverage through Liz’s employer from January 2010 until October 2012. She filed an SEP request for SMI in November 2012, before the Windsor decision and while DOMA rules were still in effect, and was denied. Sarah enrolled in SMI during the 2013 GEP and her coverage started July 1, 2013. She was assessed a 30% premium surcharge. On August 1, 2013, Sarah requested a premium surcharge rollback and provided proof of the GHP coverage from January 2010 through October 2012. Sarah meets all other factors for premium surcharge rollback. Approve the request for premium surcharge rollback to reduce the premium surcharge to 0.

2. Examples of denial

• Tom refuses SMI during his IEP, which ended February 2008. Tom is married to Robert. Tom does not have GHP coverage based on his or Robert’s employer at the time he refused SMI. Tom enrolled in SMI during the 2012 GEP and his coverage started July 1, 2012. He was assessed a 40% premium surcharge. On July 8, 2013, Tom requested a premium surcharge rollback. He provides no verification of GHP coverage. Deny the premium surcharge rollback request because Tom has not provided evidence of GHP coverage.

• Michael refuses SMI during his age 65 IEP, which ended April 2007. Michael is Edward’s domestic partner. Michael has GHP coverage based on Edward’s current employment. Michael enrolled in SMI during the 2012 GEP and his coverage started July 1, 2012. He was assessed a 50% premium surcharge. On July 8, 2013, Michael requested a premium surcharge rollback. Deny the premium surcharge rollback request because domestic partners do not qualify for premium surcharge rollback.

E. References

• HI 00805.266 - Definitions of Terms Used in the Special Enrollment Period and Premium Surcharge Rollback Provisions

• HI 00805.280 - Premium Surcharge Rollback for Individuals with GHP/LGHP Coverage

• HI 00805.285 - The SEP and Premium Surcharge Rollback for Individuals Eligible for Premium-HI

• HI 00805.295 - Evidence of GHP or LGHP Coverage Based on Current Employment Status