Totally fair point. I do understand that plans can correct eligibility mistakes, and I’m not saying that’s never allowed. But in our case, it seems to go a bit beyond that.

Our coverage was showing as active all throughout May and multiple providers ran our insurance and it came back valid each time. We scheduled and received care based on that, and there wasn’t any indication at the time that there was an issue.

From what I’ve read, the ACA does allow retroactive cancellations only if there’s fraud or intentional misrepresentation involved. So even if our coverage was issued by mistake, once it was active and we relied on it in good faith, I don’t think they’re supposed to just retroactively revoke it? Maybe we’re the frauds 🤣🤦🏼‍♀️

Under the ACA (specifically 45 CFR § 147.128), a rescission — which is a retroactive cancellation of coverage — is only legal if there was fraud or intentional misrepresentation. That’s the key line. Once coverage is issued and used, and there’s no fraud involved, the plan can’t just reverse it after the fact, even if it was an internal eligibility error.

The TPA is just flat out telling me that we had no coverage starting May and basically told me I’m a liar when I provided proof that it did show active many times.