Individuals in all FFM states along with State Exchanges of Colorado, Maine, Pennsylvania, New Jersey, California, and Rhode Island can apply for this SEP.
- An applicant’s household income does not exceed 150% of the federal poverty level (FPL)
- If the applicant is eligible for a premium tax credit (subsidy).
Medicaid-eligible individuals or individuals in the Medicaid Gap are not eligible for this SEP.
However, the new rules do clarify that if a current applicant is adding a dependent to their plan:
• Or switch to a Silver level plan and enroll the new dependent in that plan.
But the SEP cannot be used to switch the current enrollee to a non-Silver plan together with the new dependent.
Through this SEP, new clients who fit this eligibility can enroll in a Marketplace plan and existing clients could change their plan. If an existing client chooses to change their plan, their deductible and out of pocket max will reset.
Who is eligible for this SEP?
Clients are eligible for this SEP if they fit both of these criteria:
Have an estimated annual household income at or below 150% FPL
Are otherwise eligible for APTC*
*As a reminder: Consumers with income below 100% FPL but who do not qualify for Medicaid due to immigration status only may still be eligible for APTC if they meet all other Marketplace eligibility requirements. They would also qualify to use this SEP.
Who is not eligible for this SEP?
Clients must be eligible for APTC in order to use this SEP. That means they cannot be eligible for Medicaid or offered affordable employer-sponsored coverage. This also means clients who are in the Medicaid Gap (i.e. make less than 100% FPL in states that did not participate in Medicaid expansion) can’t use this SEP; nothing about this new SEP changes their eligibility for subsidies.
This SEP is live for the Federally-facilitated Marketplace and all plans on HealthSherpa. Implementation of this SEP varies for State-based Marketplaces.
What are the effective date rules?
This monthly SEP will follow accelerated effective date rules, which means you can enroll a client any day of the month and have their coverage start the first day of the next month. For example, if you enroll your client in a plan on 3/30/22, their coverage will begin on 4/1/22.