What Do I Need to Know About the New Special Enrollment Period?

After months of discussions, the United States Department of Health and Human Services unveiled a new special enrollment period (SEP) in September of 2021. For states that participate in the Healthcare.gov health insurance program, the new SEP allows eligible Americans to enroll in a health insurance plan that meets the guidelines established by the Affordable Care Act (ACA). Instead of a limited amount of time to enroll in an ACA-approved health insurance plan, qualified Americans have the opportunity to enroll in a health insurance plan throughout the year.

The key criterion that makes Americans eligible to participate in the new SEP concerns maximum household income. If your household income is not more than 150 percent of the federal poverty level (FPL) and if you qualify for a premium tax credit, you can enroll in an ACA-backed health insurance plan at any time during a 12-month period. The Department of Health and Human Services uploaded the new SEP guidelines on the Healthcare.gov website in late March of 2022.

More Flexibility for Enrollees

Expanding the new SEP throughout the year provides participants with much more flexibility when it comes to matching health insurance policies with changing health insurance needs. Any changes to health insurance coverage go into effect the month following the purchase of a health insurance policy during the new SEP. The new SEP does not restrict how often a policyholder can change plans, as well as limit the type of health insurance coverage. Americans that live on an income that is up to 150 percent of the FPL should consider choosing a Silver plan because of built-in cost savings that make the plan more attractive than enrolling in a Platinum plan.

With the American Rescue Plan offering subsidies at least throughout 2022, enrolling in one of the two-lowest costs Silver plan means you do not have to pay monthly premiums.

Who Qualifies for the New SEP?

What is 150 percent of the FPL? For 2022, 150 percent of the FPL is $19,320 for an individual For a five-member household, the 2022  FPL sits at $46,560. Meeting the FPL income thresholds is just the first hurdle to clear for becoming eligible for the new SEP. You also have to qualify for a premium tax credit to participate in the new SEP. This means that regardless of your income, you cannot participate in the new SEP if you qualify for Medicaid, Medicare Part A, or a health insurance plan that is sponsored by your employer. The new SEP also does not apply to Americans that are in a health insurance coverage gap because they do not qualify for premium tax credits.

What Do I Need to Become Eligible for the New SEP?

The key to qualifying for the new SEP involves demonstrating either your family or individual income is no more than 150 percent of the federal poverty level. When you apply for the new SEP, you can expect to submit documentation that confirms the claim that your income matches the criteria established by the new SEP. However, if the Department of Health and Human Services discovers the income information on file does not match your claim of income, you might have to submit additional documents that verify your income claim.

If you do not submit additional evidence of income in the form of documentation, the federal marketplace can rule that you no longer qualify for the premium tax credit.

Does the Income Standard Apply for Every State?

Eighteen states operate their own health insurance exchanges which means they do not have to offer residents access to the new SEP. By the time the new SEP went live on the Healthcare.gov website, several states that manage their own health insurance exchanges introduced the new SEP to residents. The states managing their own health insurance exchanges that do not offer the new SEP have introduced other health insurance programs to give residents access throughout the year.

What Else Do I Need to Know About the New SEP?

Although your annual income represents the most important factor that determines your eligibility for the new SEP, you should consider other factors that can impact your eligibility.

Most states set a 138 percent maximum income above the federal poverty level for residents to qualify for Medicaid. This means residents of these states receive Medicaid at an income that is below the 138 percent FPL threshold and they qualify for the new SEP if their income is between 139 percent and 150 percent above the FPL. In the minority of states that have not expanded Medicaid coverage, residents qualify for the new SEP if their incomes are between 100 percent and 150 percent of the federal poverty level.

Recent immigrants that do not qualify for Medicaid coverage become eligible for the SEP if their incomes are between 0 percent and 150 percent of the FPL. Americans receiving unemployment payments might qualify for the new SEP during 2022 and beyond. The Build Back Better Act contains language that triggers that unemployment rule to qualify for the new SEP, but the legislation remains stalled in the Senate.

Navigate Special Enrollment Periods With Insurance Broker Hub

The new SEP offers Americans that qualify for the program much more flexibility when it comes to enrolling in an ACA-approved health insurance plan.

Finding health insurance is still one of those things that is a mystery for many Americans, and navigating the maze that is healthcare.gov is rarely as easy as promised. If you’re looking for help understanding your options, Insurance Broker Hub can help.