The new law passed by President Biden allows year-round health insurance enrollments for individuals and families that qualify. Back in 2021 the US Department of Health and Human Services made a new law that allows individuals and families to have access to enrolling in a health insurance plan on the ACA marketplace exchange if their household income was less than 150% of the Federal Poverty Level (FPL). These people would still need to also have household income above 100% of the FPL or 133% of the FPL for states that expanded Medicaid.
The chart shows the income levels to qualify based on household income for 2023 in most states.
This new 150% SEP qualification law became official on the ACA marketplace exchange in March of 2022. To qualify for this SEP qualification on the enrollment application at healthcare.gov you must select “find out if you can enroll/change” and then choose the option for “Medicaid, Chip, or new Special Enrollment Period based on income” If you qualify based on income the portal will allow you to continue with the application.
How does this SEP affect households under 150% FPL?
This new special enrollment period allows those who qualify to choose a health insurance plan on the ACA marketplace and get enrolled at anytime during SEP which would be from January 15th to October 31 for 2023. The effective date will be the 1st of each following month after enrolling. Most state exchanges follow the same guidelines that are set by the ACA marketplace on healthcare.gov.
This new law that allows SEP year-round can be utilized as often as an individual or family chooses to do so. There are no restrictions on the number of times you enroll or switch plans. So even though someone may already have an active plan on the ACA marketplace they can still switch plans as often as they choose if they fall into this income category. The downside of switching plans during the SEP would be that your deductible and out of pocket maximum would have to start all over. This law was added in the American Rescue Plan and is guaranteed to continue at least until the end of 2025. We do not know at this time if any changes will be made in 2026 or if they will be continued.
The subsidy is only offered on- exchange. If you enroll off-exchange you are not eligible for a subsidy. The eligibility depends on many other factors that are not just income based. Although you must be between 100% FPL to 150% FPL in states that have not expanded Medicaid and 133% to 150% FPL in states that have expanded Medicaid. If your household income falls under this amount, you will not be eligible for subsidies, and you may instead qualify for Medicaid. You can not enroll in Medicaid on the ACA marketplace, but you can use your subsidy denial letter to start the Medicaid enrollment process. Also, you typically must be under 65 years of age to qualify for this SEP enrollment period (there are some exceptions to qualify if you are 65 or older). For those that are 65 or older in most cases they would qualify for Medicare which is designed for tax paying seniors. If you are offered employer sponsored health coverage deemed affordable by the ACA marketplace, then you would also not qualify for the SEP enrollment.
The Law has guaranteed this SEP through the end of 2025
The inflation reduction act has written in it the law and the extension of the SEP period for under 150% FPL through 2025. We do not know at this time whether or not it will be extended past this timeframe. If this is not extended, then it will require starting in 2026 for this income level to enroll during the traditional open enrollment period of November 1st through January 15th each year. There will still be the typical SEP qualifications such as moving to a new county, pregnancy, new immigration status, loss of job or other approved life changes. Congress will likely look at this closer to this date and make any changes at that time.
Providing Proof of Income to qualify for the SEP
If you estimate your household income to fall into the income category under 150% FPL and above the minimum, then you have the right to access this SEP through the ACA marketplace. If you are not sure if your income falls into this range, you still have the right to submit an application for review. In order to submit an application this can be done through a licensed health insurance agent or on healthcare.gov. The online application will ask for your estimated income with a series of questions. If your income qualifies you then you can enroll in a plan of your choice immediately to start on the 1st of the following month. In some cases, if the marketplace does not have your income level already in their database, then they will ask you to submit proof of income. This can be done with a paycheck stub, income tax statement or several accepted other options. If you do not submit proof of income during the time period required, you risk having your subsidy terminated and will have to pay the full premium.
What about states that have different income levels than 150% FPL for the SEP. As of 2023 ….
New Jersey, New Mexico and Vermont are based on under 200% of the FPL. Washington is under 250% of the FPL. Idaho, Maryland, and Nevada do not participate in this specific SEP income qualification. Minnesota and New York offer 200% FPL during SEP indefinitely. Massachusetts, Washington DC and Connecticut also have unique SEP set up based on different income levels. Please check with your specific state to see the qualification requirements.
For more information or to see if you qualify contact My Choice Health Insurance at 972-728-0386