New and Improved! The SEP for People Moving Out of the Medicaid Coverage Gap

As part of our Robert Wood Johnson Foundation-funded Navigator Technical Assistance project, we’ve helped Navigators and assisters answer tough questions from consumers. Many questions focused on special enrollment periods (SEPs), including a new “tax season” SEP that applied to individuals who learned about the requirement to have coverage only when they found out they were subject to a tax penalty for being uninsured in 2014.

In the past, we’ve written about individuals who fall into the Medicaid coverage gap – those individuals with income too low to qualify for premium tax credits but living in a state that hasn’t expanded Medicaid. For much of last year, if those individuals had a change in income that would qualify them for premium tax credits (PTCs), they were out of luck until open enrollment.

In August 2014, CMS released guidance that provided hope – and a way to access PTCs – to individuals whose income increased to more than 100% of the federal poverty level (FPL). They can now qualify for a SEP. Previously, federal rules only allowed a SEP for change in income to those already enrolled in a marketplace plan, which left out many individuals who might experience a change in income, including those caught in the Medicaid coverage gap. The August 2014 guidance changed that by allowing individuals in non-expansion states to get a SEP if their income rose to more than 100% FPL. However, the earlier guidance required individuals to get a formal Medicaid denial, either through the Marketplace or through their state’s Medicaid agency. That meant those individuals who didn’t bother to go through the process of applying for Medicaid, just to get a denial they knew was coming, wouldn’t be able to take advantage of the SEP. But the situation is about to improve for individuals in the coverage gap who have a change in income that would qualify them for PTCs.

Beginning April 28, 2015, a new version of the change in income SEP will take effect, thanks to the final Notice of Benefit and Payment Parameters rule published in February. Under the new rules, the SEP for change in income for those in non-expansion states will only require individuals to attest to a change in income from less than 100% FPL to more than 100% FPL. Individuals will not have to document a formal Medicaid denial if their income was previously under 100% FPL. Individuals will still have to provide documentation of their income if federal data have not yet caught up with the individual’s change in income.

“New and improved” too often means little more than fancy new packaging on the same old product. But on this one we think the change is worth sharing. We’re hopeful this means more individuals will have the opportunity to use this SEP and, if eligible, enroll in coverage with premium tax credits.

Stay tuned to CHIRblog for more updates on guidance and happy April 28th!

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