Attn: There is a new income based SEP for individuals under 150% FPL

Hello all,

It is quite surprising to me that not many of the highly active users here that I know work in the health insurance industry are aware that there is a new income-based Special Enrollment Period that has been active since last year. I’ve been seeing a lot of posts where people are simply unaware, or straight up misinformed on how the new SEP works, so I wanted to shed light so that we can better assist the users coming to us for help.

Simply put, individuals making under 150% of the FPL have a guaranteed QLE. Loss of coverage does not matter, moving does not matter, marital status does not matter. As long as an individual’s income is under 150% and they qualify for APTC, the income level alone counts as a qualifying event. This SEP applies to consumers that are both new to the marketplace and consumers that are currently enrolled in the marketplace. Unlike most SEPs, there are no deadlines; it is indefinite as long as a consumer falls within the income ranges and remains eligible for the tax credit.

This change to the marketplace was implemented in early 2022, which is why I’m surprised at the lack of awareness I see when people come asking for help because they mised their enrollment window and are simply met with “Nope, you fucked up and now you have to wait until November.” This SEP was initially set to last through the end of 2022, but back in October 2022 it was extended to last through the end of 2025.

According to KFF, between 12-15% of the US falls into this SEP criteria. Knowing that this is even an option will open up the possibility for a little over 1 in every 10 people to get medical insurance if they missed an enrollment window. This SEP even allows for a current consumer to change plans, and can even be used to change metal levels if they were not aware that CSR was available.

More importantly, if we, experts in the insurance industry aren’t even aware of all the newly implemented SEPs, how the hell can we expect the average consumer to be aware of it?

Let’s make sure we get familiar with this because this SEP will be life-changing for some people. By simply asking some basic follow up questions, we may be able to direct people onto an ACA application that may have been completely unaware they could even apply.

New SEP Guidance Document PPT: https://www.hhs.gov/guidance/document/150-federal-poverty-level-fpl-special-enrollment-period-sep

Marketplace tip sheet on new income based SEP: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/150FPLSEPTATIPSHEET

KFF FPL Census Data: https://www.kff.org/other/state-indicator/distribution-by-fpl/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D