You can continue to grow your ACA book outside of Open Enrollment. New clients will need to have a qualifying life event (QLE) to be eligible for a Special Enrollment Period (SEP).

In this article, we’ll cover the following questions around SEPs:

What are SEPs?

SEPs are certain timeframes outside of OEP when a client can enroll in an ACA plan. This timeframe is triggered by a QLE (see more details below).

For the 33 states who use the Federally-facilitated Marketplace, Open Enrollment is typically November 1st — December 15th. Outside of OEP, clients can enroll in coverage or change plans as long as they qualify for a SEP.

State-based Marketplaces can have different Open Enrollment dates. See more information on Marketplace type by state here.

What are the QLEs?

There are 19 different QLEs that break down into the following categories:

  • Loss of qualifying health coverage

  • Change in household size

  • Change in primary place of living

  • Change in eligibility for Exchange coverage or help paying for coverage

  • Enrollment or plan error

  • Other qualifying changes

CMS recently announced a new SEP category for consumers ≤150% FPL, and you can find more information about it in a later section of this article.

We’ve compiled all of the information agents need to know about QLEs in the following table.

How HealthSherpa helps agents with SEP enrollments

During Enrollment

On HealthSherpa, quoting and completing an application for a client with a SEP is very similar to Open Enrollment.

The main difference is that you will need to select your client’s QLE in the ‘Additional Questions’ section of our application. You can see what this looks like around the 6:45 mark of this video:

Post Enrollment

As you know, your customer may need to submit documentation (also known as: SVIs) in order to verify their SEP. With SEP enrollments, an agent’s true challenge is keeping track of these SVI follow-up documents.

Through your HealthSherpa account, you can see the SEP verification documents needed for all your clients, view a list of acceptable documents, upload documents, and see whether documents have been approved. Find more directions on uploading follow-up documents here.

As an example, if you needed to verify income for a hypothetical client, you would see this in their Client Profile:

After clicking the ‘Verify’ button, you would be taken to a page where you can upload the appropriate documentation for the client.

This page also includes information about what documents satisfy the ‘Verify income’ requirement.

This is one small way the HealthSherpa account saves time for agents. To see a full list of acceptable documents for SEP verification, click here.

NEW SEP Category for ≤150% FPL

Starting late March 2022, agents can enroll eligible clients through the new 150% Federal Poverty Level (FPL) SEP category. For Marketplace coverage, eligibility is based on the previous year’s FPL chart.

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.

Are there plan category limitations for existing clients?

Yes. Existing clients will only be able to switch to plans in their current metal tier or silver.

As an example, if they are enrolled in a bronze plan, they can enroll in a bronze or silver plan but could not enroll in a gold one.

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.

Will anything be different in HealthSherpa for this SEP?

There will be one noticeable change in the quoter. If you enter an income in the qualifying range, you will skip the “SEP reasons” step shown below.

All of the questions in the application will remain the same. The application will automatically detect the SEP for clients with qualifying income, so you do not need to mark anything in the Upcoming/Recent Changes section for your client to receive this SEP.

How will I know my client received this SEP?

After submitting a client’s application, you will see that they received the SEP “due to estimated household income (≤150% FPL)” on the eligibility results page.

There also may be a data-matching issue (DMI) for your client to resolve to prove their income. Learn more about DMIs here.

How long will this SEP last?

For now, this SEP only exists for this year. It will only be extended if ARPA subsidies are extended. With ARPA subsidies, most clients who are eligible for this SEP can enroll in free silver plans.

Want to learn more?

Read more information about this new SEP category from CMS.

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