New Opportunity for Residents in States That Are Not Expanding Medicaid to Get Covered

By Zachary Baron

As many of our readers know, enrollment in Medicaid and the Children’s Health Insurance Program is open year-round, and people experiencing “qualifying life events” may be able to get a Special Enrollment Period (SEP) to sign up for marketplace coverage outside of open enrollment.

But here’s what’s new, starting this week: As of April 28, 2015 (you can see all the details in this recent regulation at section 155.420), consumers in the Medicaid “coverage gap” will have an easier time accessing an SEP if they have an increase in income that makes them eligible for financial help through the marketplace!

Who does the new opportunity apply to?

  • Consumers who were previously ineligible for Medicaid solely because their state did not expand Medicaid eligibility (regardless of whether or not they applied for coverage before); AND who
  • Experienced a change in household income such that they are newly eligible for financial help (annual income of at least 100 percent of the federal poverty level for 2014, $11,670 for an individual and $23,850 for a family of four).

Consumers must call the marketplace call center at 1-800-318-2596 to see if they can get this SEP. If granted an SEP, consumers will have 60 days from the date they experienced a change in income to select a plan through the marketplace.

In addition to contacting the call center, people who have questions about whether they might be able to enroll in coverage now should work with an in-person assister to understand their options.

We are very pleased to see the Centers for Medicare and Medicaid Services improve upon its previous guidance that required consumers to have previously applied for and been denied by their state’s Medicaid agency to be able to access this SEP. This is a positive step towards streamlining the consumer experience and will help even more people gain affordable and comprehensive coverage outside the open enrollment period.

As we’ve outlined in previous recommendations, we look forward to continuing to work with federal policymakers to build on this progress. We are thankful that more people have an opportunity to get covered, and hope to see more consumer-friendly policy changes implemented to ensure that consumers who are not current marketplace enrollees but who experience a significant life event are able to gain access to coverage through an SEP without having to jump through unnecessary hoops.

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