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Thursday, April 14, 2016

CMS Updates: Coverage Gap Special Enrollment Periods, Hardship Exemptions, and More

Kara Nester

Policy Analyst

Earlier this week, CMS offered welcome clarification on special enrollment periods (SEP) for people in the coverage gap. It also issued updates about eligibility determination notices and hardship exemptions. We explain the updates below.

Coverage gap special enrollment period clarified

On Wednesday, CMS clarified the procedure for the special enrollment period (SEP) for consumers who move out of the “coverage gap.” People who are in the coverage gap live in states that have not expanded Medicaid.

They neither qualify for Medicaid nor for financial assistance to get coverage through the marketplace. The SEP enables these people to apply for coverage when their income changes, making them newly eligible for marketplace coverage with financial assistance.   

CMS tips for making sure consumers can get this SEP: CMS instructed those who qualify for this SEP to:

  • Complete a marketplace application THEN call the marketplace call center to request the SEP. 
  • A representative will then verify that the consumer is eligible for financial assistance and will forward the application to confirm their eligibility for the SEP. 
  • After the application is forwarded, the review should be complete within 10 business days or 15 calendar days. The applicant can expect a letter from the marketplace after this timeframe with instructions to return to the application if they qualify for the SEP. 
  • To help ensure that marketplace representatives recognize this SEP, CMS recommends that assisters use this language when speaking to the call center about an eligible applicant: 

“They were previously ineligible for Medicaid because they live in a non-Medicaid expansion state. And they were previously ineligible for APTC because their income was too low, but they have now experienced an increase in household income that makes them newly eligible for APTC.” 

  • After speaking with the call center and having the applicant’s application forwarded, we recommend periodically checking the status of the application because several assisters have reported having the SEP verified prior to being notified by the marketplace. 

As always, if you hear about issues with this process, please email us at

More eligibility determination notices will now include income

Applicants applying for coverage through the federally facilitated marketplace who do not qualify for financial assistance or for Medicaid/CHIP will now receive eligibility notices that include the income used to calculate their eligibility. The income used will be reported under the section “Why don't I qualify for other programs?” which is typically on page 2 of the notice document. 

  • Tip to assisters: Be sure that the correct income was used for these calculations and the correct determination was made by the marketplace. 

Hardship exemptions and catastrophic coverage

CMS clarified that people who qualify for a hardship exemption and choose catastrophic coverage must enroll in that coverage during open enrollment. This is the process to follow unless these people are also eligible for a special enrollment period

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