Millions of low-income Americans eligible for $0-premium "Secret Platinum" coverage via new Special Enrollment Period!

Tue, 03/22/2022 - 8:50am

Way back in the summer of 2020, then-Presidential candidate Joe Biden rolled out his official healthcare policy proposal. Part of the plan included the following:

Expanding coverage to low-income Americans. Access to affordable health insurance shouldn’t depend on your state’s politics. But today, state politics is getting in the way of coverage for millions of low-income Americans. Governors and state legislatures in 14 states have refused to take up the Affordable Care Act’s expansion of Medicaid eligibility, denying access to Medicaid for an estimated 4.9 million adults.

Biden’s plan will ensure these individuals get covered by offering premium-free access to the public option for those 4.9 million individuals who would be eligible for Medicaid but for their state’s inaction, and making sure their public option covers the full scope of Medicaid benefits. States that have already expanded Medicaid will have the choice of moving the expansion population to the premium-free public option as long as the states continue to pay their current share of the cost of covering those individuals.

Needless to say, the "public option" still hasn't materialized, and the Medicaid Gap population is still in limbo thanks to all 50 Republican Senators + Dem Senator Joe Manchin blocking the Build Back Better bill passed by the House last fall.

However, the Biden Administration has managed to make comprehensive healthcare coverage extremely affordable for millions of other low-income Americans thanks to a combination of the American Rescue Plan and regulatory authority by the Health & Human Services (HHS) Department.

The 4.9 million figure cited above actually includes two populations: Around 2.2 million fall into the "Medicaid Gap;" these are the people who earn less than 100% of the Federal Poverty Level (FPL) in 11 states which have refused to expand Medicaid under the ACA (since summer 2020, Oklahoma & Missouri have expanded Medicaid thanks to statewide ballot initiatives, while Wisconsin hasn't expanded Medicaid up to the 100% FPL threshold via the ACA but partly expanded its traditional Medicaid program).

The rest of this population are people who earn between 100 - 138% FPL living in those 12 states (including Wisconsin). These folks aren't eligible for Medicaid as they were supposed to be under the ACA, but they are eligible to enroll in ACA exchange policies with maximum financial assistance.

Until 2021, ACA enrollees falling into this category had to pay about 2.1% of their household income in premiums for a benchmark Silver ACA policy. For a single adult earning $17,000/year, for instance (133% FPL), this came to around $360/year or $30/month; for a family of 4 earning $35,000/year this was roughly $61/month or $740/year.

Thanks to the American Rescue Plan, however, for 2021 and 2022, any ACA enrollee earning less than 150% FPL has to pay...nothing in premiums. As in, zero dollars for the benchmark Silver ACA plan; zilch. They still have some nominal cost sharing in the form of a small deductble & co-pays, but the premiums themselves cost them nothing. I refer to this as Secret Platinum, because for this population, the healthcare policies are technically labeled as "Silver" but are effectively "Platinum" in terms of how comprehensive the coverage actually is in practice.

The only catch, of course, is that currently the $0-premium cost status for lower-income enrollees is set to expire as of the end of 2022 unless Congress is able to convince Sen. Manchin and/or at least one Republican Senator to extend it.

Millions of Americans have taken advantage of the enhanced/expanded tax credits available under the American Rescue Plan, helping make the 2022 Open Enrollment Period the most successful in the ACA's history. The official 2022 OEP ended on January 15th in most states, and normally anyone who didn't enroll by that deadline would be out of luck until 2023 unless they experience a Qualifying Life Experience (QLE) such as losing their current healthcare coverage, moving, getting married/divorced, having a child and so forth.

The good news, however, is that the Centers for Medicare & Medicaid Services (CMS) has launched a new Special Enrollment Period specifically for Americans who earn less than 150% FPL:

...CMS will offer a time-limited, monthly Special Enrollment Period (SEP) for APTC-eligible consumers with a projected household income at or below150% of the FPL (herein referred to as the “150% SEP”). This SEP will be available to consumers in states that operate under the Health Insurance Marketplace® and use HealthCare.gov. State-based Marketplaces (SBMs) that operate their own eligibility and enrollment platforms also have the option to offer this SEP. Consumers can use the SEP Screener tool at HealthCare.gov/screener for help determining if they are eligible for the 150% SEP.

Q2: When can consumers access this 150% SEP?

A2: From March 18, 2022 through December 31, 2022, APTC-eligible consumers with expected household incomes at or below 150% of the FPL can get the 150% SEP by submitting a new application or updating an existing one themselves online at HealthCare.gov, or with the help of an enhanced direct enrollment (EDE) partner, a traditional direct enrollment (DE) partner that supports SEPs, or the Marketplace Call Center. November 30, 2022 is the last day to confirm having an expected household income at or below 150% FPL and select a plan for plan year 2022 coverage that starts December 1, 2022.

Q3: How long can consumers select a plan?

A3: Unlike most other life event based SEPs, the 150% SEP doesn’t have a deadline. In other words, consumers qualify as long as they’re APTC-eligible and have an expected household income that does not exceed 150% FPL. However, consumers must select a plan before the end of the calendar month they submit or update their application for their coverage to start on the first of the next month. For example, no matter if a consumer submits a new or updated application on April 1 or April 16, they’ll have until April 30th to choose a plan for coverage that starts May 1st.

Q4: How can consumers get this new 150% SEP?

A4: In Marketplaces that use HealthCare.gov, APTC-eligible consumers with a household income at or below 150% FPL can submit a new application, or update an existing application online themselves or with the help of an EDE partner, a DE partner that supports SEPs, or the Marketplace Call Center. The application automatically determines consumers’ eligibility for the 150% SEP. Throughout plan year 2022, consumers eligible for this SEP are also generally eligible for free or low-cost plans with very low deductibles and out-of-pocket costs.

Q5: Will consumers have to go through the SEP pre-enrollment verification process or submit additional documents to qualify for the 150% SEP?

A5: No. Consumers who qualify for the 150% SEP don’t need to submit documentation to confirm their SEP eligibility. CMS notes that consumers with open or new data matching issues (DMI) are still required to submit documentation to the Marketplace to keep their financial help. Finally, as eligibility for the 150% SEP requires that consumers be APTC-eligible with a projected household income at or below 150% of the FPL, CMS notes that is it important that consumers return to their application as soon as possible to report any changes in their household or income as it may impact their 150% SEP eligibility.

Q6: Can a consumer change plans more than once under the 150% SEP?

A6: Yes, once per month, as long as the consumer maintains APTC-eligibility and a projected household income at or below 150% FPL. While consumers may change plans monthly during this opportunity, they (and their household), may be subject to certain plan category limitations. Also, CMS notes that it may cost consumers more to change plans more than once during the current 2022 plan year because their annual deductible amounts, cost-sharing, or other out-of-pocket expenses may reset.

Q7: Does this announcement of the new monthly 150% SEP for plan year 2022 also apply to State-Based Marketplaces (SBMs) that operate their own eligibility and enrollment platforms?

A7: SBMs that operate their own eligibility and enrollment platforms can offer this monthly SEP for their enrolled populations per federal regulation at 45 CFR 155.420(d)(16). Consumers in SBM states should check with their state to find out if they’re offering this SEP and any next steps.

Q8: What will issuers and direct enrollment partners need to do to appropriately process the consumers through this new 150% SEP?

A8: Issuers should be prepared to support the processing of enrollment transactions, known as “834” transactions, for this SEP. These enrollment transactions contain the SEP reason code of “FC.” Direct enrollment partners (both EDE and DE Classic Partners) may also have additional preparation activities in place related to consumer screener questions and consumer plan display pages.

The truth is that while HealthCare.Gov just launched the new 150% SEP a few days ago, several of the 18 state-based ACA exchanges have had theirs live for some time, including:

California: Covered CA
Colorado: Connect for Health CO
Maine: CoverME
New Jersey: Get Covered NJ
In fact, their income-based SEP is open to enrollees earning up to 200% FPL, not 150%.
Pennsylvania: Pennie
Rhode Island: Health Source RI

There's several states where they haven't technically launched the 150% SEP but it's moot anyway:

District of Columbia: Adult DC residents earning up to 215% FPL are eligible for Medicaid year-round.
Massachusetts: MA residents earning up to 300% FPL are eligible for ConnectorCare plans year-round...but only if your'e newly-eligible or haven't previously applied.
Minnesota: MN residents earning up to 200% FPL are eligible for MinnesotaCare year-round.
New York: NY residents earning up to 200% FPL are eligible for the "Essential Plan" year-round.

Finally, here's the states which either haven't launched the 150% SEP yet or, if they have, I can't seem to find any documentation of that on their websites: