2018 CMS Medicare Marketing Guidelines (8-01-2017)

The 2018 CMS Medicare Marketing Guidelines have been released for implementation. While many things remain the same, it is important to keep track of new regulations or new interpretation of those regulations. We will continue to review the new materials and carrier requirements to keep you informed.

The first section to note is regarding Educational and Marketing Events. This can impact agents as the carriers comply with the regulation, they will require agents to keep more records. You can find this change in section 70.4.1 Educational and Marketing Events. This sections states that while Plan Sponsors are not required to upload educational or marketing events into HPMS, they must keep accurate records of all events. At this point only some carriers currently require agents to report marketing events; we expect to see some additional guidance on this from other carriers as they implement their standards.

The second section relate to Third Party Websites. It is in the section titled 100.7 Third-Party Websites (this section is new). It addresses third-party websites. As agents, we are typically the third party. The new regulation states “…that third-party websites with which the Plan/Part D Sponsor contracts does not:

  • Provide misleading information, such as identifying a Medicare Supplement plan as a Medicare Advantage plan; or
  • Use prohibited terminology, including unsubstantiated absolute superlatives.

It is very important to note that as an agent/agency /Third-party, our websites may request, but not require, health status information.”

The third section clarifies the section 120.4.1 General Rules Regarding Compensation. CMS emphasizes and strengthens the language about a concept that most of us are familiar with. The regulation states that Plan Sponsors “may not pay agents/brokers who have not been trained and tested.” The training and testing referred to is the completion of the required certification and training.

CONGRESS NEWS (6-23-2017)

There is much commotion regarding“ American Healthcare Act” or “World’s Greatest Healthcare Plan of 2017” “Trumpcare” or whatever it is going to be called. The prospects and customers that we will deal with as agents can be very confused and want answers from you. The attached link is to the unaltered, commented on or highlighted text or the Healthcare Bill. The text is the introduction to the bill.
The first thing to remember is that it is not law yet. The bill has to go through the legislative process and more updates are coming.

1st Session
H.R. 1275

To eliminate the individual and employer health coverage mandates under the Patient Protection and Affordable Care Act, to expand beyond that Act the choices in obtaining and financing affordable health insurance coverage, and for other purposes.


March 1, 2017

Mr. SESSIONS introduced the following bill; which was referred to the Committee on Energy and Commerce, and in addition to the Committees on Ways and Means, and Education and the Workforce, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned


To eliminate the individual and employer health coverage mandates under the Patient Protection and Affordable Care Act, to expand beyond that Act the choices in obtaining and financing affordable health insurance coverage, and for other purposes.

Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,


(a) SHORT TITLE.—This Act may be cited as the “World’s Greatest Healthcare Plan of 2017”.
(b) PURPOSES.—The purposes of this Act are as follows:
(1) ELIMINATION OF INDIVIDUAL AND EMPLOYER MANDATES UNDER ACA.—To eliminate mandates on individuals and employers, and other tax requirements, imposed under Patient Protection and Affordable Care Act.
(2) PROVIDING STATES WITH ALTERNATIVE, AFFORDABLE COVERAGE OPTIONS.—To provide greater flexibility in providing States with options in making affordable health insurance coverage available by eliminating certain mandates under PPACA, while retaining essential consumer protections, by promoting health savings accounts to pay for such coverage and long-term care coverage, while permitting States to continue coverage as provided under PPACA.
(c) TABLE OF CONTENTS.—The table of contents of this Act is as follows:

Sec. 1. Short title; purposes; table of contents.
Sec. 2. Definitions.

Sec. 101. Repeal of individual health insurance mandate.
Sec. 102. Repeal of employer health insurance mandate.
Sec. 103. Clarifying employer’s ability to reimburse employee premiums for purchase of individual health insurance coverage.

Subtitle B—Limitation On Application Of PPACA Plan Requirements

Sec. 121. Limiting application of requirements to consumer protections.
Sec. 122. Offering of basic health insurance; protection of assets from liability or attachment or seizure.
Subtitle C—Health Insurance Tax Benefit

Sec. 131. Health insurance tax benefit.
Sec. 132. Application of portion of unused tax credits by States for indigent health care.
Sec. 133. Medicaid option of enrollment under private plan and contribution to an HSA.

Sec. 201. Transition to non-deductible HSAs.
Sec. 202. Elimination of medical expense deduction.
Sec. 203. Treatment of HSA after death of account beneficiary.
Sec. 204. Treatment of concierge medicine.

Sec. 301. State flexibility in regulation of health insurance coverage.

Sec. 401. Medicaid payment reform.


Have you ever been confronted with the question about whether a prescribed drug is covered under Part B? A good place to start is the information that CMS has provided to help agents guide Medicare beneficiaries through the investigation process.

Prescription drugs (outpatient)

How often is it covered?

Medicare Part B (Medical Insurance) generally doesn't cover most prescription drugs used at home, but it does cover a limited number of outpatient prescription drugs under limited conditions. Generally, drugs covered under Part B are drugs a beneficiary wouldn't usually give to themselves, like those they get at a doctor's office or hospital outpatient setting. Drugs not covered under Part B may be covered under a Medicare Prescription Drug Plan (Part D). If the beneficiary has Part D, check their plan's formulary to see what outpatient drugs are covered. Examples of drugs covered by Part B:

  • Drugs used with an item of durable medical equipment: Medicare covers drugs infused through an item of durable medical equipment, like an infusion pump or drugs given by a nebulizer.
  • Some antigens: Medicare helps pay for antigens if they're prepared by a doctor and given by a properly instructed person (who could be the patient) under appropriate supervision.
  • Injectable osteoporosis drugs: Medicare helps pay for an injectable drug for women with osteoporosis who meet the criteria for the Medicare home health benefit and have a bone fracture that a doctor certifies was related to post-menopausal osteoporosis. A doctor must certify that the woman is unable to learn how to or unable to give herself the drug by injection. The home health nurse or aide won't be covered to provide the injection unless family and/or caregivers are unable or unwilling to give the woman the drug by injection.
  • Erythropoisis–stimulating agents: Medicare helps pay for erythropoietin by injection if the beneficiary has End-Stage Renal Disease (ESRD) or needs this drug to treat anemia related to certain other conditions.
  • Blood clotting factors: If the beneficiary has hemophilia, Medicare helps pay for clotting factors they give themselves by injection.
  • Injectable and infused drugs: Medicare covers most injectable and infused drugs given by a licensed medical provider.
  • Oral End-Stage Renal Disease (ESRD) drugs: Medicare helps pay for some oral ESRD drugs if the same drug is available in injectable form and covered under the Part B ESRD benefit.
  • Parenteral and enteral nutrition (intravenous and tube feeding): Medicare helps pay for certain nutrients for people who can't absorb nutrition through their intestinal tracts or can't take food by mouth.
  • Intravenous Immune Globulin (IVIG) provided in the home: Medicare helps pay for IVIG for people with a diagnosis of primary immune deficiency disease. A doctor must decide that it's medically appropriate for the IVIG to be given in the patient's home. Part B covers the IVIG itself, but Part B doesn't pay for other items and services related to the patient getting the IVIG in his or her home.
  • Shots (vaccinations):
    • flu shots
    • Pneumococcal shots
    • Helatitis B shots
    • Other shots: Medicare helps pay for some other vaccines when they're directly related to the treatment of an injury or illness.
  • Transplant drugs (also called immunosuppressive drugs): Medicare covers transplant drug therapy if Medicare helped pay for the beneficiaries’ organ transplant. (Part D may cover other transplant drugs not covered by Part B, even if Medicare didn't pay for the transplant. If they have ESRD and Original Medicare, they may join a Medicare drug plan.)
    • If the beneficiary is entitled to Medicare only because of permanent kidney failure, their Medicare coverage will end 36 months after the month of the transplant. Medicare won't pay for any services or items, including transplant drugs, for patients who aren't entitled to Medicare.
    • Medicare will continue to pay for their transplant drugs with no time limit if the beneficiary meets either of these conditions:
      • They were already entitled to Medicare because of age or disability before they got ESRD.
      • They became entitled to Medicare because of age or disability after getting a transplant that was paid for by Medicare, or paid for by private insurance that paid primary to their Medicare Part A (Hospital Insurance) coverage, in a Medicare-certified facility.
      • Note

        Transplant drugs can be very costly. If the beneficiary is worried about paying for them after their Medicare coverage ends, the beneficiary may talk to their doctor, nurse, or social worker. There may be other ways to help them pay for these drugs.

  • Oral cancer drugs: Medicare helps pay for some oral cancer drugs taken by mouth if the same drug is available in injectable form or is a prodrug of the injectable drug. A prodrug is an oral form of a drug that when ingested breaks down into the same active ingredient found in the injectable form of the drug. As new oral cancer drugs become available, Part B may cover them.
  • Oral anti-nausea drugs: Medicare helps pay for oral anti-nausea drugs used as part of an anti-cancer chemotherapeutic regimen. The drugs must be administered immediately before, at, or within 48 hours after chemotherapy, and must be used as a full therapeutic replacement for an intravenous anti-nausea drugs.
  • Self-administered drugs in hospital outpatient settings: Medicare may pay for some self-administered drugs, like drugs given through an IV, if the beneficiary needs them for the hospital outpatient services they are getting.
  • Who's eligible?

    All people with Part B are covered under limited conditions.

    Costs in Original Medicare
  • For covered Part B prescription drugs the beneficiary gets in a doctor’s office or pharmacy, they pay 20% of the Medicare-approved amount, and the Part B deductible applies. They must accept assignment for Part B drugs, so the beneficiary should never be asked to pay more than the coinsurance or copayment for the drug itself.
  • For covered Part B prescription drugs the beneficiary gets in a hospital outpatient setting, the beneficiary pays a copayment. If they get drugs not covered under Part B in a hospital outpatient setting, they pay 100% for the drugs, unless they have Part D or other prescription drug coverage; what the beneficiary pays depends on whether their drug plan covers the drug, and whether the hospital is in their drug plan’s network.

  • For specific information, it is always best to check with the Part D plan being considered or contact CMS.

    Correspondence from CMS (4/21/17)

    CMS regulations are designed to level the playing field and to maintain the integrity of the program(s). There are times that as agents, we become aware of obscure regulations and/or CMS practices. One such CMS practice is that CMS sends out specific mailings at specific times. CMS even color codes some of the correspondence. As an agent, it is important to know what the mailings are and when they are sent out.

    An example of one such mailing is due to be sent out in May 2017. This mailing to consumers informs people who may be eligible for Medicare Savings Programs (MSPs) about MSPs and the Extra Help available for Medicare prescription drug coverage.

    For more information about CMS Consumer mailings throughout the year, click on the link below.


    Click here to download and view CMS Consumer mailings

    PPACA OEP is underway!... (11/01/16)

    PPACA OEP is underway. There was a new requirement that was introduced during FFM training. The Individual Marketplace and SHOP Privacy & Security Agreements require all agents and brokers to ensure openness and transparency about policies, procedures, and technologies that directly affect consumers’ PII. AHIA, LLC has drafted a Privacy Notice Statement for you to use.

    As a reminder PII is any information that can be used to distinguish or trace a consumer’s identity (e.g., his or her name, Social Security Number, biometric records) alone or when combined with other personal or identifying information that is linked or linkable to a specific consumer (e.g., date of birth, place of birth, mother’s maiden name).

    Click here to download and view Affordable Care Act Privacy Notice Statement

    ACA SECTION 1557 REGULATION... (10/06/16)

    The U.S. Department of Health and Human Services (HHS)/Office of Civil Rights issued a Final Rule implementing Section 1557 of the Affordable Care Act (ACA). The new regulations prohibit discrimination on the basis of race, color, national origin, sex, age, or disability in certain health programs and activities. The law establishes new protections and applies to any health programs funded by HHS, including Medicare Advantage, Medicare Part D, and the Marketplace. The law strictly prohibits discrimination on the basis of sex, pregnancy, false pregnancy, termination of pregnancy, or recovery therefrom, childbirth or related medical conditions, sex stereotyping and gender identity.

    Each carrier has instituted their own requirements and are part of the carrier training/communications. I have provided the United HealthCare agent communication and link as an example. Please make sure to check with the carriers that you contract with in order to stay compliant.

    Click here to download and view UnitedHealthcare new Requirement 10.

    Dear Valued Business Partners,

    We are reaching out to you today regarding new requirements mandated by UnitedHealthcare (UHC) relating to: Informal Sales Events, Formal Sales Events, Scope of Appointments, and Business Reply Cards.

    New Required Disclaimer For Display at UHC - only Sales Meetings

    Effective immediately, a new disclaimer (see attached pdf file) must be displayed at any UnitedHealthcare-exclusive formal or informal marketing/sales event (e.g., community meeting / kiosk). Please print the attached pdf and display at your UHC-only sales meetings until the new tabletop displays are ready.

    NOTE: This disclaimer requirement only applies to sales events where UnitedHealthcare is the only carrier being presented. If you are presenting multiple carriers at your sales events, this disclaimer requirement does not apply to those events.

    UnitedHealthcare will provide tabletop displays of this new disclaimer in the near future via the UHC Agent Toolkit path detailed below. Once you receive the tabletop, please use the tabletop instead of pdf printout.

    New UHC Scope of Appointment and Business Reply Cards

    UnitedHealthcare has also updated their Scope of Appointment (SOA) and Business Reply Cards (BRCs). Updated versions of SOA’s and BRC’s were scheduled to be available on the Agent Toolkit by the end of the day Friday, September 30. Please begin using these new SOA’s and BRC’s for all UHC sales efforts as soon as possible.

    To access the Agent Toolkit, use the login information provided previously by UHC and use the following path:

    Agent Toolkit Path

    English Material > Community Meeting and Event Marketing Materials > Presentations and Workbooks > Workbooks

    If you have any questions, please contact the Producer Help Desk at phd@uhc.com. If you have compliance questions, please email compliance_questions@uhc.com and be sure to include your full name, contact information and writing number. More information


    Golden Outlook Agent Engagement Team

    Pre-AEP Do's and Dont's... (10/04/16)

    The Annual Election Period is soon to begin. This is a great time to help current clients and prospects make sure that their needs are met for the following benefit year. This is also a time of year when you as an agent must be aware and proficient in balancing the knowledge and use of current year and upcoming year regulations and benefits.

    Although much of what is in this article is common knowledge, it is important to review and have as a reference just in case there is a question. The following is from the Medicare Advantage Enrollment and Disenrollment Manual. I have included the whole regulation; much of what is written is for carriers. Please keep in mind that carriers may have more restrictive regulations than what Medicare requires. It is important that you are aware of what each one of the carriers that you represent requires of you. Carriers will not accept paper applications from agents during Pre AEP and the submission of an AEP application will result in an investigation. It is very important to remember that if beneficiaries that have an IEP or SEP can be submitted as normal.

    Special Rule for the Annual Election Period (AEP):

    Medicare Advantage (MA) organizations may not solicit submission of paper enrollment forms or accept telephone or on-line enrollment requests prior to the beginning of the AEP. Brokers and agents under contract to MA organizations may not accept or solicit submission of paper enrollment forms prior to the start of the AEP. MA organizations and their brokers and agents also should remind beneficiaries that they cannot submit enrollment requests prior to the start of the AEP. Despite these efforts, CMS recognizes that MA organizations may receive unsolicited paper enrollment forms prior to the start of the AEP, given that marketing activities may begin prior to this date. To be considered unsolicited, the MA organization must have received the paper AEP enrollment request directly from the applicant and not through a sales agent or broker. Other enrollment request mechanisms may not be accepted prior to the actual start of the AEP. Paper AEP enrollment requests received prior to the start of the AEP for which there is indication of sales agent or broker involvement in the submission of the request (i.e., the name or contact information of a sales agent or broker) must be investigated by the organization for compliance with the requirements in the Medicare Marketing Guidelines. If an MA organization receives unsolicited paper enrollment forms on or after October 1st but prior to the start of the AEP, it must retain and process them as follows:

    • Within 7 calendar days of the receipt of a paper enrollment request, the MA organization must provide the beneficiary with a written notice that acknowledges receipt of the complete enrollment request, and indicates that the enrollment will take effect on January 1 of the following year (refer to Exhibits 4, 4a, 4b and 4c for model notices).
    • For AEP enrollment requests received prior to the start of the AEP, the MA organization must submit all transactions to CMS systems (MARx) on the first day of the AEP with an “application date” of the same date. For example, unsolicited AEP paper enrollment requests received October 1 through October 14 must be submitted on October 15th with an “application date” of October 15th of the current year in the appropriate data field on the enrollment transaction. If a beneficiary has submitted more than one AEP paper enrollment request prior to the start of the AEP, the beneficiary will be enrolled in a plan based on the first application that is processed.
    • Once the MA organization receives a MARx TRR from CMS indicating whether the individual’s enrollment has been accepted or rejected, it must meet the remainder of the requirements (e.g., sending a notice of the acceptance or rejection of the enrollment within 10 calendar days following receipt of the TRR from CMS) provided in §40.4.2. Note: If organizations receive incomplete unsolicited AEP paper enrollment requests prior to the start of the AEP, they must follow existing guidance for working with beneficiaries to complete the applications (refer to §40.2.2). Again, this policy applies only to the receipt of unsolicited paper enrollment forms prior to the beginning of the AEP. To help ensure a successful AEP season, it is imperative that organizations follow these steps and submit valid enrollment transactions promptly as directed.

    AHIP Certification... (8/15/16)

    It is that time again. The AHIP certification is in full swing. AHIP has combined the Marketing Medicare Advantage, Compliance and Fraud, Waste and Abuse requirements into a single modular course. The comprehensive online program gives you the background to make informed decisions on Medicare, including plan options, marketing, enrollment requirements, and FWA guidelines. The courses cover the following:

    Fraud Waste Abuse


    The basics of Medicare fee-for-service eligibility and benefits.
    The different types of Medicare Advantage and Part D prescription drug plans
    Eligibility and coverage
    Marketing and enrollment under the Medicare Advantage and Part D program requirements

    Fraud, Waste & Abuse (FWA)

    How to identify FWA
    An overview of the industry efforts in detecting fraud
    Legal tools to combat FWA
    Understand both the human and financial cost of FWA
    Review CMS FWA training requirements
    Who commits FWA
    Reporting FWA; loopholes and obligations

    There is a cost for the AHIP and some carriers are offering discounts for the AHIP certification. We have done the research and the carriers are listed below with the discount or reimbursement that is offered.

  • Aetna $50.00 Discount
  • BC/BS $50.00 Discount
  • Cigna $125.00 Reimbursement
  • Humana $50.00 Discount
  • UHC $50.00 Discount
  • Wellcare $50.00 Discount

  • Remember that most carriers require you to access AHIP through their online portal or hyperlink. Carriers will also have their carrier/product specific training that you must complete.

    Don’t miss out… get your certification done so that you can take advantage of the selling season.

    Customer PHI Data Breach... (7/04/16)

    What happens if you are responsible for the unauthorized dissemination of a customer's PHI? You may be subject to penalties imposed by federal law up to $1Million per incident. Here are a few DO's and DON'Ts regarding sensitive member or consumer information:

    Handling sensitive member or consumer information


  • Double check the email address, fax number, etc. to ensure the intended recipient receives the document
  • Schedule a meeting in a more non-public area, such as their home or your private office space
  • Report if your laptop (encrypted or unencrypted) has been lost or stolen
  • Ensure your laptop, hard copy documents and/or other electronic devices are with you at all times
  • Shred documents containing PHI
  • Carry the necessary documents needed in a locked briefcase or folder

  • DON'Ts

  • Send an email, fax or hard copy document containing information to someone other than the intended recipient
  • Discuss information in public settings, such as in a restaurant or an elevator
  • Assume that your lost or stolen laptop is not considered to be unauthorized/inappropriate disclosure
  • Leave your laptop, hard copy documents and/or other electronic devices in your car
  • Throw away hard copy documents in the trash
  • Expose documents in an open common area, such as the front or backseat of the car

  • Informing Consumers About Health Appeals... (5/24/16)

    The Affordable Care Act ensures a consumer’s right to appeal health insurance plan decisions, including asking that an issuer reconsider its decision to deny payment for a service or treatment, or to rescind coverage.


    The Centers for Medicare & Medicaid Services (CMS) has released a new resource that describes:

  • What issuer decisions can be appealed
  • How long consumers have to initiate appeals
  • How consumers must document and submit appeals
  • How consumers can request an expedited appeal timeline in urgent care situations
  • When and how to request an external review by state or federal authorities

  • These appeal rights and processes apply to consumers enrolled in non-grandfathered qualified health plans through a Health Insurance Marketplace.

    Please see the “Internal Claims and Appeals and External Review Processes Overview” resource slides for more information. You can also link to these slides from the Agents and Brokers Resources webpage, which provides other resources to help you assist consumers in making use of their health coverage.

    Medicare Lock-In News (3/15/16)

    During this time of Lock In, it can be difficult to focus on Medicare Beneficiaries as prospects. It is important to have all the facts in order to take advantage of opportunities that present themselves.


    Please review the following to make sure that you have the latest information:

    For income levels, see the 2016 federal poverty level guidelines at:
    Poverty Guidelines

    See the Medicaid.gov webpage that details the 2016 Dual Eligible Standards for the Medicare Savings Programs, available at:
    2016 Dual Eligible Standards for the Medicare Savings Programs

    See the Medicare.gov webpage that details Medicare costs in 2016, available at: Medicare Cost At A Glance

    See the Programs and Operations Manual System (POMS) from Social Security for the LIS/Extra Help (and therefore, the MSP resource levels) asset levels for 2016.

    Alignment of License Expiration Dates (3/1/16):

    When was the last time that you checked your license expiration date?
    You might be in for a surprise.


    One agent was set to have his license expire the middle of April 2016. After checking the tdi.texas.gov website, he found that his license expiration was extended and would not expire until almost a year later. You may be in for a pleasant surprise as well.

    This is all due to recent 84th Legislative Session Licensing Updates ( SB876) that are designed to align license expiration dates. The following is from the TDI website.

    To assist license holders with maintaining their licenses and simplify the license renewal process, SB 876 required TDI to align all individual and entity licenses as follows:

  • 1. The expiration date for individual licensees that hold only one license will be extended to the individual’s next birthday after the licenses current expiration date.

  • 2. The expiration date for individual licensees that hold more than one license will be extended to the individual’s next birthday after the latest expiration date of any existing license held.

  • 3. For entities that hold only one license, there will be no change in the expiration date of the license.

  • 4. For entities that hold more than one license, the license expiration date for all licenses held will be extended to the latest expiration date of any existing license held.

  • The alignment of license expiration dates to an individual licensee’s birth month and birth day, without a pending renewal, has been implemented for licenses expiring on or after January 1, 2016. No additional continuing education hours will be required for any extended periods provided, as part of the implementation of the alignment.

    The expiration date of any renewals pending on January 14, 2016, will be aligned as they renew. Going forward, any new license issued to a license holder will have an initial period that aligns its expiration date to the same expiration date of licenses already held.

    TDI will not be providing updated copies of existing licenses reflecting the new expiration dates. The new license expiration dates may be viewed as early as January 19, 2016 at: TDI Insurance Licensing Search and Renewal.

    OEP is almost done... (1/14/16)

    OEP is almost done... and now is the time to start preparing for potential opportunities outside of the OEP. Take some time to review these life events that can extend your selling season.


    Common Special Enrollment Periods (SEP) Enrollment Windows

    Not all special enrollment periods are the same length. Some life events trigger a special enrollment period, some trigger a hardship exemption, some trigger shorter periods with no exemption, and some only trigger the ability to purchase outside of open enrollment. Below are common qualifying life events and enrollment windows. See full lists of qualifying events below.

    NOTE: You can apply early to ensure your coverage starts on the day you would lose coverage. Even though you can enroll before the Special Enrollment window, your coverage won’t start until the day of the event or denial.

  • Losing other health coverage. From 60 days before to 60 days after losing your other coverage

  • Being Denied Medicaid or CHIP. Up to 60 days after the denial.

  • Getting Married. Up to 60 days after the event.

  • Having a baby, adopting a child, or placing a child for adoption. Up to 60 days after the event.

  • Having a change in income or household status that affects eligibility for premium tax credits or cost-sharing reductions (if already enrolled in coverage). Only triggers special enrollment if it’s not open enrollment. Up to 60 days after the event.

  • Moving, gaining citizenship, leaving incarceration. Only triggers special enrollment if it’s not open enrollment. Up to 60 days after the event.

  • Employer special enrollment. Employer special enrollment periods typically last 30 days. If moving from a Marketplace plan, make sure to avoid gaps in coverage or overlapping coverage.

  • Hardship Exemptions and Enrolling in the Marketplace. Most hardship exemptions and even the act of simply enrolling in the Health Insurance Marketplace trigger a 60 day special enrollment window. Even more incentive to sign up during open enrollment or apply for a hardship exemption, even if you don’t have time to enroll properly.
  • While not a hardship exemption, it’s worth noting that you are allowed a coverage gap of less than 3 months each year. That covers two full months. For any other month, you’ll need to have coverage for at least one day of the month to avoid the fee unless you qualify for an additional exemption. When you qualify for special enrollment, you may qualify for additional exemptions that extend the time you can go without coverage.

    The following life events will generally qualify you for a special enrollment period:

    You signed up for the marketplace, but you were unable to complete the enrollment process for any reason (until mid-April 2014)
  • Getting married

  • Birth, adoption, or placement of a child

  • Permanently moving to a new area that offers different health plan options

  • Losing other health coverage (including job loss for any reason, divorce, loss of eligibility for Medicaid or CHIP, expiration of COBRA coverage, aging of a parents plan, or a health plan being decertified). Note: loss of coverage does not include voluntarily quitting other health coverage or being terminated for not paying your premiums. Losing coverage that is not minimum essential coverage also fails to qualify as loss of coverage.

  • For people already enrolled in Marketplace coverage, having a change in income or household status that affects eligibility for tax credits or cost-sharing reductions

  • An individual who was not previously a citizen, national, or lawfully present individual gains such status.

  • A qualified individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange, HHS, or its instrumentalities as evaluated and determined by the Exchange.

  • An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee.

  • An individual is determined to be newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. The Exchange must permit individuals whose existing coverage through an eligible employer-sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such an eligible employer-sponsored plan.

  • An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month.

  • A qualified individual or enrollee demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.

  • Above information compiled from
    healthcare.gov and section 155.420 gpo.gov Federal Register.

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