Truth

Consumers may quality for an SEP if they (or anyone in their household who is seeking coverage) lose qualifying health coverage. Examples of quality health coverage include:

• Coverage through a job or through another person’s job
• Most Medicaid or CHIP coverage
• Medicare Part A, or Medicare Advantage Plan
• Some student health plans
• Dependent coverage that a consumer has through a parent’s plan
• COBRA continuation coverage.

For additional information regarding the loss of MEC SEP, refer to this webinar.

Myth

Some consumers mistakenly think they must wait until Open Enrollment each year to enroll in new insurance after losing minimum essential coverage, such as Medicaid/CHIP, or employer sponsored coverage. This is incorrect.

Truth

Starting November 1, you can assist consumers to apply for 2025 coverage or update their applications with any changes they expect for the year ahead. Keep the following key dates in mind:

• November 1: Open Enrollment starts — first day consumers can enroll in, renew, or change health plans through the Marketplace for the coming year. Coverage can start as soon as January 1.
• January 1: Coverage starts for those who enroll in or change plans by December 15 and pay their first premium.
• January 15: Open Enrollment ends — last day to enroll in or change Marketplace health plans for the year. After this date, consumers can enroll in or change plans only if they qualify for a Special Enrollment Period.
• February 1: Coverage starts for those who enroll in or change plans December 16 through January 15 and pay their first premium.

Myth

Some people mistakenly think all plan enrollments made during Open Enrollment will have a plan effective date of January 1. This is incorrect and could result in consumers missing the opportunity for a January 1 effective date. Assisters should be sure to advise their clients of the correct key dates.

Truth

Consumers who are determined eligible for, or are enrolled in, coverage through Medicaid or the Children’s Health Insurance Program (CHIP) that counts as qualifying health coverage (also known as minimum essential coverage, or MEC) are ineligible for advance payments of the premium tax credit (APTC), and for cost-sharing reductions (CSRs) to help pay for the cost of their Marketplace coverage premium and covered services.

Myth

Some consumers assume they can be eligible for both Medicaid/CHIP and Marketplace coverage with APTC/CSRs. This is incorrect.

Truth

If consumers believe there was a mistake or disagree with certain eligibility determinations made by a Marketplace, they have the right to request an appeal. These determinations include:

• Eligibility to buy a Marketplace Qualified Health Plan (QHP), including a Catastrophic plan.
• Eligibility for lower costs, including the amount of advance payments of the premium tax credit (APTC), and cost-sharing reductions (CSRs).
• Eligibility for a Special Enrollment Period (SEP) to enroll in a Marketplace QHP outside the regular Open Enrollment Period (OEP).

For information regarding the appeals process, check out this presentation.

Myth

Once consumers complete their Marketplace application and receive their eligibility determination notice, they have no further options if they believe they have been inaccurately determined. This is incorrect.

Truth

The Final Rule will impact eligibility for certain groups of noncitizens beyond DACA recipients. These groups include:

• Noncitizens with Work Authorization;
• Family Unity Beneficiaries;
• Lawful Permanent Resident Applicants;
• Children Impacted by the Removal of 180 Day Waiting Period for Certain Noncitizen Children; and
• Special Immigrant Juvenile Children.

Assisters should review the resource available here to understand what consumers will be newly eligible for a QHP through the Marketplace.

Myth

When the Final Rule goes into effect on November 1, 2024, only DACA recipients will be newly eligible for coverage through the Marketplace.

Truth

In May 2024, the Department of Health and Human Services (HHS) published a final rule which modified the definition of “lawfully present” applicable to eligibility for enrollment in a QHP through the Marketplace. With this modification, DACA recipients will no longer be excluded from that definition, thereby making it possible, effective November 1, 2024, for DACA recipients who meet all other eligibility requirements to enroll in a QHP through the Marketplace with financial assistance. For more information regarding this final rule, refer to this fact sheet from CMS.

Myth

Consumers who are DACA recipients do not meet the “lawfully present” criteria needed to qualify for a Qualified Health Plan (QHP) with financial assistance through the Marketplace.

Truth

Consumers who have been denied or lost Medicaid or CHIP have fair hearing rights. Anyone applying for or enrolled in Medicaid who disagrees with certain decisions made by their state Medicaid agency has the right to request a fair hearing about those decisions. This includes decisions to deny, suspend, terminate, or reduce a person’s Medicaid eligibility or services. 

Myth

If a consumer is denied Medicaid or CHIP, or loses their Medicaid or CHIP coverage, they are out of options. Consumers who have been denied or lost Medicaid or CHIP should always apply for other coverage, such as Marketplace coverage.

Truth

If parents’ income increases and they are no longer eligible for Medicaid coverage, their children may still be eligible for Medicaid or CHIP coverage. Many states have higher income eligibility thresholds for children than adults. Assisters are an important resource for helping consumers understand their renewal notices and what coverage each member of their household may be eligible for. 

Myth

If an entire household was enrolled in Medicaid coverage due to income below their state’s Medicaid eligibility threshold, but the parents now earn an income above the Medicaid eligibility threshold, the entire household will be disenrolled from Medicaid, and will need to seek coverage through other means, such as through an employer or the Marketplace.

Truth

In cases where a consumer’s annual income is below 100% of the FPL but their monthly income is too high for Medicaid eligibility, Medicaid agencies are required to use a household’s projected annual income to determine eligibility. The consumer will need to provide evidence such as a signed contract of employment, or a clear history of predictable fluctuations in income, in this instance.

Myth

Consumers whose income fluctuates month to month, but with an annual income below 100% of the federal poverty limit (FPL) will be determined ineligible for Medicaid due to the use of monthly income, rather than annual income for Medicaid eligibility determinations.

Truth

When applying for Marketplace coverage through HealthCare.gov, consumers will be asked questions regarding Medicaid and CHIP coverage and should answer those questions truthfully. Those questions are used to make sure consumers get the right eligibility determination and are not improperly sent back to the state.   

Myth

Consumers who recently lost Medicaid or CHIP coverage will be sent back to their state when they submit a Marketplace application automatically.