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Small Business Employee Benefits and HR Blog

Clarification on ACA Special Enrollment Period vs. Hardship Exemption

Under the ACA, consumers in certain situations may qualify for either a special enrollment period to purchase individual health insurance and/or a hardship exemption from the individual mandate.

And, according to HHS, many consumers are seeking hardship exemptions when they actually qualify for a special enrollment period. CMS and HHS recently released clarification about when consumers qualify for a special enrollment period over a hardship exemption.which_way

Here’s how HHS has distinguished between the two, and how health insurance brokers can help consumers understand when the hardship exemption and special enrollment periods apply.

ACA Hardship Exemptions

“Hardship Exemptions – The ACA recognizes that individuals with a hardship making it difficult to afford coverage with comprehensive benefits may qualify for a “hardship” exemption from the individual responsibility requirement. Individuals who qualify for such an exemption may also be able to purchase catastrophic coverage on the Marketplace.

A complete listing of circumstances that might qualify an individual for a 'hardship' exemption is available at this link: https://www.healthcare.gov/exemptions/. Information on how to apply for a hardship exemption is available at this link: http://marketplace.cms.gov/getofficialresources/publications-and-articles/hardship-exemption.pdf."

ACA Special Enrollment Periods (SEP)

"Special Enrollment Periods – The ACA and Exchange final regulations permit consumers to be granted an SEP for specific situations. As of January 1, 2014, individuals who contact CMS stating that they have evidence of an attempt to complete the enrollment process within the enrollment deadlines, believed they had enrolled in coverage for a January 1st effective date but were not enrolled in the QHP because of incorrect enrollment data transmitted by the FFM to the issuer, may qualify for a special enrollment period with coverage retroactive to January 1st. To qualify for this SEP, the individual will need to provide an attestation and proof that he or she completed the steps to enroll in a QHP. We note that consumers who cannot provide proof of completion of the enrollment process by the enrollment deadline will receive coverage for a February 1st or otherwise applicable effective date."

Click here for additional information on special enrollment periods.

Source: NAHU

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