1. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Part 1
Federal Coverage Updates
Expanded Enrollment Periods
Affordability Features
Fixing the Family Glitch
Medicare Part D Updates
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2. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Expanded Marketplace
Enrollment Periods
CMS has updated the final rule for
the Updating Payment Parameters,
Section 1332 Waiver Implementing
Regulations, and Improving Health
Insurance Markets for 2022 and
Beyond. These changes have
expanded opportunities to enroll in
Marketplace coverage.
This Photo by Unknown Author is licensed under CC
BY-SA
2
3. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Expanded Marketplace
Enrollment Periods
• Low Income Special Enrollment
Period (SEP) created in 2021 as
part of the American Rescue Plan.
• SEP allowing patients with income
up to 150% FPL, to switch to a
Silver tier plan or to a different
plan within the Silver tier multiple
times per year.
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4. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Unwinding Special Enrollment Period
The end of the Continuous Enrollment provisions of the Public Health
Emergency (PHE) set for March 31, 2023, creates a SEP.
4
5. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Expanded Marketplace Enrollment Periods
Applicants must still meet the regular criteria for the Advanced
Premium Tax Credits and Cost Sharing Reductions.
5
6. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Advanced Premium Tax Credits
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7. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Advanced Premium Tax Credits
Allows the federal government to make payments directly to insurance
companies to bring down the cost Marketplace premiums. The amount of
Advanced Premium Tax Credit a person qualifies for is determined on a
sliding scale based on income. To qualify, the applicant:
Must not have access to affordable Minimum Essential Coverage
Must have a qualifying tax filing status
Household income between 100%-400% FPL
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8. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Cost Sharing Reductions
Cost Sharing Reductions put a cap
on out-of-pocket expenses such as
deductibles and out of pocket
maximums. To qualify, the
applicant:
Income between 100% -250%
FPL
Qualify for Advanced Premium
Tax Credit
Enroll in a Silver Plan
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9. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Eased Restrictions
For the 2023 coverage year, health plans can no longer refuse to renew coverage for
enrollees who have fallen behind on their premium or whose coverage has lapsed
due to nonpayment.
9
10. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
What is the “Family Glitch?”
What is the “Family Glitch”?
The Family Glitch came as a result of
an IRS interpretation that if access to
insurance through an employer that
was considered affordable, then the
employee, their spouse and
dependents were ineligible for
Premium Tax Credits.
Affordable was defined as the cost of
the “employee – only” coverage being
less than 9.12% of household income.
10
11. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Fixing the “Family Glitch”
For many with employer-based
insurance, the difference in cost
between employee only coverage and
family coverage often put the cost of
that coverage well above 9.12% of
household income.
Many families have been spending
more than 15% of household income on
insurance premiums. Approximately 6
million people who would otherwise
been eligible for Premium Tax Credits
were blocked from that assistance. A
disproportionate share of those affected
are in the lower income brackets.
11
12. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Fixing the “Family Glitch”
The Internal Revenue Service finalized
a rule December 12, 2022, that fixes
the Family Glitch.
Now the affordability of health
coverage is based on the employee
only cost for the employee and
affordability for family coverage will
be based on the cost of the family
plan.
This means nearly 6 million people
now have access to Marketplace
affordability features!
12
13. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Changes in Medicare Part D
The Inflation Reduction Act
signed into law August 16,
2022, implemented changes
in Medicare Part D that cap
some of the out-of-pocket
costs for members.
13
14. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Changes in Medicare Part D
Beginning in 2023, cost sharing
for insulin will be capped at $35
per month. In 2024, the
coinsurance above the
catastrophic coverage level will be
eliminated and then in 2025,
there will be a cap on out-of-
pocket spending of $2000 for
Medicare Part D enrollees.
14
15. This material is proprietary to ClaimAid. Not for duplication or distribution
without the express permission of ClaimAid.
Federal Coverage Updates
Changes in Medicare Part D
The Inflation Reduction Act also
expanded the Low-Income Subsidy (LIS)
program. Currently the LIS program
provides only partial relief for drug costs
for those between 135-150% FPL. In
2024, enrollees in LIS will no longer have
a premium for their qualifying Part D
plan and only modest copayments for
prescriptions.
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Editor's Notes
We will now take a look at some of the changes in Marketplace coverage that will ease the transition during the PHE Unwinding.
We start with the Low-Income Special Enrollment Period.
In order to make it easier for low-income people to enroll in Marketplace coverage throughout the year, a Low-Income SEP was created in 2021 as part of the American Rescue Plan. This Special Enrollment Period began in March 2022. To qualify, enrollees must:
Qualify for the Advance Premium Tax Credit
Have household income below 150% FPL
Individuals at this income level qualify for $0 or very low premium silver plans. Additionally, those qualifying for the Low-Income Special Enrollment period will have access to not only the Advance Premium Tax Credit, they will also benefit from Cost Sharing Reductions.
For Marketplace enrollees with income up to 150% FPL, this SEP will allow them to switch to a Silver tier plan or to a different plan within the Silver tier multiple times per year.
This SEP will be in place through the 2025 coverage year as part of the provisions of the Inflation Reduction Act of 2022.
CMS Guidance 1/27/2023
https://www.cms.gov/technical-assistance-resources/temp-sep-unwinding-faq.pdf
With the end of the Continuous Enrollment provisions of the Public Health Emergency (PHE) set for March 31, 2023, Marketplace has created the Unwinding Special Enrollment Period. This Special Enrollment period will be continuously open to those losing state health coverage through July 31, 2024.
APTC is the most recognizable feature of the Affordable Care Act. It is based on anticipated ANNUAL income. APTC are available to consumers with household income between 100-400% FPL. The amount is based on a sliding scale with those consumers with lower household income qualifying for a larger APTC and those with higher income qualifying for a lower APTC
Changes in income at any point in the year can have a big impact on the correct amount of APTC that a consumer is considered to be entitled to. We want avoid situations that gravely impact a consumer’s tax liability.
Changes in income are obviously the most impactful change in the APTC . Simply reporting the increase income may not protect consumers., consumers may also need to change the amount of APTC they are receiving as well.
Another change that is designed to remove barriers to Marketplace Coverage for 2023, health plans can no longer refuse to renew coverage for enrollees who have fallen behind on their premium or whose coverage has lapsed due to nonpayment. People may enroll for 2023 coverage and the first payment to begin coverage will not be applied to any past due balance, but rather to the first payment for the coverage year.
What is the “Family Glitch”?
The Family Glitch came as a result of an IRS interpretation that if access to insurance through an employer that was considered affordable, then the employee, their spouse and dependents were ineligible for Premium Tax Credits.
Affordable was defined as the cost of the “employee – only” coverage being less than 9.12% of household income.
For many with employer-based insurance, the difference in cost between employee only coverage and family coverage often put the cost of that coverage well above 9.12% of household income.
Many families have been spending more than 15% of household income on insurance premiums. Approximately 6 million people who would otherwise been eligible for Premium Tax Credits were blocked from that assistance. A disproportionate share of those affected are in the lower income brackets.
The Internal Revenue Service finalized a rule December 12, 2022, that fixes the Family Glitch.
Now the affordability of health coverage is based on the employee only cost for the employee and affordability for family coverage will be based on the cost of the family plan.
This means nearly 6 million people now have access to Marketplace affordability features!
(Kaiser Family Foundation 11/21/2022)
What is the “Family Glitch”?
The Family Glitch came as a result of an IRS interpretation that if access to insurance through an employer that was considered affordable, then the employee, their spouse and dependents were ineligible for Premium Tax Credits.
Affordable was defined as the cost of the “employee – only” coverage being less than 9.12% of household income.
For many with employer-based insurance, the difference in cost between employee only coverage and family coverage often put the cost of that coverage well above 9.12% of household income.
Many families have been spending more than 15% of household income on insurance premiums. Approximately 6 million people who would otherwise been eligible for Premium Tax Credits were blocked from that assistance. A disproportionate share of those affected are in the lower income brackets.
The Internal Revenue Service finalized a rule December 12, 2022, that fixes the Family Glitch.
Now the affordability of health coverage is based on the employee only cost for the employee and affordability for family coverage will be based on the cost of the family plan.
This means nearly 6 million people now have access to Marketplace affordability features!
(Kaiser Family Foundation 11/21/2022)
What is the “Family Glitch”?
The Family Glitch came as a result of an IRS interpretation that if access to insurance through an employer that was considered affordable, then the employee, their spouse and dependents were ineligible for Premium Tax Credits.
Affordable was defined as the cost of the “employee – only” coverage being less than 9.12% of household income.
For many with employer-based insurance, the difference in cost between employee only coverage and family coverage often put the cost of that coverage well above 9.12% of household income.
Many families have been spending more than 15% of household income on insurance premiums. Approximately 6 million people who would otherwise been eligible for Premium Tax Credits were blocked from that assistance. A disproportionate share of those affected are in the lower income brackets.
The Internal Revenue Service finalized a rule December 12, 2022, that fixes the Family Glitch.
Now the affordability of health coverage is based on the employee only cost for the employee and affordability for family coverage will be based on the cost of the family plan.
This means nearly 6 million people now have access to Marketplace affordability features!
(Kaiser Family Foundation 11/21/2022)
This SEP will not roll out on healthcare.gov until end of March. Anyone who applied after January 15 and who meets these criteria will be contacted by HHS staff to enroll during this SEP.
This SEP will not roll out on healthcare.gov until end of March. Anyone who applied after January 15 and who meets these criteria will be contacted by HHS staff to enroll during this SEP.
This SEP will not roll out on healthcare.gov until end of March. Anyone who applied after January 15 and who meets these criteria will be contacted by HHS staff to enroll during this SEP.
