A change in subsidy eligibility changes your options

SEP currently applies to people already enrolled in an exchange, but will also apply to off-exchange enrollees starting in 2020


The ACA provides two types of subsidies for eligible individuals who enroll in health plans through the exchanges:

  • Premium subsidies are available to people who aren’t eligible for Medicaid, and whose household income is at least 100 percent of the federal poverty level, and no more than 400 percent of the poverty level (the lower limit for subsidy eligibility in states that have expanded Medicaid is 139 percent of the poverty level, as Medicaid is available in those states to people with income up to 138 percent of the poverty level, and subsidies aren’t available to people who are eligible for Medicaid).
  • Cost-sharing subsidies, otherwise known as cost-sharing reductions (CSR), are available to people who aren’t eligible for Medicaid, who purchase a Silver plan, and whose income is at least 100 percent of the poverty level but no more than 250 percent of the poverty level (the same caveat applies regarding the lower income limit for subsidy eligibility in states that have expanded Medicaid).

For people who are already enrolled in a plan through the exchange, an income change counts as a qualifying event if it results in a change in eligibility for either type of subsidy. The enrollee then has 60 days to select a different plan.

And starting in 2020 (in states that use HealthCare.gov and in other states at the option of the state-run exchanges), people who have off-exchange coverage and who experience a change in income that makes them newly eligible for premium subsidies will have a special enrollment period during which they can switch to a plan in the exchange. This will give these individuals the ability to take advantage of the premium subsidies — and cost-sharing subsidies, if applicable — for which they are newly eligible, since the subsidies are only available through the exchange.

For people who are currently enrolled in Medicaid and whose income increases to make them eligible for a premium subsidy instead (or even above 400 percent of the poverty level, making them ineligible for both Medicaid and premium subsidies), the special enrollment period also applies. In this case, it’s also a special enrollment period triggered by loss of other coverage, as an increase in income above the Medicaid eligibility level will result in loss of Medicaid coverage, and loss of coverage triggers a special enrollment period.

And for people who are uninsured but in the Medicaid coverage gap in a state that hasn’t expanded Medicaid, there’s a special enrollment period that applies if the person’s income increases to above the poverty level, making them newly-eligible for subsidies in the exchange. This SEP does not have any sort of prior coverage requirement, as the assumption is that people in the Medicaid coverage gap do not generally have realistic access to health coverage.

(If you’re uncertain about your eligibility for a special enrollment period, call (800) 436-1566 to discuss your situation with a licensed insurance professional.)

Examples: changes in premium subsidy eligibility

Newly ineligible for premium subsidies:

If John is receiving a premium subsidy and experiences a mid-year increase in income that makes him ineligible to continue receiving a subsidy, he’ll have access to a 60-day special enrollment period during which he can switch to a different plan. He may decide he wants to keep his plan, or he may prefer to pick a less expensive option once his premium subsidies are no longer available. The choice is his.

And federal regulations allow people who lose eligibility for premium subsidies to switch from an on-exchange plan to an off-exchange plan. This is detailed in § 147.104(b)(2)(i)(B), and confirmed in the 2020 Notice of Benefit and Payment Parameters. Giving people the flexibility to switch from on-exchange to off-exchange when they lose eligibility to premium subsidies is particularly helpful now that insurers in many states are adding the cost of CSR to silver plan premiums in the exchange, but offering off-exchange silver plans without the cost of CSR added to their premiums. So for example, if a person has a Silver plan in the exchange, with premium subsidies, and then experiences an income increase that makes them ineligible for premium subsidies, they may be able to find an off-exchange Silver plan that costs less (for people who have to pay full-price, without any subsidies) than the on-exchange version. The availability of a SEP in this circumstance facilitates the transition, although as is always the case with mid-year policies changes, out-of-pocket costs reset to zero each time a person switches to a new plan.

Newly eligible for premium subsidies:

If Mary’s income is too high for premium subsidies, she may have initially selected a low-cost plan since she has to pay the entire bill herself. If her income subsequently drops into the subsidy-eligible range, she’ll have a 60-day SEP during which she can change plans. [Through the end of 2019, this only applies to people who already had a plan that they purchased through the exchange, and wish to switch to a different plan once they’re eligible for subsidies. But starting in 2020, off-exchange enrollees (in most states) who experience a drop in income that makes them subsidy-eligible will have an opportunity to enroll in an on-exchange plan.]

Mary’s premium subsidy can be applied to any metal-level plan in the exchange, including the plan she already has (as long as it’s not a catastrophic plan). If her existing plan is a catastrophic plan, this SEP will be particularly helpful, since catastrophic plan premiums can’t be subsidized. Even if she already had a metal-level plan, she’ll have the option to pick a different one during her SEP.

Examples: changes in cost-sharing subsidy eligibility

If Kylie’s income was initially higher than 250 percent of the federal poverty level, she may not have selected a Silver plan when she enrolled, since she wasn’t eligible for cost-sharing subsidies. But if her income drops under 250 percent of the poverty level later in the year, the SEP gives her an opportunity to enroll in a Silver plan with cost-sharing subsidies included in the coverage. (Cost-sharing subsidies are only available on Silver plans.)

There are three different levels of cost-sharing subsidies, depending on income. The subsidies are more robust at lower income levels, and relatively modest for people with income above 200 percent of the poverty level. If Trent’s income initially placed him in one eligibility bracket for cost-sharing subsidies, and it changes mid-year to one of the other eligibility brackets, he’ll have a SEP during which he can select a different plan.

If Elaine initially qualifies for cost-sharing subsidies but her income increases during the year and she loses her eligibility for cost-sharing subsidies, she’ll have a SEP during which she can pick a new plan. [Note that if you’re already enrolled in a CSR plan and you report an income change to the exchange that makes you eligible for a different CSR plan instead, the exchange may automatically transition you to the new CSR plan offered by the same insurer you already have. In some cases, this might reset your cost-sharing for the year to $0, and you’d need to contact the exchange and/or the health insurer to make sure that the out-of-pocket costs that you’ve already paid get credited towards your “new” plan.]

Currently limited to those already enrolled through exchange, but this will change in 2020

Form 2014 through 2019, the SEP triggered by an income change only applied if the person was already enrolled in a plan through the exchange. If you were enrolled in an off-exchange plan, you were not eligible for a SEP if your income changed mid-year.

This has made it challenging for some people to take advantage of the “silver switch” option that many states have offered as a solution to the cost of CSR. People who aren’t eligible for premium subsidies — but who want a silver plan — may find that the full-price cost of the plan is lower if they shop outside the exchange. But then if they experience a change in income mid-year that makes them eligible for a subsidy, they’re still stuck with their full-price off-exchange plan until the following year.

Income changes and job changes can sometimes be difficult to predict, but from 2014 through 2019, neither of those have counted as a qualifying event if you weren’t already enrolled through the exchange.

In finalizing the new SEP that allows off-exchange enrollees to switch to the exchange, HHS noted that people enrolled in employer-sponsored coverage or exchange coverage who become newly-eligible for premium subsidies in the exchange have an opportunity to take advantage of those subsidies, as do uninsured people in the Medicaid coverage gap who experience a change in income that makes them subsidy-eligible.

But there has never been such an opportunity for people enrolled in off-exchange coverage to take advantage of a premium subsidy for which they are newly eligible. The new rules change that, starting in 2020.

Details for the off-exchange income change SEP

The new SEP for people who have off-exchange coverage and experience an income change that makes them subsidy-eligible was confirmed in the 2020 Notice of Benefit and Payment Parameters that HHS finalized in April 2019. Here are the details:

  • HHS will add a new section (v) at § 155.420(d)(6) describing the new SEP.
  • The new SEP will be available in all states that use HealthCare.gov (including state-run exchanges that use the federal enrollment platform), but HHS “anticipates it will not be available until after January 1, 2020.”
  • The new SEP will be optional for states that run their own exchange platforms.
  • Consumers will have 60 days from the date of their income change to enroll in a plan through the exchange.
  • If other members of the person’s household are already enrolled in a plan through the exchange, the person will be allowed to join them on that plan. Alternatively, the person will be allowed to enroll in a separate plan of their own choosing during the SEP.
  • Consumers will have to provide proof of their income change, as well as proof that they had minimum essential coverage (or pregnancy Medicaid, CHIP unborn child, and Medically Needy Medicaid) prior to the income change (for at least 1 of the 60 days prior, as is the standard with other SEPs that require proof of prior coverage).
  • Off-exchange minimum essential coverage obviously includes ACA-compliant plans that are sold outside the exchange, but it also includes grandmothered and grandfathered plans. So a person who has retained one of these plans — because they weren’t eligible for subsidies — will be able to switch to an on-exchange ACA-compliant plan with premium subsidies in the future if you have an income change mid-year that makes them subsidy eligible.
  • However, plans that are not minimum essential coverage, including short-term health plans, will NOT satisfy the prior coverage requirement for this SEP. So a person who enrolled in a short-term health plan (maybe because they weren’t eligible for a premium subsidy in the exchange and considered all of the available ACA-compliant plans to be too expensive) would not be eligible for a SEP to switch to an on-exchange plan mid-year if they experience a change in income.
  • As is always the case when people switch from one plan to another mid-year, out-of-pocket amounts will start over at $0 on the new plan (unless the enrollee is switching to the exact same plan on-exchange that they already have off-exchange, and the insurer agrees to credit their out-of-pocket spending towards the new plan; there is nothing that requires insurers to do this, but it can never hurt to try).

A third-party enrollment site like healthinsurance.org will let you compare both on- and off-exchange plans, and it’s worth looking at both if you’re not eligible for subsidies. Subsidies are only available in the exchange, but starting in 2020, the flexibility added by this new SEP will make it easier for people with an uncertain income to pick the plan that works best based on their current income, knowing that they can make changes later in the year if they experience an income change.


Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.

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Special Enrollment Guide cover illustration

Special Enrollment Guide

Table of Contents

Why a guide to special enrollment periods?
1 Qualifying events and why we need them
2 Who doesn’t need a special enrollment period?
3 Involuntary loss of coverage is a qualifying event
4 How your ‘big move’ can trigger an SEP
5 Divorce, death, or legal separation: SEP is optional
6 A change in subsidy eligibility changes your options
7 Citizenship or lawful immigrant status can deliver coverage
8 An SEP if your employer plan doesn’t measure up
9 Non-calendar-year renewal as a qualifying event
10 Leaving the coverage gap? This SEP’s for you.
11 Proving you deserve an SEP
12 An SEP for your growing family
13 Exceptional circumstances for special enrollment
14 An SEP if you have a QSEHRA or ICHRA

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