Under the Affordable Care Act (ACA), initial rules imposed a federal tax penalty on individuals without health insurance that met the ACA’s minimum essential coverage criteria. This federal penalty has since been eliminated, but some states continue to enforce their penalties for lack of coverage. To understand the specifics and whether they affect you, consulting a tax advisor within your state is advisable.

For those potentially facing a state penalty, various exemptions could be applicable, ranging from income and health coverage circumstances to group membership or hardship conditions. If you suspect you might qualify for an exemption, detailed information on potential waivers and the process for application is available at Healthcare.gov, covering both fees and exemptions.

Special Enrollment

Special enrollment periods (SEP) exist for policies being purchased on or off the Marketplace (aka Exchange). Unless otherwise stated in federal regulations, the SEP will last a period of 60 calendar days for individual policies and 30 days for small group policies.

Listed below are the common SEPs for coverage purchased on or off the Exchange:

1. An individual loses minimum essential coverage. Please note that loss of coverage does not include termination or loss due to failure to pay premiums on a timely basis, including COBRA premiums prior to expiration of COBRA coverage, or situations allowing for a rescission. Individuals who are losing or lost COBRA premium assistance from a federal or state program can qualify for a SEP.

2. An individual gains a dependent or becomes a dependent through marriage, birth, adoption, or placement for adoption.

3.Your household income decreased, and now you qualify for savings on a Marketplace plan.

4. An individual gains citizenship or qualifying immigration status.

5. An individual becomes newly eligible or ineligible for Advanced Premium Tax Credit (APTC),or change in eligibility for Cost Sharing Reduction (CSR) benefits.

6. An individual gains access to new Qualified Health Plans (QHP) because of a permanent move.

7. An individual is enrolled in an eligible employer-sponsored plan that is not qualifying coverage and is allowed to terminate existing coverage.

8. An individual's enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and as the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Marketplace or HHS.

9. An individual adequately demonstrates to the Marketplace that the QHP in which they are enrolled substantially violated a material provision of its contract.

10. Members of a federally-recognized Indian tribe may enroll or change QHPs one time per month.

11. Exceptional circumstances, as determined by HHS.

There are additional SEPs depending on whether coverage is purchased on or off the Exchange. If you have additional questions about SEPs, please contact us at (386)200-3600 or schedule an appointment and we will help to see if you qualify.