Plan Option Limitations for Affordable Care Act (ACA) SEPs

As part of new changes implemented by the Federally Facilitated Marketplace (FFM), a limited number of plan options will be available for existing Individual and Family Affordable Care Act (ACA) members who qualify for a Special Enrollment Period (SEP) in 2019.

Available plan options will be determined by the existing members Qualifying Life Event (QLE), current plan configuration and any necessary plan changes a member is wanting to make.

Plan Category Limitations

Plan category limitations may apply when an existing member experiences a certain type of SEP-qualifying event, and wants to change from their current plan. Members, and their dependents, may be subject to a plan category limitation if they:

  • Qualify for a certain SEP and are already enrolled in Marketplace coverage
  • Add new household members to an existing family plan

The most common type of SEP(s) in which a member may be subject to a plan category limitation include:

  • Loss of qualifying coverage
  • Change in primary place of living
  • Change in household size

For most of the above types of SEPs, existing members will only be able to choose from plans within the same plan category (Bronze, Silver, Gold or Platinum) as their current plan.

Online Enrollment Updates

We have updated content to reflect these new changes on ‘Shop and Apply.’

As a member is guided through the process of applying for coverage during an SEP, any applicable restriction(s) will display based on the member’s Change in Circumstances (CIC).

Informational Resources Available 

You can view additional information on plan category limitations here or by visiting www.HealthCare.gov. You can also view a detailed presentation by the Centers for Medicare and Medicaid Services (CMS).

If you have any questions, please contact your marketing representative.

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