Temporary Special Enrollment Period (SEP) for Consumers Losing

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop 00-00-00

Baltimore, Maryland 21244-1850

Center for Consumer Information and Insurance Oversight

RELEASED: January 27, 2023

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

Temporary Special Enrollment Period (SEP) for Consumers Losing Medicaid or the Children’s

Health Insurance Program (CHIP) Coverage Due to Unwinding of the Medicaid Continuous

Enrollment Condition– Frequently Asked Questions (FAQ)

The guidance referenced in this document is applicable to all Marketplaces, and provides specific

operational details for consumers in Marketplaces using the federal eligibility and enrollment platform.

This guidance does not replace or revise previously issued guidance, and it references current federal

regulations at 45 CFR 155.420(d)(9) and (d)(1), Section 5131 of the Consolidated Appropriations Act of

2023 (CAA, 2023), the Center for Medicaid and CHIP Services (CMCS) Informational Bulletin dated

January 5, 2023, and the CMCS State Health Official (SHO) letter #23-002, published on January 27,

2023. This guidance describes flexibilities for consumers and Marketplaces with regard to the Medicaid

Continuous Enrollment Condition Unwinding SEP for plan years 2023 and 2024.

Since the onset of the novel coronavirus disease of 2019 (COVID-19) Public Health Emergency (PHE),

state Medicaid agencies have made policy, programmatic, and systems changes to respond effectively to

the pandemic. State Medicaid agencies also have made changes to qualify for the temporary Federal

Medical Assistance Percentage (FMAP) increase under section 6008 of the Families First Coronavirus

Response Act (FFCRA), including satisfying a continuous enrollment condition for most Medicaid

beneficiaries who were enrolled in the program as of or after March 18, 2020.

Similarly, during the

COVID-19 PHE, some states have been granted 1115 demonstration authority to provide continuous

enrollment for Children’s Health Insurance Program (CHIP) beneficiaries in addition to other

flexibilities that have had this effect.

The Consolidated Appropriations Act, 2023 (CAA, 2023) amends the expiration of the FFCRA section

6008 continuous enrollment condition and availability of the temporary FMAP increase, such that it will

no longer be linked to the end of the COVID-19 PHE. The continuous enrollment condition will end on

March 31, 2023. Beginning April 1, 2023, states will be able to terminate Medicaid enrollment for

individuals no longer eligible. Beneficiaries whose coverage is terminated on April 1 could have their

last date of Medicaid coverage be March 31, 2023. The temporary FMAP increase will be gradually

reduced and phased down beginning April 1, 2023, and will end on December 31, 2023, for states that

meet certain conditions. As described in prior Centers for Medicare & Medicaid Services (CMS)

To help keep beneficiaries in coverage during the COVID-19 PHE, under the continuous enrollment condition, states

received additional federal funding if they paused Medicaid terminations starting in March 2020.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless

specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing

requirements under the law.

guidance,

after the expiration of the continuous enrollment condition, states will have up to 12 months

to initiate, and 14 months to complete, a renewal for all individuals enrolled in Medicaid, CHIP, and, if

applicable, the Basic Health Program (BHP), in a process commonly referred to as “unwinding” and the

12-month period has been called the “unwinding period.”

After the continuous enrollment condition ends on March 31, 2023 and states’ unwinding periods begin,

many beneficiaries may lose Medicaid or CHIP coverage on or after April 1, 2023, and therefore may

need to transition to other coverage, such as Marketplace coverage. Therefore, CMS is providing

additional flexibilities for states and Marketplaces during the unwinding period to help beneficiaries

maintain continuity of coverage as they transition off Medicaid or CHIP coverage and into a

Marketplace qualified heath plan (QHP).

Q1: What is the Centers for Medicare & Medicaid Services (CMS) announcing today?

A1: Today, CMS is announcing a Marketplace Special Enrollment Period (SEP) for qualified

individuals and their families who lose Medicaid or CHIP coverage due to the end of the continuous

enrollment condition, also known as “unwinding.” This SEP, hereinafter referred to as the “Unwinding

SEP,” will allow individuals and families in Marketplaces served by HealthCare.gov to enroll in

Marketplace health insurance coverage outside of the annual open enrollment period. CMS will update

HealthCare.gov so that Marketplace-eligible consumers who submit a new application or update an

existing application between March 31, 2023

and July 31, 2024; and attest to a last date of Medicaid or

CHIP coverage within the same time period, are eligible for an Unwinding SEP. Consumers who are

eligible for the Unwinding SEP will have 60 days after they submit their application to select a

Marketplace plan with coverage that starts the first day of the month after they select a plan.

Q2: Why is CMS offering this Unwinding SEP?

A2: Many states and other stakeholders have raised significant concerns that, due to the unprecedented

nature of unwinding, Medicaid and CHIP beneficiaries may face exceptional challenges when

transitioning from Medicaid or CHIP coverage to other forms of coverage, such as Marketplace

coverage. Medicaid and CHIP beneficiaries may be confused as to why their Medicaid or CHIP

coverage is ending for the first time in several years. They may not have been in contact with, or

received regular communications from, their state Medicaid agencies while the continuous enrollment

CMS. (March 3, 2022). Promoting Continuity of Coverage and Distributing Eligibility and Enrollment Workload in

Medicaid, the Children’s Health Insurance Program (CHIP), and Basic Health Program (BHP) Upon Conclusion of the

COVID-19 Public Health Emergency [State Health Official Letter #22-001]. Available at

https://www.medicaid.gov/federal-

policy-guidance/downloads/sho22001.pdf.

March 31, 2023 is the earliest date that a beneficiary can have their last day of Medicaid coverage if coverage is terminated

following the end of the continuous enrollment condition.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless

specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing

requirements under the law.

condition was in place, since many Medicaid and CHIP eligibility and enrollment operations were

paused while it was in place, which could increase confusion about a sudden loss of coverage. Due to

the volume of individuals expected to lose Medicaid and CHIP coverage, Medicaid and CHIP agencies

may be unable to provide timely information about the termination of coverage and coverage options

that would enable consumers to make an informed decision about their coverage options within 60

days.

For example, a consumer may need clarity as to whether a loss of Medicaid or CHIP coverage

was procedural or due to ineligibility before deciding whether to pursue Marketplace coverage.

Additionally, many Medicaid and CHIP beneficiaries may have moved or changed addresses since last

receiving communications from their state Medicaid or CHIP agency. As a result, they may not receive

termination notices from their Medicaid or CHIP agency timely or at all. CMS anticipates that many

former Medicaid and CHIP beneficiaries would qualify for the SEP available for individuals who did

not receive timely notice of triggering events under 45 CFR § 155.420(c)(5), and in light of the

exceptional circumstances described here, that this rises to the level of eligibility for Exceptional

Circumstances SEPs under § 155.420(d)(9), we think it is appropriate to streamline access to and

eligibility for these SEPs using the Unwinding SEP.

Q3: When can consumers access this Unwinding SEP?

A3: Between March 31, 2023 and July 31, 2024, Marketplace-eligible consumers who are losing

Medicaid, CHIP, or, if applicable, BHP, coverage due to unwinding can access the Unwinding SEP by

submitting or updating an application through HealthCare.gov, a certified partner that supports SEPs, or

the Marketplace Call Center. Consumers who are determined eligible for this Unwinding SEP will have

60 days from the date on which they submit a new or updated HealthCare.gov application to make a

plan selection. Note: After July 31, 2024, consumers who were unable to enroll in Marketplace coverage

because they did not receive a timely notice of termination of Medicaid or CHIP coverage, may contact

the Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) to request an SEP, which will

be granted on a case-by-case basis.

Finally, consumers do not have to wait for their Medicaid or CHIP coverage to end, before submitting

an application for Marketplace coverage. Per regulation, consumers losing minimum essential coverage

(MEC), such as Medicaid or CHIP, may report that loss of coverage up to 60 days before their last day

of Medicaid or CHIP coverage.

Under 45 CFR 155.420(c)(1) and (d)(1), an individual who loses minimum essential coverage, including most types of

Medicaid and CHIP coverage, is generally eligible for an SEP for 60 days after the date of loss of coverage.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless

specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing

requirements under the law.

Q4: When will coverage start for consumers eligible for the Unwinding SEP?

A4: Consumers’ Marketplace coverage will start the first day of the month following plan selection

under this Unwinding SEP.

For example, if a consumer who is eligible for the Unwinding SEP selects a

plan on August 20, 2023, Marketplace coverage will start on September 1, 2023.

Q5: Is there a new application question that consumers have to answer to be determined eligible

for the Unwinding SEP?

A5: No. However, CMS has made updates to the existing application question on HealthCare.gov that

asks about a recent loss of Medicaid or CHIP coverage and updated existing functionality to grant the

Unwinding SEP to eligible consumers. Consumers can also be determined eligible for the Unwinding

SEP through existing questions on partner applications that ask about a recent loss of Medicaid or CHIP

coverage.

Q6: What steps should consumers take to make sure they can be determined eligible for the

Unwinding SEP?

A6: The Unwinding SEP will be available to Marketplace-eligible consumers who:

1) Submit a new application or update an existing application between March 31, 2023 and July 31,

2024 and answer “Yes” to the application question asking if their Medicaid or CHIP coverage

ended recently or will end soon, and

2) Attest to a last date of Medicaid or CHIP coverage between March 31, 2023 and July 31, 2024.

In order to help avoid gaps in coverage during unwinding, CMS recommends that consumers who have

received notice from their state Medicaid or CHIP agency that they are no longer eligible for Medicaid

or CHIP coverage submit a new application or update an existing application on HealthCare.gov as soon

as possible. This recommendation also applies to consumers whose Medicaid or CHIP coverage was

terminated due to procedural reasons, so that the Marketplace can evaluate their eligibility for Medicaid,

CHIP, or qualified health plan (QHP) coverage with advance payments of the premium tax credit

(APTC) or cost-sharing reductions (CSR), as applicable.

Finally, to help consumers learn about their opportunity to enroll in Marketplace coverage through this

Unwinding SEP, CMS will:

(1) notify partners and stakeholders who regularly interact with or on behalf of potentially qualified

consumers;

Consumers eligible for another SEP may receive an earlier coverage effective date as described in Q8.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless

specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing

requirements under the law.

(2) provide technical assistance and training to enrollment assisters, such as agents, brokers, and

Navigators;

(3) provide information to news media;

(4) conduct direct consumer outreach and communications, along with general outreach, education and

marketing to raise consumer awareness including tactics such as social media, email, search, and digital

video; and

(5) provide educational information and resources for consumers on HealthCare.gov about what to do

and next steps if they are losing their Medicaid or CHIP coverage.

Q7: Will consumers need to provide documentation to verify their eligibility for the Unwinding

SEP?

A7: No, consumers will not be required to submit documentation of a qualifying life event to be eligible

for the Unwinding SEP. Consumers will be required to attest to a loss of Medicaid or CHIP coverage as

part of the application.

Q8: If consumers are eligible for multiple SEPs, what will their Marketplace coverage effective

date be?

A8: In general, if a consumer is eligible for multiple SEPs due to multiple qualifying life events, the

consumer will be given the earliest coverage effective date associated with the applicable SEPs. If a

consumer is eligible for the Unwinding SEP and another SEP, the consumer will be given the coverage

effective date associated with the Unwinding SEP, unless the other SEP has a retroactive coverage

effective date. If a consumer qualifies for an SEP with a retroactive coverage effective date but doesn’t

want coverage to start on the date of their triggering event, such as the date of a birth or adoption date,

the consumer can contact the Marketplace Call Center to have coverage start on a different date.

Q9: What should consumers do if they aren’t sure whether their Medicaid or CHIP coverage was

terminated by their state Medicaid or CHIP agency?

A9: Consumers can find contact information for their state Medicaid or CHIP agency by visiting

https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-

returning-regular-operations-after-covid-19/renew-your-medicaid-or-chip-coverage/index.html, which

provides state Medicaid or CHIP agency enrollment links and contact information for each state.

Consumers should contact their Medicaid or CHIP agency as soon as possible to ensure the agency has

their up-to-date contact information, and to ensure they are receiving all communications regarding the

status of their enrollment.

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense.

The contents of this document do not have the force and effect of law and are not meant to bind the public in any way, unless

specifically incorporated into a contract. This document is intended only to provide clarity to the public regarding existing

requirements under the law.

Q10: Does this announcement of the temporary Unwinding SEP also apply to State-Based

Marketplaces (SBMs) that operate their own eligibility and enrollment platforms?

A10: SBMs that operate their own eligibility and enrollment platforms can offer this Unwinding SEP for

their populations per federal regulation at 45 CFR 155.420(d)(9). Consumers losing Medicaid or CHIP

coverage in SBM states should check with their SBM to find out if they’re offering this SEP and any

next steps. Consumers can find information about their respective State Marketplace by visiting

https://www.healthcare.gov/marketplace-in-your-state/.