Guidance on Hardship Exemptions for Individuals Ineligible for APTC or CSRs Due to Income; Streamlining Exemption Pathways
Guidance governing FFE hardship exemptions for plan year 2026 and future years that allow individuals ineligible for APTC or CSRs due to projected household income to obtain catastrophic coverage; applies to consumers using the Federally-facilitated Exchange and SBEs that opt into FFE processing.
No material clinical or coverage changes in this revision.
Hardship Exemption Coverage Criteria
Hardship exemption criteria for APTC/CSR ineligibility
Covered when ALL of the following are met:
ALL of the following
Income-based ineligibility (ONE of)
- Projected annual household income below 100% of the federal poverty level (FPL)
- Projected annual household income above 250% of the federal poverty level (FPL)
- Applies to consumers in FFE states and to consumers in SBEs that choose FFE exemption processing (currently all SBEs except CA, CT, MD, and DC)
- Exemption may cover the month before, the month(s) during which, and the month after the circumstance as provided under 45 CFR §155.605(d)(1)
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