Guidance on Hardship Exemptions for Individuals Ineligible for APTC/CSRs Due to Income; Streamlining Exemption Pathways
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Guidance governing circumstances and processing for FFE hardship exemptions that allow individuals ineligible for APTC or CSRs due to projected household income to enroll in catastrophic coverage; affects consumers applying through the FFE and SBEs that opt into FFE processing.
Adds an example of hardship for plan year 2026 and future years allowing individuals who are ineligible for APTC or CSRs based on projected household income to qualify for a hardship exemption to enroll in catastrophic coverage.
Begins streamlining application processing starting November 1, 2025 to allow consumers to apply for the income‑based hardship exemption via HealthCare.gov, enhanced direct enrollment partners, or the paper hardship application.
Specifies which SBEs currently choose to have exemptions processed through the FFE (all except California, Connecticut, Maryland, and DC).
Income-based Hardship Exemption Coverage Criteria
Income-based hardship exemption criteria
Covered when ALL of the following are met:
ALL of the following
ONE of
- Application submitted through HealthCare.gov (FFE).
- Application submitted through a certified enhanced direct enrollment partner.
- Signed paper hardship exemption application submitted selecting 'Hardship 14 - You experienced another hardship' and including a brief explanation of how circumstances prevented obtaining coverage.
Operational: this exception is intended to expedite determination and access to catastrophic coverage when documentation supports an alternative hardship reason.
Coding and Eligibility Thresholds
| No codes listed |
Application Pathways and Processing Guidance
Application & eligibility evaluation pathways
Allow consumers to apply for coverage and financial assistance on HealthCare.gov or through certified enhanced direct enrollment partners and have eligibility for the income‑based hardship exemption evaluated based on projected annual household income; consumers may also submit a paper hardship exemption application. To apply for catastrophic coverage via this pathway, consumers may apply starting November 1, 2025, when open enrollment for plan year 2026 begins.
- Consumers may apply on HealthCare.gov or through a certified enhanced direct enrollment partner.
- Consumers may also complete and submit the paper hardship exemption application (select Hardship 14 in Section 2 and provide a brief explanation).
- Eligibility will be evaluated and determined based on projected annual household income.
Paper application processing exception (CMS may change hardship reason)
When processing a completed, signed paper hardship exemption application, CMS may approve a different hardship reason than the one originally requested if the documentation or written explanation provided meets the established criteria for another applicable hardship reason. This streamlined paper‑processing exception begins November 1, 2025.
- Applies only when the consumer has completed and signed the hardship exemption application.
- CMS may approve a different hardship reason if accompanying documentation or written explanation supports a different applicable hardship reason than the one attested on the form.
Key Definitions
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