SSM creates SEP

June was a huge month for the Supreme Court. Not only did we receive the long-awaited decision on the premium tax credits, confirming that they are indeed available in every state, but the Court also issued a historic ruling permitting same-sex marriage nationwide.

We all know the implications of the King v. Burwell decision – it means the subsidies to help people purchase health insurance will continue uninterrupted and that we’ll continue to see massive growth in the individual market. More than ever, brokers need a strategy to sell individual health plans quickly and efficiently. The same-sex marriage ruling, though, will also create some big changes in the health insurance industry, changes that will affect agents no matter what market segment they serve.

Group brokers, for instance, will need to inform their employer clients that marriage is a qualifying event under HIPAA, and that now includes same-sex couples. Some companies that previously allowed domestic partners to be covered on the group health plan may now reconsider their policy and require employees who want to cover their same-sex partners to be married. And, of course, some employers will object to covering same-sex spouses and may ask agents how to get around the ruling. This is one that brokers will need to be careful answering. As NAHU Explains:

The ruling will be applied differently for fully insured plans and self-insured plans. Any fully insured plan will be required to extend coverage to spouses regardless if they are same-sex. However, self-insured plans have more discretion, as there is no legal requirement that a self-insured plan include a same-sex spouse. Companies with religious objections to extending benefits to same-sex spouses could theoretically self-insure to avoid offering coverage, but legal scholars warn that companies may open themselves up to discrimination lawsuits in the future should they decide not to offer benefits to same-sex spouses. A patchwork of different state laws relating to non-discrimination of benefits may further complicate this. (Source:

Agents who serve the Medicare market will also need to be prepared to answer their clients’ questions. The following is taken directly from the website:

On June 26, 2013, in United States v. Windsor, the Supreme Court ruled that Section 3 of the Defense of Marriage Act (DOMA) is unconstitutional. Medicare is no longer prevented by DOMA from recognizing same-sex marriages for determining entitlement to, or eligibility for, Medicare. Social Security is now processing some Medicare enrollments for same-sex spouses, including:

  • Enrollments for free Medicare Part A (Hospital Insurance) for uninsured spouses age 65 or older based on the work history of a current or former spouse
  • Enrollments for people with End Stage Renal Disease (ESRD) based on the work history of a current or former spouse
  • Reductions in Part A premiums based on the work history of a current or former spouse
  • Requests for Special Enrollment Periods based on group health plan coverage from current employment of a same-sex spouse
  • Reductions in late-enrollment penalties based on group health plan coverage from current employment of a same-sex spouse60-day

And, of course, agents who sell to individuals are impacted by this decision. Specifically, it could create an opportunity for brokers to make a few more sales in-between open enrollment periods. That’s because marriage is one of the qualifying events that creates a 60-day special enrollment period for Marketplace plans.

As explains, same-sex spouses have exactly the same rights as any other married couple: “For coverage starting in 2015, an insurance company that offers health coverage to opposite-sex spouses must do the same for same-sex spouses.” Additionally, ” an insurance company can’t discriminate against them when offering coverage. This means that it must offer to same-sex spouses the same coverage it offers to opposite-sex spouses.”

Same-sex couples who get married can also apply for premium tax credits as a family: “The Marketplace also treats married same-sex couples the same as married opposite-sex couples when they apply for premium tax credits and lower out-of-pocket costs on private insurance plans. This is true in all states. A couple may be eligible for premium tax credits on Marketplace plans as long as the taxpayer and spouse file a joint federal tax return for the year they’re getting Marketplace coverage. Married couples must file jointly in order to be eligible for tax credits, regardless of gender.”

For brokers who have a private exchange site through HPA, the call center is well-equipped to handle these special enrollment opportunities. Brokers who don’t yet have a private exchange site can learn more here.


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