CMS Outlines Special Enrollment Period Rules for ACA Exchanges
CMS will enforce newly adopted rules for special enrollment periods on the Affordable Care Act (ACA) exchanges.
Source: Thinkstock
By - Starting on June 23, 2017, CMS will be enacting its new rules regarding special enrollment periods (SEP) for the ACA marketplace.
The agency released the new special enrollment rules earlier this year that will alter participation criteria for enrollees who utilize the marketplace exchanges’ special enrollment windows.
The special enrollment period pre-enrollment verification (SEPV) program will apply to all states and counties which are currently served by the ACA health insurance exchanges.
“CMS is committed to ensuring access to high quality affordable healthcare for all Americans and these actions are necessary to increase patient choices and to lower premiums,” said CMS Administrator Seema Verma.
The SEPV will ensure that individuals seeking to enroll during a SEP prove their eligibility before finalizing enrollment in a healthcare plan.
The SEPV will only apply to new marketplace applicants who have experienced one of the four qualifying life events: loss of qualifying coverage or minimum essential coverage (MEC); a permanent move; gaining a dependent (marriage, birth, adoption); or a Medicaid or CHIP denial.
Consumers will need to obtain and submit acceptable documentation verifying these life events.
In the case of changing address, recent policy changes require applicants to confirm that they moved in the 60 days before applying for marketplace coverage, and also that they had qualifying coverage at least one day in the 60 days prior to the move.
The SEPV process will be implemented in two phases over the summer: in June for those consumers losing MEC and permanently moving and in August to those gaining a dependent and experiencing a Medicaid/CHIP denial.
SEPV applicants will receive a special enrollment period verification issue (SVI). Applicants will then have 30 days after selecting a plan to submit verifying documents of their qualifying event.
During the 30-day window, a consumer’s plan selection is pended until the consumer resolves the SVI. Once a consumer resolves the SVI, the Marketplace sends the plan enrollment to the insurer. A consumer is then enrolled into coverage after paying his or her first month’s premium.
Marketplace officials will reach out to applicants as to what types of qualifying documents are acceptable, with follow up warning and reminder notices to submit the documents before the 30-day deadline.
If the marketplace determines the documents submitted are not sufficient, it will inform the applicant who may then apply for an extension to the 30-day deadline.
For applicants who are homeless, or have been residing abroad, there are different document requirements.
Traditionally, public awareness of SEPs has been low when contrasted to the numbers of individuals who lose employer-based coverage annually.
CMS does not have conclusive data about the number of applicants who started applications during SEPs, but did not complete due to a lack of, or difficulty in obtaining, qualifying documents.
CMS noted that since implementing its previous Special Enrollment Confirmation Process, there had been a 20 percent reduction in the number of enrollments during the special enrollment periods compared to 2015. Data from CMS showed a 2016 week-by-week decrease in enrollment via special enrollment periods over corresponding weeks in 2015.
