Special enrollment periods (SEPs) are an important way to make sure that people who lose health insurance during the year or who experience major life changes like getting married or having a child have the opportunity to enroll in coverage through the Health Insurance Marketplaces outside of the annual Open Enrollment period. SEPs are a longstanding feature of employer insurance, and without them many people would lack options to maintain continuous coverage. But it’s equally important to avoid SEPs being misused or abused.
At CMS, we are always monitoring the health and operations of the Marketplace and looking for ways to improve. We are focused on continually maintaining and refining a set of Marketplace rules that create a healthy, stable and balanced risk pool. Concerns have been recently raised about whether current Marketplace rules and procedures are sufficient to ensure that only those who are eligible enroll through SEPs. In response to that feedback, today we are announcing a new Special Enrollment Confirmation Process that will address these concerns in the 38 states using the HealthCare.gov platform. These changes will enhance program integrity and contribute to a stable rate environment and affordability for consumers.
Once the new Special Enrollment Confirmation Process is implemented, all consumers enrolling through the most common HealthCare.gov SEPs will need to submit documentation to verify their eligibility to use an SEP. The Special Enrollment Confirmation Process will be accompanied by other improvements to the SEP application process, described below. Today’s announcement represents a major overhaul of the SEP process.
Over the next few weeks, CMS will invite comment from consumer advocates, insurance companies and other stakeholders on the key features of the new Special Enrollment Confirmation Process, such as communication with consumers, acceptable documentation, and refining and targeting the verification process. These comments will help inform implementation of the new process. This announcement builds on action CMS has taken to eliminate unnecessary SEPs and clarify the rules for other SEPs.
HOW SPECIAL ENROLLMENT CONFIRMATION WORKS
Document Submission by Consumers: Beginning in the next several months, all consumers who enroll or change plans using an SEP for any of the following triggering events will be directed to provide documentation:
· Loss of minimum essential coverage,
· Permanent move,
· Adoption, placement for adoption, placement for foster care or child support or other court order, or
These SEPs represented three quarters of HealthCare.gov consumers who enrolled or changed plans using an SEP in the second half of 2015.
We will provide consumers with lists of qualifying documents, like a birth or marriage certificate. Consumers will be able to upload documents to their HealthCare.gov account or mail them in.
Document Verification by CMS: CMS will institute a verification process for consumers who enroll or change plans using an SEP in 2016. The Special Enrollment Confirmation Process is modeled after approaches used by the Internal Revenue Service. We will review documents to ensure consumers qualify for an SEP and will follow up with consumers if there is a question or problem. Consumers need to be sure to provide sufficient documentation. If they don’t respond to our notices, they could be found ineligible for their SEP and could lose their insurance.