The Centers for Medicare and Medicaid Services (CMS) recently announced two major policy changes related Special Enrollment Periods in the Marketplace. Here we will explain what has changed, why, and what consumers need to know.
Special Enrollment Periods (SEPs) allow consumers to enroll in a Marketplace health insurance plan outside the open enrollment period that occurs near the end of each year. The most common SEPs are triggered by changes in life circumstances, such as loss of employer-based insurance coverage, marriage, or moving to a new state, but there are other circumstances that trigger SEPs as well.
In January, CMS announced the elimination of certain SEPs and clarified the use of an SEP for a consumer’s relocation. In February, CMS announced a new process for verifying the need for the most common SEPs.
Elimination of Some SEPs
Elimination of Some SEPs
There won’t be as many circumstances allowed for special enrollment as were previously permitted. The following are circumstances that will no longer trigger SEPs:
- Receipt of excess advance premium tax credits due to duplicate policies
- Errors in Social Security income for dependents
- Errors in advance payments for tax credits for lawfully-present non-citizens, or delayed processing for individuals with incomes below 100% FPL (federal poverty level)
- Lack of information about options for coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act -- right to choose to continue group health benefits after employment)
- Previous enrollment in the Pre-existing Condition Health Insurance Program
Change in Location
Clarification has been made regarding eligibility for an SEP as it relates to moving to a new location. Special enrollment will be allowed only if the move is intended to be permanent, not temporary. It is important for families of children with special needs to know that a long-term hospital stay in a different area does not constitute a reason for special enrollment.
New SEP Confirmation Process
Beginning within the next several months, all consumers who enroll or change plans using an SEP for the following reasons will be required to provide documentation of the need to use the SEP:
- Loss of minimum essential coverage
- Permanent move
- Adoption, placement for adoption, placement for foster care or child support or other court order
Rationale for and Enforcement of the Changes
In addition to requiring documentation for some SEPs, CMS will monitor plans chosen through an SEP to ensure that the special enrollment was justified. This may include contacting consumers for additional information requests to verify eligibility. These changes in SEP policies were meant to ensure the proper use of SEPs, so that insurers are not disadvantaged by people misusing SEPs as a means to avoid purchasing insurance until they get sick. Without such protection, insurers might not be able to offer affordable coverage or might choose to leave the Marketplace. There still will be special enrollment for individuals who lose coverage due to life changes and other special circumstances. (See resources.)
- https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-02-24.html (new SEP confirmation process)
- https://blog.cms.gov/2016/01/19/clarifying-eliminating-and-enforcing-special-enrollment-periods/ (elimination of certain SEPs)
- https://blog.cms.gov/2016/02/24/the-new-special-enrollment-confirmation-process/ (new SEP confirmation process)
- https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ (most common circumstances that trigger an SEP)
- https://www.healthcare.gov/sep-list/ (additional circumstances that trigger an SEP)
Center of Budget and Policy Priorities Health Reform Beyond the Basics: Special Enrollment Periods: