The Ins and Outs of the New Approach to Special Enrollment Periods: Pre-enrollment Verification (SEPV)

As we’ve blogged about previously, healthcare.gov will be rolling out a special enrollment period pre-enrollment verification (SEPV) process starting June 23, 2017. This means that people experiencing certain life events allowing them to enroll into Marketplace coverage through a special enrollment period will need to prove their eligibility before they can enroll.

Who does the SEPV apply to?

The SEPV will apply to new Marketplace applicants experiencing any of the following four events: loss of qualifying coverage or minimum essential coverage (MEC); a permanent move; gaining a dependent (marriage, birth, adoption); and a Medicaid or CHIP denial. The SEPV process will be implemented in phases: applying to consumers losing MEC and permanently moving in June; and then extending to those gaining a dependent and experiencing a Medicaid/CHIP denial in August.

How will the SEPV work?

Similar to the data matching issue (DMI) process, Healthcare.gov will generate a special enrollment period verification issue (SVI) when consumers who are experiencing a loss of MEC or a permanent move apply for coverage. Consumers have 30 days after selecting a plan to submit verifying documents of their qualifying event. Consumers can either upload their verifying documents via healthcare.gov or submit them by mail. If there are multiple applicants on an application with the same qualifying event, one applicant can submit verifying documents to resolve the SVIs.

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. When coverage becomes effective depends on the rules under the qualifying event. For loss of MEC, the effective date of coverage is the first of the month following the loss of MEC or plan selection. For a permanent move, the effective date of coverage depends on when the consumer has selected a plan: if between the 1st and 15th of the month, coverage begins the first day of the following month; if between the 16th and end of the month, coverage begins the first day of the second following month.

What can consumers expect under the SEPV?

Marketplace officials have pledged to conduct outreach to consumers with a SVI. After submitting an application for Marketplace coverage, consumers will receive an eligibility determination notice (EDN). In addition to information about the consumer’s eligibility for marketplace coverage and financial assistance, the EDN  will inform the consumer that he or she needs to prove eligibility for the special enrollment period (SEP), what types of documents are acceptable, and when they are due. After selecting a plan, consumers will also receive a pended plan selection (PPS) notice that their plan selection is pended until they resolve their SVI. The PPS notice will also include a list of next steps for the consumers to take to resolve their SVI. The Marketplace will also send warning and reminder notices to select a plan or to submit documents or both, and also call consumers about submitting documents before the 30-day deadline.

What happens after consumers submit SVI documents?

Once a consumer submits verifying documents, the Marketplace is supposed to review them to ensure that they verify the qualifying event. If the documents are in order, the Marketplace will send a SVI resolution notice. If the documentation is insufficient, the Marketplace is supposed to explain why it cannot resolve the SVI and ask for additional documentation. While the Marketplace will not stop the 30 day clock for an insufficient document notice, consumers may ask the Marketplace for a “good faith extension (GFE)” and request additional time to submit documents. Consumers who do not receive a notice after submitting their documents will be encouraged to contact the Marketplace to check on the status of their SVI.

Issues for Assisters and Consumers

The SEPV process will require more hands-on help for consumers. Consumers will need to obtain and to submit acceptable documentation verifying their life events. Pursuant to recent policy changes, consumers who are moving must not only confirm that they moved in the 60 days before applying for marketplace coverage, but also that they had qualifying coverage at least one day in the 60 days prior to the move. Consumers who are homeless may submit a reference letter from a person who can confirm their residency, but the person confirming residency must also submit documents confirming his or her own residency. Additionally, consumers moving from outside of the U.S. do not need to prove prior coverage, but will need documents to provide that they lived outside of the U.S. for at least one of the 60 days prior to their move to the U.S.

In some cases, consumers may generate more than one SVI if they update their Marketplace application with a different qualifying life event. Once the consumer selects a plan under an updated application, the SVI will apply for the updated qualifying event and the Marketplace will close the prior SVI. However, if the consumer resolves the SVI associated with the initial application and makes a plan selection, the Marketplace will close the second SVI.

At the same time the process of applying for SEPs gets more complicated and burdensome for consumers, it appears this administration is doing very little to raise general awareness that SEP opportunities exist for people undergoing life changes. As we blogged about before, SEP awareness and use are low compared to the millions of people who lose their job-based coverage and move annually, many of whom are young and healthy. Also unclear is whether the administration will be tracking and making available data on how many consumers start but do not complete enrollment in a Marketplace plan because of a problem with their SEP verification. If previous data on the previous SEP confirmation process is any indication, this process will likely decrease the already low enrollment through SEPs.

One thought on “The Ins and Outs of the New Approach to Special Enrollment Periods: Pre-enrollment Verification (SEPV)

  1. I think there’s a mistake in your article regarding coverage effective dates. For loss of MEC, coverage always begins the first day of the following month even if the consumer enrolled after the 15th of the current month. That’s how the rule works now and I don’t believe the new process changes it. The article is correct regarding coverage effective dates for the permanent move SEP.

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