New Rules on Special Enrollment Periods: What Do They Mean for Consumers and the Assisters Who Help Them?

The administration recently issued a new rule tightening the special enrollment periods (SEP) for the individual insurance market. In doing so, the Centers for Medicare and Medicaid Services (CMS), which administers the ACA’s health insurance marketplaces, is responding to reports from insurers that some consumers who did not sign up during open enrollment are taking advantage of SEPs when they get sick later in the year.

What do the new rules for SEPs require?

The new rule focuses on the SEP that’s triggered when a consumer permanently moves to a new area and gains access to new marketplace plans. Under the previous rule, consumers could access this SEP when they moved, regardless of whether or not they had prior coverage. Under the new rule, consumers who are moving must have had at least one day of other health insurance coverage or minimum essential coverage in the 60 days prior to their move.

There are a few exceptions to this requirement. If one of the following applies then the consumer doesn’t have to show prior coverage:

  • being released from incarceration;
  • moving back to the United States from abroad; and
  • moving to a state that expanded Medicaid and having a change in income making that consumer eligible for financial assistance.

The rule also eliminates the requirement that people be allowed to use the moving SEP 60 days in advance of a move and eliminates the SEP for the loss of a dependent due to death, divorce, or separation, both of which were scheduled to go into effect in January 2017. The new rule goes into effect on July 11, 2016.

What does this mean for consumers and assisters?

There currently is no change in how consumers can access a SEP either through healthcare.gov or by calling the marketplace. They can still access special enrollments if they have a qualifying life event by attesting to eligibility. These life events include:

  • loss of other qualifying health coverage or minimum essential coverage, for example, losing employer sponsored coverage
  • changes in household size due to marriage, birth or adoptions
  • permanently moving*
  • changes in eligibility for marketplace coverage or financial assistance*
  • enrollment or health plan error by the marketplace, assister or health plan
  • special circumstances like being a victim of domestic abuse or spousal abandonment or other situations like a natural disaster preventing someone from enrolling during open enrollment

*additional requirements apply

However, CMS indicates that it will implement its special enrollment confirmation process sometime in 2016, which we previously blogged about here. While consumers can continue enrolling in coverage through one of the above SEPs, healthcare.gov may require them to upload or mail in verifying documents for the most frequently used SEPs: loss of minimum essential coverage or other qualifying health coverage, permanent move, birth, adoption and marriage. As part of the confirmation process, the FFM will be sending notices to consumers whose verifying documents it does not receive and can terminate coverage if they don’t receive documents or cannot verify SEP eligibility.

CMS has not provided a specific date of when it will be rolling out their special enrollment confirmation process, nor have they provided a list of qualifying documentation. CMS, however, has promised resource guides about the special enrollment confirmation process and acceptable documents to assisters, brokers and agents. We will be sure to update you on any movement in this area.

2 thoughts on “New Rules on Special Enrollment Periods: What Do They Mean for Consumers and the Assisters Who Help Them?

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