The Obama administration recently issued guidance eliminating six qualifying events for a special enrollment and clarifying the marketplace residency requirement and the special enrollment related to a permanent move. The administration took this step in response to insurer concerns about special enrollment periods (SEPs). Insurers argue that some consumers are taking advantage of special enrollment policies to enroll outside of open enrollment when they become sick and then rack up high medical claims.
Elimination of Certain SEPs
The administration has concluded that some special enrollment periods are no longer necessary. Specifically, the administration has said that the following events will no longer trigger a SEP:
- Consumers who enrolled with too much advance premium tax credit because of a redundant or duplicate policy
- Consumers who were affected by an error in the treatment of Social Security income for tax dependents
- Lawfully present non-citizens that were affected by a system error in determining their advance premium tax credits
- Lawfully present non-citizens with incomes below 100 percent of the Federal Poverty level who experienced certain processing delays
- Consumers eligible for or enrolled in COBRA and not sufficiently informed about their coverage options
- Consumers who were previously enrolled in the Pre-Existing Condition Health Insurance Program
The administration announced two additional measures related to special enrollment periods. First, it will review the most frequently used special enrollments – loss of minimum essential coverage and permanent moves – and try to determine whether people are using them legitimately. CMS will provide additional information about this review and will use the results of its review to inform future policy. Second, it will review healthcare.gov call center scripts to ensure that they clearly inform consumers about penalties associated with providing false information on enrollment applications.
Clarifying the Marketplace Residency Requirement and the “Permanent Move” SEP
CMS also published a guidance document on the residency requirements for marketplace coverage and the special enrollment opportunity that accompanies a permanent move. In an effort to address insurers’ concerns about how some people may be using this SEP, the administration clarifies that moving temporarily to a state for medical treatment at a hospital or health system does not establish residency in that state, nor does it trigger a special enrollment right. Residency is established by meeting two requirements: (1) living at a location and (2) intending to live at that location or having a job commitment or looking for a job. The person does not need to have a fixed address or be employed.
So what does this mean for consumers who have moved or changed their location and need new health coverage? We’ve added some new frequently asked questions to our Navigator Guide, and reproduced them here:
I’m a seasonal worker and spend 4 months of the year in a different state. Can I get a special enrollment opportunity to sign up for a new plan during the time I’m in that state?
Yes, in this situation, you meet the marketplace residency requirements of the state you live in for 8 months and the state you work in for 4 months. Since the residency requirements are met, you are eligible for a special enrollment right to sign up for a new plan when you move to the new state.
My husband and I are retired and spend 6 months of the year in Florida. Can we get a special enrollment opportunity to enroll in a new plan when we move to Florida, even though we’ll only be there for half the year?
Yes. You have the “intent to reside” in Florida for six months, which the marketplace does not consider a “temporary absence” from your home state. Because you will be there for at least an “entire season or other long period of time,” you are eligible to enroll in Florida under a permanent move special enrollment period. You will also qualify for a SEP when you move back to your home state in the spring.
I have been diagnosed with a serious health condition and will be obtaining care from an out-of-state hospital. During my course of treatment I’ll be living near the hospital. Can I qualify for a special enrollment period based on my “move” to a different state?
No, you do not meet the marketplace residency requirements for the permanent move special enrollment since your absence is temporary and do not intend to live in the state where you’re receiving treatment, but rather intend to be in the state to receive treatment. Current guidance is clear that residency requirements are not met in this circumstance.
I’m a college student and will be going to an out-of-state university. Can I qualify for a special enrollment period to sign up for a new plan in the state where I’ll be going to school?
It depends. You may be eligible to buy coverage in the state where you attend school as long you can establish residency; otherwise your residency is determined by your parents or caregivers’ residency. If you can establish residency, then you may qualify for a permanent move SEP.
You can access these and many more questions about marketplace eligibility and enrollment via Georgetown CHIR’s Navigator Resource Guide.