As Congress shifts from deliberating on how to replace the Affordable Care Act (ACA) to considering ways to stabilize the individual market, enrollment in ACA marketplaces continues. Recently, the administration implemented two operational changes: part 2 of pre-verifying eligibility for certain special enrollment periods (SEPs) and a new process of verifying immigration status. Both changes affect enrollment through the federally facilitated marketplace and states using healthcare.gov.

Phase 2 of Special Enrollment Period Pre-enrollment Verification (SEPV)

The administration implemented phase 2 of the special enrollment period pre-enrollment verification (SEPV) process that was announced in the market stabilization rule issued earlier this year. As we blogged about previously, the SEPV process requires individuals that experience common life events to submit documentation verifying their special enrollment eligibility before they can enroll into coverage. Earlier this summer, the administration implemented SEPV for individuals losing qualifying coverage and permanently moving. On August 23, the SEPV process began applying to individuals getting married, gaining or becoming a dependent through adoption, foster care or court order, and getting denied for Medicaid or CHIP.

Under the SEPV process, after an applicant has selected a plan and submitted an application, the marketplace’s eligibility determination notice will indicate whether or not a SEP verification issue (SVI) exists requiring documentation before the applicant can enroll. The updated eligibility determination notice will also include a list of acceptable documents to verify the qualifying life event and instructions on how to submit them. Unlike other types of qualifying events, the marketplace will attempt to electronically verify the special enrollment periods based on a Medicaid or CHIP denial. If the marketplace is successful, the individual can enroll without having to submit documentation of his or her SEP eligibility. However, if the marketplace is unable to electronically verify the Medicaid or CHIP denial, an individual will have to submit documentation to resolve the SVI. Verifying documents must clearly identify who was determined ineligible for Medicaid or CHIP and also include the date of determination.

Regardless of which type of qualifying event triggers a SEP, consumers have the option to contact the marketplace after resolving a SVI to request a later coverage effective date if a consumer has to pay two or more months of retroactive premiums because of verification issues. The later date can be no more than one month from the date coverage would otherwise have been effective. Consumers must contact the marketplace call center within 30 days of receiving their SVI resolution notice to request this later coverage effective date.

Additional New Functionality for Verifying Immigration Status

The second operational change involves the process to verify citizenship or immigration status. The marketplace uses the Department of Homeland Security’s (DHS) Systematic Alien Verification of Entitlements (SAVE) to verify citizenship or immigration status in real-time when an applicant applies for marketplace coverage. If an applicant’s immigration status cannot be immediately verified, the marketplace will notify the applicant of a data matching issue (DMI) that will require the applicant to send verifying documents to resolve. Under the new marketplace functionality called Step 2, the marketplace may automatically send information to DHS to electronically verify applicants’ citizenship or immigration status. The new Step 2 process, which can take three to five days, will attempt to resolve citizenship or immigration issues without requiring additional documentation from an applicant.  Applicants, however, are still free to provide verifying documents to the marketplace if they choose.

So how will this work? Upon completing a marketplace application, the marketplace provides an eligibility determination notice that has new language indicating the marketplace is attempting to electronically verify the citizenship or immigration-related DMI. If Step 2 is able to resolve the DMI, the marketplace sends a resolution notice to the applicant; if Step 2 cannot resolve the issue, the marketplace sends a follow up notice to let the applicant know that they will need to send documents to resolve the DMI.

Since the first phase of the SEPV process began just two months ago, it may still be too early to get data or to know how well this process is working. According to some groups providing technical assistance to assisters, the process appears to be working smoothly. However, whether this new SEPV process discourages potential consumers from enrolling continues to be an unanswered question; in particular, whether these additional requirements discourage healthier individuals who may not see the value of going through the process. And until the administration releases SEP-related data, we may never know. As to the new Step 2 process, we’ll have to wait to see if this new functionality helps to reduce some of the problems that have been previously identified for immigrant applicants.