New Special Enrollment Confirmation Process Effective June 17, 2016: What it Means for Consumers

In its continuing effort to address insurers’ concerns about consumers using special enrollment periods only when they get sick, the administration announced that the new special enrollment confirmation process begins June 17, 2016. The special enrollment confirmation process, which we blogged about previously here, requires verifying documentation for the five most commonly used special enrollment periods (SEPs): loss of qualifying coverage (referred to as minimum essential coverage); permanent move; marriage; birth; and adoption or court order to provide health insurance.

The administration also provided eligibility determination notices that the marketplace will send to consumers after they have applied for marketplace coverage if they’ve used one of the five most commonly used SEPs. In general, consumers will have 30 days from when they submitted the marketplace application to submit the verifying documentation. The eligibility determination notice will have the specific deadline date. Consumers are encouraged to use the document uploading function on to submit their documents. While consumers can still mail in their documents, the uploading function will provide confirmation that documents have been uploaded successfully. Under the confirmation process, the marketplace will not be sending notices that documents were received. Consumers that provide their documentation, however, do not need to take any further action unless the marketplace notifies them.

With the announcement that the special enrollment confirmation process will be implemented, consumers and assisters are likely to have questions. We’ve come up with a few, below, that may help.

What happens if I don’t submit the verifying documents?

According to the eligibility determination notices, consumers that don’t send verifying documents “could be found ineligible for this Special Enrollment Period,” and “could lose Marketplace coverage and any advance payments of the premium tax credit and cost-sharing reductions (if applicable), possibly going back to the date it started.”

I can’t get a copy of any of the documents verifying my special enrollment, what can I do?

For SEPs based on losing qualifying coverage or permanently moving, the corresponding eligibility determination notices allow consumers to submit letters explaining why they cannot get the documents to prove the SEP. With a loss of qualifying coverage SEP, the letter must include information about the coverage you had and when you lost it or will lose it. For the permanent move SEP, the letter must provide the old and new address. The marketplace may ask for additional information. The other SEPs based on marriage, birth of a child or adoption/court order do not have explanation letters on the list of verifying documents. However, under all three SEPs, consumers can submit letters or statements from witnesses of the event to verify their SEP; examples include: for marriage – a statement signed from the person officiating the event, for birth of a child – a letter from the doctor or hospital, for adoption – a letter showing the date of adoption signed by the court.

Will I get a notice from the marketplace that my documents were received?

No. Once you submit documentation, no further action is required and your coverage is confirmed unless the marketplace contacts you for additional information.

If I lose coverage because I never submitted my verifying document, can I apply again for a special enrollment?

Yes, but only if you qualify for another special enrollment. In this particular situation, loss of marketplace coverage because you failed to submit verifying documents does not trigger a special enrollment due to loss of qualifying coverage or loss of minimum essential coverage. If you do have another life event like you move or get married, then you could apply based on those events for a special enrollment.

Can I submit more than one verifying document?

Yes, you can.

It’s unclear how well or easily the confirmation process will work for consumers and insurers alike. As some consumer advocates have noted, awareness about special enrollment periods is low and any process requiring additional documentation may deter the millions of people experiencing a life event like moving or losing qualifying coverage to forgo getting health insurance. Ultimately the confirmation process may work in deterring those who wish to take advantage of SEPs, but may also keep out the many healthy consumers who do legitimately qualify for a SEP. Going forward, we’ll keep watching this area for any developments.



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