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Health Care Reform

Today, CMS issued a Blog on Clarifying, Eliminating and Enforcing Special Enrollment Periods as well as two FAQs:

(1) SEPs no longer utilized by the Federally-facilitated Marketplace and State-based Marketplaces using the Federal Platform and Future CMS Actions, and (2)FAQs on the Marketplace Residency Requirement and the Special Enrollment Period due to a Permanent Move. The action we are taking today announces the elimination of several unnecessary special enrollment periodsclarifies the definitions of other special enrollment periods, and provides stronger enforcement so that special enrollment periods serve the purpose for which they are intended and do not provide unintended loopholes.

1.  Eliminating Unnecessary Special Enrollment Periods: Last month, we announced that the Tax Season special enrollment period will no longer be offered. Today we are announcing the elimination of six other special enrollment periods that are no longer needed. Just as the Marketplace evolves, so too does consumer behavior. The rules we use to operate the Marketplace need to keep up with these changes. As such, special enrollment periods are no longer available for:

    • Consumers who enrolled with too much in advance payments of the 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 determination of their advance payments of the premium tax credit
    • Lawfully present non-citizens with incomes below 100% FPL who experienced certain processing delays
    • Consumers who were 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

We’ll continue to monitor how special enrollment periods are used and may make changes in the future as Marketplace systems and operations continue to improve.

2.  Clarifying Eligibility: Our review of current special enrollment periods also showed that some of the eligibility guidelines need to be further clarified so consumers can understand the intent and so they will not be abused. Today we are updating guidance to more clearly define the special enrollment period that is available to consumers who permanently moved, and as a result, gained access to new health plans. Specifically, we clarify that this special enrollment period cannot be used for a short-term or temporary move where the consumer doesn’t plan to stay in their new location, including situations in which a consumer is admitted to a hospital for treatment in a different area. This clarification is intended to assist consumers, brokers, issuers and others in understanding who is eligible for this special enrollment period.

If we identify other areas where the rules for special enrollment periods are unclear, we will issue additional clarifying guidance as needed.

3.  Enforcing the Rules: Finally, we will take steps to make sure that consumers understand and comply with the rules. We will conduct an assessment of plan selections that are made through certain special enrollment periods to evaluate whether consumers properly accessed coverage. Our program integrity team will pull samples of consumer records nationally and may request additional information from some consumers or take other steps to validate that consumers properly qualified for these special enrollment periods. The findings from the assessment will help us to inform future policy and operational improvements to enhance program integrity. Additional details will be provided in the coming weeks.

We will also emphasize more strongly to applicants that the law requires that consumers provide accurate information to the Marketplace, and they may be subject to penalties under federal law if they intentionally provide false or untrue information.