CMS Announces New Requirements To Enroll In Special Enrollment Periods

Implementing Health Reform. The Affordable Care Act, of course, abolished health status underwriting in the individual market and required coverage of preexisting conditions. This, however, created a problem — if individuals could sign up for coverage literally on their way to the hospital, individuals could forego coverage while healthy and the insured risk pool would become untenable. Insurance would become unaffordable, if insurers were willing to offer it. This problem was solved in part through the individual responsibility provision. Individuals must maintain coverage or pay a penalty. But it is also addressed through requiring people to sign up for coverage during an annual open enrollment period and not wait until they get sick.

But the life circumstances of individuals change over the course of a year — people get married, have children, lose their coverage when they lose their jobs, or move. Thus the ACA provides for special enrollment periods so that individuals can enroll throughout the year rather than have to wait for the next open enrollment period when making them wait would be unreasonable.

The ACA regulations and guidance define when special enrollment periods are available. Until now, individuals have been able to claim special enrollment period eligibility and enroll through Healthcare.gov enroll through Healthcare.gov on the basis of their attestation of eligibility without having to produce documentary proof. Insurers have claimed, however, that special enrollment periods are being abused and that high-cost individuals enrolling through special enrollment periods are distorting the risk pool.

On February 24, 2016, CMS announced at The CMS Blog that it is going to begin requiring documentary verification to determine eligibility for some special enrollment periods for the federal exchange, Healthcare.gov. In an accompanying fact sheet, CMS said that it would require documentary verification for the most common SEPs:

• loss of minimum essential coverage;
• permanent move;
• birth;
• adoption, placement for adoption, placement for foster care or child support, or other court order; or,
• marriage.

These SEPs account for three quarters of special enrollments.

Applicants will be required to attest their understanding of the SEP eligibility requirements, including documentation requirements, and that their statements are truthful. CMS will provide a list of documents that are acceptable for verification of eligibility. Consumers may upload these documents to their account or mail them in. CMS will review the documents and inform the consumer if more information is needed. Consumers who fail to provide appropriate documentation may lose their eligibility. Although the guidance does not address this, presumably consumers will continue to have 90 days to provide verification.

CMS will modify the Healthcare.gov application process to clarify eligibility requirements for the permanent move and loss of minimum essential coverage SEPs. It will work with assisters, navigators, and brokers, as well as consumer groups, to clarify SEP eligibility requirements. CMS is seeking feedback from stakeholders over the next few weeks to determine what verification requirements are appropriate to address areas of SEP misuse without discouraging appropriate enrollment. It will phase in the documentation process over the next several months.

from Health Affairs Blog http://ift.tt/1QdWidL