On Tuesday, the Centers for Medicare and Medicaid Services (CMS) announced changes for the marketplace special enrollment periods (SEPs). The Administration will be eliminating six SEPs, clarifying others, and increasing enforcement. These six eliminated SEPs are in addition to the elimination of the tax-time SEP, which the Administration has previously announced will not be in place for the 2016 tax season. The changes come from criticism by insurers given the wide range of exemptions for consumers to purchase health coverage outside of the standard open enrollment period (OEP), with 41 possible reasons. This has led to more adverse selection in the marketplace, with sicker and costlier enrollees, many of whom wait to enroll and then dis-enroll after receiving care. The announcement this week was intended to better convey the purposes of the OEP and SEPs. CMS noted that they will continue to offer SEPs for those who legitimately qualify due to a loss of coverage or life changes, but they will now be more strictly enforcing the SEPs, emphasizing the need to provide accurate information and will be enforcing penalties for those providing false information.
- Those with too much in advance payments of the premium tax credit because of a redundant or duplicate policy;
- Those 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% Federal Poverty Level who experienced certain processing delays;
- Those eligible for or enrolled in COBRA and not sufficiently informed about their coverage options, and;
- Those previously enrolled in the Pre-Existing Condition Health Insurance Program.
- Change of address is available for those who permanently moved, and as a result, gained access to new health plans; it is not to 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.
- CMS will conduct an assessment of plan selections that are made through certain SEPs to evaluate whether consumers properly accessed coverage. The 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 CMS to inform future policy and operational improvements to enhance program integrity.