As we wrote in a previous post, the Center for Medicare & Medicaid Services (CMS) under the new administration issued new rule changes for the Marketplace. Rule changes do not require legislative approval, and they can go into effect as soon as 60 days after they are finalized. The CMS announcement did not list a specific start date for these rule changes, so we are assuming the changes will begin at the earliest possible date, June 19.
These changes will affect consumers who are eligible for Special Enrollment Periods (SEPs). Typically, consumers who buy their own health coverage must enroll in the Marketplace during Open Enrollment. Consumers can only enroll outside of that period if they experience certain major life changes, called qualifying life events. They must apply for an SEP 60 days before or after the life event.
Qualifying life events include losing other health coverage, getting married, having a baby or adopting a child, or a permanent move.
Here are the changes to Special Enrollment Periods:
Consumers have always been required to provide certain eligibility documents to the Marketplace after enrolling. The change is that now every consumer who applies for an SEP will be required to submit documentation that proves they qualify for the SEP within 30 days. They not be permitted to enroll in their Marketplace health plan until the Marketplace has verified the eligibility paperwork. Consumers may choose their plan, but enrollment into the plan will be put on hold, and premiums cannot be paid, until the verification is complete.
CMS says this change will not delay consumer enrollment. If the verification process would delay consumer enrollment to the point that the consumer would owe two months of premiums at once, the consumer can request to forego enrollment in the previous month of coverage and not pay that premium.
For example, if a consumer’s coverage is supposed to begin July 1, but the verification process delays enrollment until August 1, the consumer would be expected to pay premiums for both July and August in order to begin their coverage. Due to the verification delay, the consumer can request to change their start date to August 1, and pay only the premium for August. This scenario leaves the consumer uninsured for one month, so it may not be advisable for someone with continuing healthcare needs.
Changes to Eligibility Criteria for Several SEPs
The rule further restricts eligibility for four SEPs. Here are the new rules:
Loss of Coverage SEP – Insurers will be allowed to refuse enrollment to a consumer through an SEP if that insurer had previously terminated the consumer’s coverage due to nonpayment of premiums. The insurer can require payment of past premium debt before enrolling the consumer into coverage.
Marriage SEP – At least one spouse must show proof that they were enrolled in minimum essential coverage (MEC) for at least one day in the 60 days before the marriage, or that they lived outside of the United States or in a U.S. territory (and therefore were exempt from the individual mandate to obtain health insurance). Those who are members of a federally recognized American Indian tribe or Alaska Native are exempt.
Permanent Move SEP – Consumers must show proof of their permanent move and will only qualify for the permanent move SEP if they can prove that either they had MEC for at least one day in the 60 days prior to the move, or can prove they lived outside the U.S. or in a U.S. territory. These changes had already been in place, but were not officially documented as official rules until now.
Exceptional Circumstances SEP – Consumers applying for this SEP will be required to provide “sufficient documentation” to prove the consumer experienced a “highly exceptional” circumstance. HHS did not release details on the documentation that will be required, but said they will do so at a later point.
Limited Plan Choice for Existing Marketplace Enrollees
Consumers already enrolled in a Marketplace plan and who now qualify for an SEP will only be able to switch plans, but they must chose a new plan with the same metal level (bronze, silver, gold, platinum) as their current plan.
Consumers using an SEP due to marriage or gaining a new family member through birth or adoption can only add the family member to their current plan or switch to a plan in their current metal level. However, if the addition to the family creates a new eligibility for Silver-level plan benefits, the entire family can use the SEP to switch to a Silver plan.
For example, a if a consumer is currently enrolled in a Bronze plan and is not eligible for tax credits, having a child (and therefore increasing her family size but not her income) makes her newly eligible for tax credits and cost-sharing reductions. She would be eligible to switch herself and her baby to a Silver plan through the SEP.
This new rule has very few exceptions for:
• People who become members of a federally recognized American Indian or Alaska Native tribe, or who become eligible for services through the Indian Health Service.
• People experiencing domestic violence or spousal abandonment.
• People eligible for an SEP due to Marketplace error, misconduct, or misrepresentation.
As advocates, Consumer Health Coalition encourages people to be proactive.
People who think they could be eligible for an SEP should submit their application, carefully read their Eligibility Results, and upload any verification documents to their online account ASAP.
Less than 5% of consumers eligible for an SEP actually enroll. If you think you may be eligible for an SEP, please contact our certified Navigators to be screened. You can also use the Marketplace’s screening tool online at Healthcare.gov. Click here to contact CHC for free, in-person assistance.
About the Author
Cassie Narkevic is a Health Care Navigator at Consumer Health Coalition.