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CMS: New Rules Restrict Enrolling Outside Open Enrollment Period

The Open Enrollment Period for 2016 ends on January 31, however the Centers for Medicare and Medicaid Services (CMS), the agency responsible for the nations’ healthcare, allows individuals with special ‘life events’ to enroll outside of this period, known as Special Enrollment Periods (SEPs). The SEPs are very successful, with about 944,000 beneficiaries enrolling last year between Feb. 23 and June 30, 2015.

The time and need for SEP changes

Recently, the government has announced some adjustments to the SEPs, redefining the definitions and rules. According to a Jan. 19, 2016, memo, written by Kevin Counihan, the CMS’ Director and Marketplace Chief Executive Officer, these changes were necessary, due to multiple factors. First, there were the needs of insurance carriers, who are crucial to the ACA’s well-being. It was also determined that some beneficiaries were taking advantage of the SEPs. The large number of consumers unable or unwilling to meet the OEP’s deadlines made these changes vital, as well.

Meeting carriers’ requests

While the CMS may offer official SEPs, the agency has been eliminating some of these, at the request of insurance carriers. For example, the CMS put an end to the Tax Season SEP, which ran from March 15-April 30, 2015. This SEP was originally meant for 2015 alone, though. But the Jan. 19 memo revealed that another six SEPs will be eliminated, including those for:

  • Consumers who enrolled with too much in advance payments of the premium tax credit because of a redundant or duplicate policy
  • Consumers affected by an error in the treatment of Social Security Income for tax dependents
  • Lawfully present non-citizens affected by a system error in determination of their advance payments of the premium tax credit
  • Lawfully present non-citizens with incomes below 100 percent FPL (federal poverty level) who experienced certain processing delays
  • Consumers eligible for or enrolled in COBRA and not sufficiently informed about their coverage options
  • Consumers previously enrolled in the Pre-Existing Condition Health Insurance Program

Addressing system abuses

In regard to possible abuses of the SEPs, the CMS wanted to educate beneficiaries, brokers, issuers and other involved parties by better defining certain eligibility guidelines. Specifically, the agency provided guidance for the SEP dealing with consumers who had permanently moved and gained access to new health plans. The CMS stated that these consumers cannot use the SEP for short-term or temporary moves, where they wouldn’t stay in their new locations. For example, these moves included being admitted to hospital for treatment in different areas.

Enforcing the rules

The last factor involved the enforcement and understanding of the SEPs’ specific rules and requirements. The CMS will be performing an assessment to determine whether consumers that purchased policies during certain SEPs did so properly. This will involve the agency’s program integrity team examining national samples of consumer records and possibly requesting other information.

The CMS believes that these findings will help them to better plan for the future and make necessary improvements.  In addition, the CMS will stress the need for applicants to provide accurate information. Those who intentionally provide false or untrue information may be subject to penalties under federal law.

The role of QLEs for enrollment extensions

When Special Enrollment Periods are permitted, they allow consumers to enroll in ACA-compliant plans outside of the traditional time window. This spares people otherwise in need from expensive tax penalties. In most cases, SEPs are granted to those individuals who may have lost their coverage or are experiencing certain life changes, known as Qualifying Life Events (QLEs). For individuals qualifying for their own SEPs, these typically begin 60 days after a QLE. However, you may enroll up to 60 days before, preventing coverage gaps. Examples of QLEs include:

  • Childbirth, adoption, foster care –Provided you enroll within the 60-day period, new coverage starts on the day of the birth, adoption, or placement.
  • Marriage –As long as someone marries on or before Nov. 30 of a given year, they can enroll in coverage starting on Dec. 1. However, getting married Dec. 1 or later requires filling out an application for the following year; coverage will start on Jan. 1. The marriage rules also apply to divorce.
  • Loss of coverage –If you leave your job, or lose any coverage on or before Nov. 30, you can enroll in a plan that starts Dec. 1. These requirements apply to ACA-compliant, employer-sponsored, private and COBRA plans. The new plan must be selected on or before Nov. 30. Coverage lost Dec. 1 or later requires an application for the next year, with coverage starting Jan. 1. It should be noted that this QLE doesn’t apply if you voluntarily give up other coverage or are terminated for not paying premiums.
  • Minimum essential coverage – Coverage lost not considered to meet the ACA’s individual responsibility requirements doesn’t apply; the uninsured fee isn’t required either. Among those policies affected are Marketplace and private policies, Medicare, Medicaid, CHIP and TRICARE, healthcare for active-duty and retired uniformed services members and their families.
  • Medicaid or CHIP changes – Those found ineligible for Medicaid or the Children’s Health Insurance Program (CHIP), the joint federal-state health insurance program for low-income children.
  • Marketplace plan changes, this includes not being enrolled, enrolling in the wrong plan and related plan contract violations.
  • Changes in income affecting payment for coverage, such as qualifying or disqualifying for subsidies. This includes those newly determined to be eligible or ineligible for advance payments of the premium tax credits or cost-sharing reductions.
  • Experiencing domestic abuse, violence or spousal abandonment
  • Hardships preventing enrollment, such as natural disasters or serious medical conditions occurring during the OEP
  • Changes in citizenship, including gaining status as a citizen, national or lawfully present individual. In particular, this impacts those gaining or maintaining status as members of a federally recognized tribe or Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder.
  • Relocating to a new state, including states that haven’t expanded Medicaid or those with new Marketplace plan options.
  • Leaving incarceration

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