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Special Enrollment Period

(Updated 10/27/16)

Under Affordable Care Act, the Open Enrollment Period (OEP) serves as the official time period in which consumers are able to enroll in major medical coverage for the following year. As recent findings illustrate, millions have taken advantage of the opportunity to enroll. But for those many beneficiaries who have missed the deadline, there may be hope in the form of  (SEPs).

These additional enrollment periods, held outside of the regular OEP, are available to people who meet certain qualifying life events, such as changes in family status or income. But despite the popularity and practicality of SEPs, the Centers for Medicare and Medicaid Services (CMS), a division of the Department of Health and Human Services (HHS), has made far-reaching changes as of 2016. These changes were necessary for various reasons, particularly to combat abuse of the system and to appease the demands of insurance companies competing on the marketplace.

Why are additional enrollment periods necessary?

By all accounts, the third enrollment season was a huge success. According to the CMS, the agency responsible for the nation’s healthcare system, an estimated 12.7 million people signed up for marketplace coverage in 2016. That number include enrollees on the federal exchange site as well as state exchanges. Of the 12.7 million people who signed up, 4 million new enrollees got coverage for the first time on the marketplace, representing 42 percent of total Healthcare.gov enrollment.

Despite solid enrollment numbers for last year, many people are still unable to enroll within the open enrollment period, which is why the SEPs are so valuable. These extra enrollment opportunities allow those in need to purchase coverage and they’re particularly effective. During a Special Enrollment Period that ran from Feb. 23 to June 30, 2015, about 944,000 people signed up for health insurance.

Carrier Requests and System Abuses

Consumers appreciate the value of SEPs, whether they’re government-sponsored or for individuals. Nevertheless, the CMS has been working on addressing key issues with special enrollment periods. According to Kevin Counihan, director and marketplace chief executive officer of the CMS, changes will be made to special enrollment periods going forward due to system abuses and concerns from insurers. Mr. Counihan outlined these changes in a memo issued on January 19, 2016.

First, for the ACA to work, beneficiaries must have access to a wide array of plans from multiple insurance carriers. These carriers include large national companies that requested the elimination of certain special enrollment periods. In 2015, a special tax-based enrollment period was created to help people who didn’t realize that they owed a penalty fee for noncompliance. This SEP was a one-time offering. The Jan. 19 memo issued by the CMS states that six more SEPs will be eliminated, including those for:

  • People who enrolled with too much in advance payments of the premium tax credit due to redundant or duplicate policies.
  • People who experienced errors related to Social Security Income treatments for tax dependents
  • Non-citizens (lawfully present) who experienced system errors when trying to determine advance payments for premium tax credits
  • Lawfully present non-citizens who experienced certain processing delays and have incomes below 100 percent of the federal poverty limit (FPL). The HHS uses the FPL to determine consumers’ eligibility for cost assistance, and the figure changes annually. Individuals and families earning between 100-400 percent of the FPL qualify for financial assistance.
  • People who had or were eligible to have COBRA coverage, but who weren’t properly informed about their options
  • People who were previously enrolled in the Pre-Existing Condition Health Insurance Program (PCIP). This plan option existed until 2014, when the ACA required insurers to cover people with pre-existing conditions on regular health plans.

Second, SEP-related changes are being made to address possible abuses. To combat abuses from people who take advantage of special enrollment periods, the CMS sought to better educate beneficiaries, brokers, issuers and other involved parties about eligibility guidelines. One key area involved consumers who have permanently moved, thereby gaining access to new health plans. But the agency stressed that these relocated beneficiaries cannot request SEPs for short-term or temporary moves. In particular, the CMS focused on those who may soon leave their new locations. People who are admitted to hospital for treatment in different areas would fall under this category.

Third, the CMS is making changes regarding the enforcement and understanding of specific SEP-related rules and requirements. As such, the agency will be performing an assessment to determine if changes made during SEPs were done properly. To accomplish this, the CMS program integrity team will examine national samples of consumer records. The team may also request additional information from consumers to ensure that they were actually eligible for SEPs.

The agency hopes that these findings will assist in future planning and necessary improvements. The CMS is also reaching out to Healthcare.gov applicants to ensure that enrollees provide accurate information when they sign up. For those intentionally providing false or untrue information, there may be penalties due under federal law.

Are you eligible for your own SEP?

Special enrollment periods for individuals are available year-round because if you qualify, you can enroll when applicable. Typically, they’re made available to those who may have lost their coverage. But they’re also designed for people who meet the requirements of certain life changes, known as  (QLEs).

Should a consumer be found eligible for their own SEP, this enrollment window generally begins 60 days after a QLE. But in an effort to avoid any potential coverage gaps, the government allows people to enroll up to 60 days before a QLE. Many qualifying life events trigger special enrollment periods, including:

  • Marriage: As long as you pick a plan before the last day of the month, your coverage can start on the first day of the following month.
  • Divorce: Divorce and separation only qualify for an SEP if they result in a loss of health insurance.
  • Childbirth: This QLE also applies to adoption and foster care. Under its requirements, as long as you purchase a plan within the 60-day period, new coverage begins on the same day the birth, adoption or foster placement occurs.
  • Loss of coverage: If you lose your current health insurance – whether you bought it through a private company, signed up with a work-based plan or enrolled in COBRA coverage – then you may be entitled to an SEP within certain parameters. Specifically, you have to have lost the coverage unintentionally, which means you can’t drop it voluntarily and trigger a Special Enrollment Period. Check with Healthcare.gov for specifics about when loss of coverage guarantees an SEP.
  • Losing eligibility: If you previously qualified for Medicaid, CHIP, TRICARE or another government-funded option for health insurance but no longer do, you may be able to sign up for coverage outside of open enrollment.
  • Marketplace plan errors: If an error – technical, personal or administrative – caused you to miss enrollment or enroll in the wrong plan, then you may be able to use an SEP to sign up for coverage outside of open enrollment. This QLE is listed under “Special Enrollment Periods for complex issues” on the Healthcare.gov website.
  • Changes in income: Consumers experiencing any changes involving payment for coverage, including being qualified or disqualified for government subsidies, are considered eligible. This includes those newly found to be eligible or ineligible for advance payments of the premium tax credits or cost-sharing reductions.
  • Domestic abuse, violence or spousal abandonment: If you’re a survivor of domestic abuse, violence or abandonment, then you may be able to enroll in a plan that’s separate from your abuser or abandoner within 60 days of the QLE. Contact the Marketplace Call Center (1-800-318-2596 or TTY: 1-855-889-4325) for more information about this scenario.
  • Hardships preventing enrollment: People who experience a natural disaster or suffer a serious medical condition during OEP may qualify for a special enrollment period.
  • Changes in citizenship: This QLE may include anyone who has gained status as a citizen, national or lawfully present individual. Consumers who have gained or maintained status as members of a federally recognized tribe or are Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders may also benefit from this QLE.
  • Relocation: If you move, you may qualify for a special enrollment period. This includes anyone moving to a state that hasn’t expanded Medicaid. It may also be applicable for people who have relocated to states offering new marketplace plan options. In order to qualify for an SEP under this provision, the change in residence has to be long-term, so vacations and temporary relocation for hospital treatments don’t count.
  • Leaving incarceration: Under this QLE, enrollees must have served time in prison for being convicted of a crime, and they must be released before starting the 60-day SEP. The following scenarios do not meet the criteria: parole, probation, home confinement, voluntarily living in a residential facility under the criminal justice system’s supervision, and being held in jail or prison pending disposition of charges.

Changes to Special Enrollment Period unveiled by CMS

(Published 1/28/16)

Under the healthcare law, the OEP (Open Enrollment Period) serves as the official time period in which consumers are able to enroll in ACA-compliant plans for the following year. And as recent findings illustrate, millions have taken advantage of the opportunity to enroll. But for those many beneficiaries who have missed the deadline, there may be hope, in the form of Special Enrollment Periods (SEPs).

These additional enrollment periods, held outside of the regular OEP, are established by the Centers for Medicare and Medicaid Services (CMS), which is under the umbrella of the Department of Health and Human Services (HHS). Individuals may also be eligible for their own SEPs, provided they meet certain requirements (see below). But despite the SEPs’ popularity, the CMS has made far-reaching changes. These were necessary for various reasons, including specific demands of insurance carriers and to combat potential system abuses.

Why are additional enrollment periods necessary?

By all accounts, this latest OEP, the third since the ACA was enacted, has been a huge success. According to the CMS, the agency responsible for the nation’s healthcare system, as of Jan. 20, 2016, the OEP’s 11th week, an estimated 11.5 million people had purchased ACA-compliant coverage. This breaks down to include both those 38 states utilizing the Federally facilitated Marketplace’s HealthCare.gov platform and those 12 states (and the District of Columbia) with their own exchanges in place.

Specifically, 8.8 million in the federal Marketplace purchased plans, while 2.7 million purchased plans through state-run exchanges. The 11.5 million has actually eclipsed the Obama administration’s earlier enrollment estimates. Previously, 9.1 million had been forecast to purchase coverage. But the latest statistics have led them to update their estimates, with as many 14.7 million ACA sign-ups expected by the end of 2016.

Even so, many consumers, new and existing, are unable to enroll within the OEP. And that’s why the SEPs are so valuable, as they provide additional opportunities for those in need to purchase coverage. The most recent government-sponsored SEP, which ran from Feb. 23-June 30, 2015, 944,000 beneficiaries enrolled on Healthcare.gov.

Changes address carriers’ requests, system abuses

Consumers appreciate the value of SEPs, whether those government-sponsored or for individuals. Nevertheless, a Jan. 19, 2016, memo was released by the CMS illustrating necessary changes to these enrollment extensions’ rules and requirements. According to Kevin Counihan, the CMS’ Director and Marketplace Chief Executive Officer, these changes were made for various factors.

First, for the ACA to work, beneficiaries must have access to a wide array of plans from multiple insurance carriers. These carriers include big companies, such as Aetna, Humana and United Health., that requested the elimination of certain Special Enrollment Periods. From March 15-April 30, 2015, the CMS offered the Tax Season SEP. However, this SEP will not be offered in coming years; it was actually envisioned for 2015 alone. However, the Jan. 19 memo states that six more SEPs will be eliminated, including those for:

  • Consumers who enrolled with too much in advance payments of the premium tax credit due to redundant or duplicate policies
  • Consumers who experienced an error in Social Security Income treatments for tax dependents
  • Lawfully present non-citizens who experienced system errors in determination of premium tax credit advance payments
  • Lawfully present non-citizens who experienced certain processing delays and have incomes below 100 percent of the FPL (federal poverty level). The HHS uses it to determine consumers’ income levels, and it changes annually. The FPL determines consumers’ eligibility for certain programs and benefits.  Individuals and families earning between 100-400 percent of the FPL qualify for financial assistance.
  • Consumers eligible for or enrolled in Consolidated Omnibus Budget Reconciliation Act (COBRA) and not sufficiently informed about their coverage options
  • Consumers previously enrolled in the Pre-Existing Condition Health Insurance Program (PCIP)

Second, SEP-related changes are being made to address possible abuses. To combat these, the CMS sought to better educate beneficiaries, brokers, issuers and other involved parties about eligibility guidelines. One key area involved consumers who have permanently moved, thereby gaining access to new health plans. But the agency stressed that these relocated beneficiaries cannot request SEPs for short-term or temporary moves. In particular, the CMS focused on those who may soon leave their new locations. People who are admitted to hospital for treatment in different areas would fall under this category.

Third, the CMS is making changes regarding the enforcement and understanding of specific SEP-related rules and requirements. As such, the agency will be performing an assessment to determine if consumers’ changes made during SEPs were performed properly. To accomplish this, the CMS program integrity team will examine national samples of consumer records, and may also request additional information from consumers to ensure that they were actually eligible for SEPs.

It is the agency’s hope that these findings will assist them with future planning and necessary improvements. And, the CMS is reaching out to Healthcare.gov applicants to ensure they provide accurate information. For those intentionally providing false or untrue information, there may be penalties due under federal law.

Are you eligible for your own SEP?

As for the additional SEPs for individuals, should someone qualify, these are available at any time throughout the year. Typically, they’re made available to those who may have lost their coverage. But they’re also designed for people who meet the requirements of certain life changes, known as Qualifying Life Events (QLEs).

Should a consumer be found eligible for their own SEP, this enrollment window generally begins 60 days after a QLE. But in an effort to avoid any potential coverage gaps, the government allows people to enroll up to 60 days before a QLE. Among the multiple QLEs eligible for an SEP’s consideration are:

  • Marriage – With this QLE, a consumer must get married on or before Nov. 15th of a given year. This allows them to enroll in coverage starting on Dec. 1. But if you get married Dec. 1 or later, you will be required to fill out an application for the following year; this coverage will then begin on Jan. 1.
  • Divorce – The rules applying to marriage are also applicable for divorce.
  • Childbirth – This QLE also applies to adoption and foster care. Under its requirements, as long as potential consumers purchase a plan within the 60-day period, their new coverage will begin on the same day the birth, adoption or placement occurs.
  • Loss of coverage – For those who leave their job, or lose any coverage on or before Nov. 15, this QLE enables them to enroll in a plan that starts on Dec. 1. The new plan must be purchased on or before Nov. 15th. But if coverage is lost Dec. 1 or later, the beneficiary must fill out an application for the next year; their coverage will begin on Jan. 1. This QLE’s requirements apply to ACA-compliant, private and employer-sponsored plans. It also applies to those enrolled in COBRA. However, you should know that those if you voluntarily give up other coverage or are terminated for not paying premiums, this QLE is not applicable.
  • Individual responsibility requirements – People with plans not meeting the ACA’s coverage requirements have their own QLE. They’re also not responsible for the uninsured fee. These plans include Marketplace, private and Medicare policies. It’s also applicable for TRICARE, the healthcare plan for active-duty and retired uniformed services members and their families.
  • Medicaid or CHIP changes – This QLE applies to beneficiaries found ineligible for Medicaid or the Children’s Health Insurance Program (CHIP). This is the joint federal-state health insurance program for low-income children.
  • Marketplace plan changes – Under these criteria, those people who are not currently enrolled or enroll in the wrong plan qualify. It also applies to those found to have related plan contract violations.
  • Changes in income – Consumers experiencing any changes involving payment for coverage, including being qualified or disqualified for government subsidies, are considered eligible. This includes those newly found to be eligible or ineligible for advance payments of the premium tax credits or cost-sharing reductions.
  • People experiencing domestic abuse, violence or spousal abandonment
  • Hardships preventing enrollment – If anyone experiences a natural disaster or suffers a serious medical conditions during the OEP, they may qualify for a Special Enrollment Period.
  • Changes in citizenship – This QLE may include anyone who has gained status as a citizen, national or lawfully present individual. Consumers who have gained or maintained status as members of a federally recognized tribe or are Alaska Native Claims Settlement Act (ANCSA) Corporation shareholders may especially benefit from this event.
  • Relocating to a new state — This includes anyone moving to a state that hasn’t expanded Medicaid. And, it may be applicable for people who have relocated to states offering new Marketplace plan options.
  • Leaving incarceration – Under this QLE, enrollees must have served time in prison for being convicted of a crime. However, the following do not meet the criteria: parole; probation; home confinement; voluntarily living in a residential facility under the criminal justice system’s supervision; and being held in jail or prison pending disposition of charges.

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