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CMS announces confirmation changes to SEP process

A Picture of Adam Weisshouse Adam Weisshouse
04/22/2016

Over the past three years, Americans have taken full advantage of the Affordable Care Act (ACA)’s annual Open Enrollment Period (OEP). This is the official window in which people are able to select and purchase ACA-compliant health insurance plans. By all accounts, the OEPs are successful, with the final estimates for the 2016 OEP showing that 12.7 million Americans signed up for coverage. This is an increase of one million people (8.5 percent more) over 2015; this figure is also right in line with the Obama Administration’s earlier predictions.

Despite the OEP, millions of Americans miss out on purchasing coverage at this time, whether due to financial matters, family obligations or other reasons. As such, the Centers for Medicare and Medicaid Services (CMS), the agency tasked with the nation’s healthcare, offers Special Enrollment Periods (SEPs). Held outside of OEPs, these specific time windows enable qualified individuals and families to sign up for coverage. During the most recent SEP (Feb. 23-June 30, 2015), 944,000 beneficiaries enrolled through the federal Healthcare.gov platform.

However, the future of these enrollment periods may be in question, as the CMS has made changes involving the need for certain consumers’ confirmation. This new legislation was due to insurance carriers’ complaints regarding customers’ habits when purchasing coverage. They also claimed that they were experiencing big ACA-related financial losses. These new changes come on the heels of previous SEP-related initiatives.

Responding to carriers,’ consumers’ concerns

Consumers — both in the 38 states utilizing HealthCare.gov, the federal exchange, and the 2.7 million with access to state-run exchanges (and the District of Columbia) – are responding well to the OEPs. However, the marketplace can only provide coverage if there are enough insurance carriers. As such, the CMS must take the carriers’ feedback, good and bad, very seriously. Therefore, CMS has established a new confirmation process for consumers in the 38 states utilizing Healthcare.gov. This new process, which will take effect on the next few months, will specifically apply to those people who attempt to enroll in an ACA-compliant plan outside of the OEP.

In order to qualify for an SEP, beneficiaries will now have to submit proof that they are, indeed, eligible for most special enrollment periods. Currently, to qualify, consumers simply have to check a box, which states that they “… attest that they meet the conditions for special enrollment.” But now, they’ll have to actually upload or mail copies of specific documents to qualify, such as birth or marriage certificates.

This change comes as a result of carriers’ complaints involving the enrollment process. They felt that it was too easy for people to enroll in plans after the OEP’s Jan. 31 deadline, once they were sick, and then drop coverage following treatment. Multiple carriers, such as UnitedHealth, reported decreased profits resulting from the ease in which people were changing policies. The carriers also felt that under the ACA, a sicker-than-expected customer pool had been created, leading to greater financial losses for exchange plans.

Aside from the carriers, CMS is taking into account other viewpoints regarding this confirmation change, including consumers and advocates. “Most consumers are still learning about how the new health insurance marketplaces work, how to navigate a complex enrollment process, and when to apply,” stated Rachel Klein, of Families USA, a nonprofit group supporting increased healthcare access. “In fact, data show that fewer than 15 percent of those eligible for SEPs have used them. The administration should focus on raising consumer awareness about these opportunities instead of putting bureaucratic roadblocks in the path of people trying to protect their health and that of their families.”

While CMS and others understand these concerns, they also recognize the carriers’ issues. According to HealthCare.gov CEO Kevin Counihan, for the exchanges to work properly, they “must be attractive for insurance companies that offer plans on it.” “It remains to be seen what the impact will be, but this suggests awareness that for the market to succeed in the long run, CMS needs to focus on more than the consumer experience and getting ‘butts in the seats,'” stated Katherine Hempstead, director of the insurance coverage team at Robert Wood Johnson Foundation. “It also needs to ensure that there are market conditions that are conducive to sellers as well as buyers.”

2016’s earlier SEP changes

Already in 2016, there have been other SEP-related changes in 2016. Again, at the carriers’ urging, these involved the elimination of multiple federal SEPs; besides 2015’s Tax Season SEP, six others were eliminated, including:

  • Consumers enrolling with too much in advance payments of the premium tax credit, due to redundant or duplicate policies
  • Consumers affected by errors in the treatment of Social Security Income for tax dependents
  • Lawfully present noncitizens affected by system errors in determination of their advance payments of the premium tax credit
  • Lawfully present noncitizens with incomes below 100 percent FPL (federal poverty level) who experienced processing delays
  • COBRA-eligible consumers not sufficiently informed about their coverage options
  • Consumers previously enrolled in the Pre-Existing Condition Health Insurance Program (PCIP)

CMS has also made it a point to ensure that consumers provide accurate information. Those found to have intentionally provided false or untrue information may face penalties under federal law. To prevent these crimes, the agency is providing education regarding eligibility guidelines to those involved, such as consumers, brokers and issuers. For instance, people who have permanently relocated and enrolled in new plans  may request SEPs for short-term or temporary moves. And, the SEP process itself is being addressed by the CMS program integrity team. They’re performing an assessment of consumers’ changes and reviewing nationwide records to ensure that SEPs are properly run.

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