The U.S Department of Health and Human Services (HHS) just announced changes to the special enrollment period (SEP) used by the federal exchange that enables individuals to obtain coverage outside of designated open enrollment periods (OEP). Individuals in the thirty-eight states using the federal exchange to provide coverage pursuant to the Affordable Care Act (ACA) must now submit qualifying documentation if they wish to begin or change coverage because they moved, had a baby, adopted a child, were recently married or lost their minimum essential coverage.
A primary goal of these changes is to reduce the number of Americans who are waiting until they are sick to enroll outside of the annual open enrollment period to reduce adverse risk selection. As a result, the changes to the SEP have been met with mixed results.
Consumer advocates like Judy Solomon, vice president for health policy at the Centers for Budget and Policy Priorities, assert that the more restrictive HHS rules are unnecessary and overly burdensome, especially in light of the fact that there is no real evidence that consumers are unfairly manipulating the OEP process or lied to get special enrollments.
Industry insiders, such as America’s Health Insurance Plans (AHIP) and Blue Cross Blue Shield Association (BCBSA) have applauded the changes to the process. Many of the one million individuals who obtained coverage outside of the OEP, they argue, waited to get coverage until they were sick, thus making it more difficult to set premium amounts, negatively impacting insurer risk pools, and leading to increased prices for all consumers. Additionally, these consumers were also utilizing more services. According to BCBSA, “individuals enrolled through special enrollment periods are utilizing up to 55 percent more services than their open enrollment counterparts.”
According to the Centers for Medicare and Medicaid Services (CMS), the changes made to the SEP will enhance program integrity and contribute to a stable rate environment and affordability for consumers. Previously, consumers could check a box indicating their category for special enrollment. Now, consumers will be asked to upload or mail a qualifying document to CMS. CMS will also include additional attestations requiring consumers to acknowledge document requests and the need to be truthful. Brokers should be aware of these changes in order to assist enrollees in the months ahead.
BenefitMall has published several blogs covering the third open enrollment over the past several months. CMS has not updated its final enrollment numbers since our blog last month and is still reporting “(s)ince Open Enrollment for the Health Insurance Marketplace began on November 1, about 11.6 million people have signed up for or renewed a health plan (2.7 million through State-based Marketplaces through December 26 and over 8.9 million through HealthCare.gov or CuidadodeSalud.gov through January 23)…”
Stay tuned as we continue to track and report on the technical aspects of the federal exchange, the final numbers for the 2016 ACA enrollment season, including any special enrollment issues.
The views expressed in this post do not necessarily reflect the official policy, position, or opinions of BenefitMall. This update is provided for informational purposes. Please consult with a licensed accountant or attorney regarding any legal and tax matters discussed herein.