CMS Acts on Documentation for Special Enrollment Periods (SEPs)

In an effort to stabilize the individual insurance marketplaces and improve the risk pool CMS has rolled out a new Special Enrollment Verification process. Individuals who assert that they have qualified for one of five Special Enrollment Periods (SEPs) will be sent a Marketplace Eligibility Determination Notice requesting documentation to support their eligibility for the SEP.

The five SEPs that will trigger the Marketplace Eligibility Determination Notice are:

  1. Loss of minimum essential coverage
  2. Change in primary place of living
  3. Birth
  4. Adoption, placement for adoption, placement for foster care, or child support or other court order
  5. Marriage.

The Marketplace Eligibility Determination Notice will be tailored to the specific circumstances of each individual applying for coverage. The notice will provide the list of acceptable documents to prove an individual’s eligibility for the SEP.

After the person has enrolled in coverage and sent in the proof for the SEP, no further action is required. Coverage will be considered confirmed unless there is an additional contact from the exchange.

The fastest method to provide documents to prove eligibility is by uploading them. The notice includes instructions on how to upload a document. Alternatively, documents can be mailed to the processing center with a bar code page that is included with the notice.

Examples of documents that support eligibility for an SEP include:

Loss of minimum essential coverage

  • Letter from an employer stating that the employer dropped coverage for the employee, including the date coverage ended or will end
  • Letter or other document from an employer stating that the employer stopped or will stop contributing to the cost of coverage
  • Letter showing an employer’s offer of COBRA coverage

Place of Living

  • Lease or rental agreement
  • Mortgage or rental payment receipt
  • Utility bill

Marriage

  • Marriage certificate showing the date of the marriage
  • An official public record of the marriage, including a foreign record of marriage
  • A religious document that recognizes the marriage

Birth

  •  Birth certificate or application for a birth certificate for the child
  • Application for a Social Security Number (SSN) for the child
  • Medical record from a medical provider showing the date of birth

Adoption

  • Court order showing effective date of the order
  • Adoption letter or record showing the date of adoption dated and signed by a court official
  • Government-issued or legal document showing the date legal guardianship was established.

Depending on the SEP reason, the types of documents that can be used for verification purposes are more expansive than the few listed in this article.  More information is available on the CMS notices webpage. Click here to go to the notices page. Then scroll down to “Eligibility Notice” and click on the “English” link that appears below “Special Enrollment Periods (2016 coverage) (June 2016).”