Rule on Market Stabilization Finalizes Special Enrollment Documentation

Starting in June 2017, new consumers in all states served by the HealthCare.gov platform attempting to enroll through applicable special enrollment periods (SEPs) will have to undergo pre-enrollment verification of eligibility. Enrollees would have their enrollment delayed or “pended” until verification of eligibility is completed by the Exchange.

The goal of SEP documentation is to help stabilize the individual insurance market and limit a person’s ability to enroll in coverage only after they discover they need medical care.

A quick review of the final rule’s requirements finds the following regarding SEPs:

  • Pre-enrollment verification applies to federally facilitated and state based exchanges that use the HealthCare.gov platform
  • Enrollees claiming special enrollment period (SEP) eligibility must submit their application and select a Qualified Health Plan (QHP)
  • Enrollment is “pended” until verification of SEP eligibility
  • Start date of coverage is determined by date of QHP selection
  • Consumers have 30 days from date of QHP selection to provide documentation of their qualification for the SEP
  • The exchange will attempt to obtain eligibility through automated means such as verifying birth by “confirming baby’s existence” or electronically verifying that the consumer was denied Medicaid or CHIP
  • Enrollees have proof of previous year health coverage via tax statements which may be helpful in some circumstances
  • Letters from insurers, employers and government health programs are acceptable documentation
  • SEP verification will be phased in with emphasis on the highest volume situations
    • Loss of minimum essential coverage
    • Permanent move
    • Medicaid/CHIP denial
    • Marriage
    • Adoption.

State based exchanges not using the federal platform have the flexibility to determine whether and how to implement pre-enrollment verification of eligibility for SEPs. The final rule suggests that states that have difficulty implementing verification should consider allowing issuers to conduct verification.