CMS Issues Fact Sheet on Pre-Enrollment Verification of Special Enrollment Periods

On Dec. 12, 2016, CMS issued a fact sheet regarding a pilot program to implement a Marketplace confirmation process for special enrollment periods (SEPs). SEPs allow individuals to enroll in coverage through the exchange when they experience certain mid-year life changes (outside of the annual enrollment period), such as marriage or birth/adoption of a child.

As background, concerns have been raised about whether current exchange rules and procedures are sufficient to ensure that only those who are eligible enroll through SEPs. In response to those concerns, CMS introduced a new SEP confirmation process, back in June 2016, which provided important data on the effects to exchange enrollment numbers. As a result, CMS announced this pilot program, which is designed to test the impact of pre-enrollment substantiation of SEP eligibility on various outcomes including compliance, enrollment, continuity of coverage, the risk pool and other effects.

The pilot program is set to begin in June 2017 for all states currently using the federally-facilitated exchange on Fifty percent of applicants will be randomly selected to participate in the pilot, which will subject those consumers to an enhanced verification process for all SEP types. Applicants selected will be required to provide documents proving eligibility for the SEP within 30 days. The Marketplace will then hold enrollment until sufficient documentation is provided by the applicant. Once approved, premium payment can be made and coverage will generally begin as of the original effective date. Conversely, if proper documentation is not provided, coverage may be terminated.

Using 2017 data expected to become available in spring 2018, CMS will evaluate the impact of the pre-enrollment verification program on the risk pool, enrollment numbers and other key metrics. Further, CMS will provide additional training for brokers assisting consumers with enrollment and document submission, and enhanced consumer information will be available on the website.

For employers, the fact sheet and pre-enrollment verification process do not contain any new compliance obligations. However, employers may want to be aware of the verification process (and Marketplace enrollment process) should employees raise questions relating to exchange enrollment and SEPs.

CMS Fact Sheet on SEP Pre-Enrollment Verification »