Enrollment and actuarial value criteria — proposed regulatory changes and operational requirements affecting open enrollment periods, special enrollment periods (SEPs), prior-coverage verification, plan-change restrictions, and actuarial value (AV) de minimis ranges.
Open Enrollment Period (OEP) change: For benefit years beginning January 1, 2018 and beyond, the annual OEP is proposed to begin on November 1 and end on December 15 of the calendar year preceding the benefit year (§155.410(e)). This shortens the prior OEP (November 1–January 31 for 2016–2017 benefit years) and is expected to reduce adverse selection but could reduce overall enrollment, particularly among younger and healthier consumers, and may require additional outreach and operational support.
Pre-enrollment verification and SEP handling: HHS proposes expanding pre-enrollment verification of eligibility for all categories of individual market SEPs on the HealthCare.gov platform to 100 percent of new consumers starting June 2017, with enrollments pended until verification completes. Consumers must provide supporting documentation within 30 days; Exchanges will attempt automated electronic verification where possible. The Exchange may offer, at the consumer's option, a coverage effective date up to 1 month later than the otherwise applicable effective date when verification delays would otherwise require the consumer to pay 2 or more months of retroactive premium or risk termination for non-payment (§155.420(b)(5)).
SEP plan-selection restrictions (individual market): For enrollees (and their dependents) who qualify for most SEPs during the coverage year, Exchanges must limit plan changes so that the enrollee may (1) remain in the same QHP, or (2) change only to another QHP within the same metal level as defined in §156.140(b), provided other QHPs at that metal level are available. This restriction applies to most triggering events in paragraph (d) of §155.420, with explicit exclusions for SEPs listed at paragraph (d)(4), (d)(8) [Indians and dependents], (d)(9), and (d)(10). The rule also contemplates transitional flexibility for State-based Exchanges and off-Exchange individual market operationalization.
Prior-coverage verification requirements for certain SEPs: For SEPs that require prior coverage (e.g., marriage SEP when newly enrolling), qualified individuals must demonstrate they had minimum essential coverage as described in 26 CFR 1.5000A-1(b) for 1 or more days during the 60 days preceding the qualifying event, or alternatively demonstrate that they lived outside the United States or in a U.S. territory for 1 or more days during that 60-day period (§155.420(5) / new paragraph (a)(5)). For the permanent move SEP (d)(7), HHS proposes requiring documentation proving prior and new addresses and evidence of prior coverage as applicable; guidance would specify acceptable documentation.
Treatment of terminations for non-payment in SEP eligibility: Exchanges (FFEs and SBE-FPs) would permit issuers to prevent individuals who were terminated for non-payment of premiums from qualifying for the loss-of-coverage SEP (d)(1) unless the individual fulfills premium obligations (consistent with the §147.104 guaranteed availability interpretation). HHS may collect issuer data on terminations for non-payment to automatically prevent SEP qualification for renewals within 60 days of termination.
Expanded verification and more rigorous use of exceptional-circumstances SEP: HHS proposes to limit use of the exceptional circumstances SEP (d)(9), applying a more rigorous, evidence-based test and requiring supporting documentation where practicable; guidance will outline examples and documentation. HHS will evaluate existing SEPs and formalize elimination of certain previously guidance-based SEPs.
Prior coverage look-back and alternative continuity policies (request for input): HHS solicits comment on additional policies to promote continuous coverage, including longer look-back periods (e.g., 6–12 months with limited gap allowance), waiting periods (e.g., 90 days) before effectuating enrollment, or late enrollment penalties for individuals unable to demonstrate longer prior coverage, analogous to maintenance-of-coverage rules considered for the individual market.
Actuarial value (AV) de minimis range changes: HHS proposes amending §156.140(c) to change the AV de minimis range for non-grandfathered individual and small group market plans from +/-2 percentage points to -4/+2 percentage points for standard metal levels (bronze, silver, gold, platinum) beginning in 2018. For expanded bronze plans the de minimis would change from +5/-2 to +5/-4 to align with this policy. Silver variation AV ranges (e.g., 73, 87, 94 percent) are not changed at this time. HHS notes potential short-run transfers from consumers to insurers and possible reductions in consumer value, balanced against issuer flexibility that may lower premiums (estimated up to 1–2 percent) and affect premium tax credit calculations.
Interaction with guaranteed availability and premium-payment policies: HHS proposes that issuers may apply premium payments to outstanding debt for coverage from the same issuer enrolled within the prior 12 months and refuse to effectuate new coverage for failure to pay past-due premiums, subject to State law and nondiscrimination requirements (§147.104). Exchanges would coordinate SEP eligibility decisions (e.g., loss-of-coverage SEP) with issuer premium-payment records to prevent gaming.
Operational implications and transitional considerations: HHS recognizes State-based Exchanges may need transitional time or optionality to implement SEP plan-change restrictions and expanded verification. HHS seeks comment on appropriate transition periods and operational approaches (e.g., pending enrollment until document review versus restricting plan selections until verification completes).