SEP verification and limitation criteria — finalized special enrollment period (SEP) eligibility, pre-enrollment verification procedures, and limitations for existing enrollees in the individual market. Consolidated summary of the final rule provisions affecting SEPs, verification, and related operational requirements.
If a new consumer applies for Exchange coverage through an applicable SEP on HealthCare.gov, the Exchange will pend the enrollment until verification of SEP eligibility is completed; consumers have 30 days from QHP selection to provide documentation, which may be uploaded or mailed. (Pre-enrollment verification applies to all States on the HealthCare.gov platform, FFEs and SBE-FPs; SBEs may implement their own approach.)
Where possible the Exchange will attempt to verify eligibility through automated electronic means to minimize burden. HHS will expand electronic verification efforts and aim to expedite review to minimize delays.
Pre-enrollment verification will be phased in starting June 2017, prioritizing high-volume and higher-risk SEP categories (e.g. loss of minimum essential coverage, permanent move, Medicaid/CHIP denial, marriage, adoption). Implementation includes conducting verification for all applicable SEP categories for new consumers in HealthCare.gov states.
Operational impacts and burdens: HHS estimates an additional 650,000 individuals will have enrollments pended annually; Federal eligibility staff will review documents (estimated 12 minutes per review) and associated government burden and costs were accounted for in ICR revisions (OMB control 0938-1207). SBEs that adopt pre-enrollment verification will incur administrative costs; issuers may see reduced claim processing during pended periods but may incur retroactive processing once eligibility is confirmed.
For effectuating coverage after pended enrollment due to SEP verification, binder (initial) payment rules allow an issuer to require payment of premiums due for all months of retroactive coverage through the first prospective month of coverage consistent with §155.420(b) and the binder payment deadline must be no earlier than 30 calendar days from the date the issuer receives the enrollment transaction.
HHS will exercise reasonable flexibility regarding acceptable documentation and review standards (including for individuals formerly enrolled in Medicaid or other programs) and will provide training and status updates to call centers and stakeholders to reduce barriers for vulnerable populations and expedite verifications.
Existing Exchange enrollees face limitations on plan changes via SEPs: except as specified in paragraph (a)(4) of §155.420, an enrollee may be allowed to add a dependent to their current QHP or change to another QHP within the same metal level (or one metal level up or down if no QHP exists at that level). Paragraph (a)(4) applies to current enrollees and to applications where a new applicant's SEP triggers enrollment for others on the application.
Prior coverage requirement for certain SEPs (individual market): qualified individuals required to demonstrate prior coverage may satisfy that requirement by showing (within 60 days before the qualifying event) either minimum essential coverage as described in 26 CFR 1.5000A-1(b) for 1 or more days, or residence in a foreign country or U.S. territory for 1 or more days, or status as an Indian as defined in section 4 of the Indian Health Care Improvement Act.
Marriage SEP: when newly enrolling through marriage, at least one spouse must demonstrate prior MEC (or foreign residence as above); Indians are exempt from the prior coverage requirement; HHS finalized the provision for the individual market with minor clarifications.
Permanent move SEP: new applicants must provide acceptable documentation of the move and, when applicable, evidence of prior coverage; HHS will provide guidance on acceptable documentation and will verify prior coverage via pre-enrollment verification where applicable; electronic verification is encouraged.
Exceptional circumstances SEP: HHS will apply a more rigorous, verifiable test for granting exceptional circumstances SEPs, generally requiring supporting documentation where practicable; SBEs retain flexibility to determine exceptional circumstances but HHS will provide guidance for consistent application.
Limitations and eliminated SEPs: certain previously available SEPs (for example, APTC too large due to duplicate policy, temporary Social Security Income treatment errors for tax dependents, some lawfully present non-citizen processing delays, COBRA-related insufficient notice) that have been eliminated in prior guidance are codified as no longer available.
Verification burden mitigation: HHS commits to expedited document adjudication, stakeholder trainings, and maximizing electronic data source use to reduce consumer and administrative burden; HHS does not anticipate net additional re-billing or re-filing costs to issuers due to timely document review.
SBEs may allow issuers to conduct verification if the SBE cannot implement pre-enrollment verification itself; States maintain authority to implement narrower approaches, and HHS encourages States to adopt similar policies but allows States to limit circumstances and conditions under which past-due premium attribution or SEP verification apply.