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CMS reveals new verification process for special enrollment eligibility

Rules will require consumers to submit supporting documentation when enrolling

Consumers who enroll in health plans outside of the open enrollment period will face new documentation requirements to ensure they meet special enrollment period (SEP) qualifications.

The new rules add to previous tweaks to the SEP process, which eliminated certain enrollment periods and improved enforcement efforts through the Centers for Medicare & Medicaid Services' (CMS) program integrity unit. Federal officials announced the changes following concerns from insurers that SEPs were subject to abuse that saddled both plans and consumers with higher costs.

The new confirmation process will require consumers who enroll through Healthcare.gov to submit supporting documentation for five qualifying events, which represented three-quarters of SEP enrollees during the second half of 2015:

  • Loss of minimum essential coverage
  • Permanent move
  • Birth
  • Adoption, placement for adoption, placement for foster care or child support
  • Marriage

CMS will use a process modeled after the Internal Revenue Service to review qualifying documents (including marriage or birth certificates) uploaded or mailed by consumers at the time of enrollment. Additionally, Healthcare.gov will include several new web features during the enrollment process in which consumers must acknowledge they meet SEP qualifications. 

CMS is soliciting feedback from consumer advocates and insurers "over the next few weeks," according to a CMS blog post.

"We are committed to making sure that special enrollment periods are available to those who are eligible for them," CMS officials wrote. "But it's equally important to avoid misuse or abuse of special enrollment periods."

A recent report from Covered California offered an inside look at SEP enrollment in the state, which has been climbing steadily since 2014 and contributes to 15-50 percent higher costs each month. Federal officials have been addressing concerns from the insurance industry about SEP enrollment for the last several months, although some policy analysts have warned that tightening SEP rules could deter healthy individuals from enrolling in SEP plans, further damaging the risk pool.

To learn more:
- here's the CMS announcement
- read the CMS blog post

Related Articles:
The downside of tightening special enrollment period rules
Special enrollment periods costly and open to abuse, insurers warn
CMS outlines changes to special enrollment period rules
CMS to tighten rules for special enrollment periods
Covered California offers peek at consumers who use special enrollment periods