CMS outlines changes to special enrollment period rules

The federal government has made good on its pledge to tighten the rules for the Affordable Care Act's open enrollment periods (SEPs) amid health insurers' complaints about customers gaming the system.

Last week, Centers for Medicare & Medicaid Services Acting Administrator Andy Slavitt said during the J.P. Morgan healthcare conference that the agency plans to eliminate certain criteria for SEP sign-ups and clarify other language related to eligibility. CEO Kevin Counihan added more details to CMS' efforts in a blog post Tuesday.

"As the marketplace matures and consumers learn more about how and when to enroll, we continue to review the rules around special enrollment periods in order to keep them fair for consumers and for issuers," he wrote.

With that in mind, Counihan says CMS will take three main steps to ensure the stability of the ACA marketplaces:

  • The agency will end six types of special enrollment periods, including those for people who enrolled with too much in advance payments of the premium tax credit because of a redundant or duplicate policy; those affected by an error in the treatment of Social Security Income for tax dependents; and people who were eligible for or enrolled in COBRA and were not sufficiently informed about their coverage options, among others.
  • CMS will update guidance to clarify that special enrollment periods for individuals who have moved can't be used for a short-term or temporary move--such as being treated in a hospital in a different area than the person lives. Counihan adds that the agency will issue additional clarifying guidance about eligibility as needed.
  • The government will enforce the rules by employing its "program integrity team" to pull samples of customer records, in some cases asking for more information from enrollees or taking other steps to validate their eligibility. It will also make it clear to consumers they are required by law to provide accurate information when signing up and can face penalties for failing to do so.

The issue of SEP abuse has come to the forefront recently as insurers have indicated that customers who sign up during these periods tend to be sicker and keep their plans for shorter periods of time. UnitedHealth, which recently announced it lost $720 million on its ACA exchange products last year, previously cited costly SEP customers as one of the factors driving its losses.

To learn more:
- here's Counihan's blog post

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