New Exchange Enrollment Periods

On March 26, 2014, the Centers for Medicare & Medicaid Services (CMS) issued two separate pieces of guidance providing the following special enrollment periods (SEPs) in the federally-facilitated Exchange (FFE):

  • SEP for “In Line” Individuals —those who have begun the enrollment process but haven’t finished—as of March 31. CMS also issued an instructional sheet for assistors who are helping “in line” individuals enroll.
  • Limited Circumstance SEPs for individuals who were not able to enroll during the initial open enrollment period due to certain limited circumstances. CMS also issued an instructional sheet for assistors who are helping consumers with complex cases enroll in SEPs.

If certain conditions are met, these SEPs allow individuals to enroll in Exchange coverage after the initial open enrollment period closes.

SEPs for “In Line” Individuals

CMS has expressed concern over whether high consumer traffic leading up to the March 31 enrollment deadline could potentially keep consumers from completing the enrollment process, despite efforts to meet the deadline.

Should this occur, CMS will provide an SEP for consumers in the FFE who are “in line” as of March 31. Thus, consumers who tried to enroll during the open enrollment period, but did not complete the process by March 31, will be allowed a limited amount of additional time to finish the application and enrollment process.

For consumers who were “in line” with paper applications (or whose applications were pending submission or review of supporting documentation) on March 31, CMS will process applications received by April 7 . These consumers may select a plan through April 30 .

It is anticipated that enrollments made in the limited time after March 31 will have a May 1 coverage effective date , as long as consumers who were “in line” pay their first month’s premium on time. This is the coverage effective date that consumers would have had if they were able to complete enrollment by March 31, and is the normal effective date for enrollments between March 16 and April 15.

To be eligible for the “in line” SEP, individuals must attest that they tried to enroll, either online or over the phone, by March 31, 2014, and didn’t complete enrollment because of a problem that wasn’t their own fault.

  • Effect on the Individual Mandate – Individuals who receive an SEP for being “in line” by March 31, and who select new coverage within the applicable timeframes, will be treated as if they had enrolled in coverage by March 31. Thus, under previous CMS guidance, these individuals will be able to claim a hardship exemption from the individual mandate for the months prior to the effective date of their coverage.

Limited Circumstance SEPs

There are several systems issues that may have prevented timely application submission, produced incorrect eligibility determinations or hindered Exchange enrollment during the initial open enrollment period. As a result, CMS will provide an SEP for individuals in any of the following categories of limited circumstances. Additional categories that warrant SEPs may be added in the future if other circumstances, as determined by CMS, become known.

  • Exceptional Circumstances – ( i.e.- natural disaster, serious medical condition or planned Exchange outage.)
  • Misinformation, Misrepresentation or Inaction
  • Enrollment Error
  • System Errors Related to Immigration Status
  • Display Errors on Exchange Website
  • Medicaid/CHIP Transfer
  • Error Messages
  • Unresolved Casework
  • Victims of Domestic Abuse
  • Other System Errors

To receive a limited circumstance SEP, a consumer must generally call the Exchange Call Center (1-800-318-2596) and ask the Call Center to request the SEP. In certain circumstances, however, the Exchange or issuer may contact the consumer to inform them of the potential SEP.

In most cases, consumers will have 60 days to select a plan from the date they are granted the limited circumstance SEP.

Generally, these SEPs will result in prospective coverage effective dates. Coverage effective dates may be based on either the date of the SEP triggering event or the regular prospective effective dates described in HHS guidelines. If the date a consumer would have effectuated coverage is unknown, the regular effective dates should apply.

For more information on Exchange enrollment period or have other ACA-related questions, please call 954.375.7771.

Source: Center for Medicare & Medicaid Services & Zywave, Inc.