Special Enrollment Periods and the Consumer Operated and Oriented Plan Program

Centers for Medicare & Medicaid Services (CMS) just released new information regarding new Special Enrollment Period (SEP) rules. The Department of Health and Human Services (HHS) is tightening the rules for certain SEPs and clarifying that SEPs are only available in six defined and limited types of circumstances. Please read below for details regarding the new rules being implemented.

Permanent Move SEP

To ensure individuals are not moving for the sole purpose of obtaining health coverage outside of the open enrollment period, CMS has included a new rule for permanent move SEPs. This new rule limits the circumstances in which someone may qualify for the permanent move SEP to ensure consistency with the original purpose of that SEP.  An Interim Final Rule with Comment (IFC) published in the Federal Register provides that individuals requesting a “permanent move” SEP must have minimum essential coverage for one or more days in the 60 days prior to the permanent move, unless the individual was living outside of the United States or in a United State territory prior to the permanent move.

Incarceration SEP

CMS also made changes to make sure that individuals who were incarcerated, or were previously in the coverage gap in a non-Medicaid expansion state and have moved and become newly eligible for advance payments of the premium tax credit (both of whom would previously have qualified for the permanent move SEP) may continue to qualify for an SEP. Since these individuals were previously unable to have minimum essential coverage or were exempt from having minimum essential coverage prior to the qualifying event that qualifies them for this SEP, CMS is not requiring that they have minimum essential coverage prior to qualifying for an SEP.

Implementation Deadline

The IFC also removed a January 1, 2017 implementation deadline by which Marketplaces would otherwise have had to provide advance availability of the permanent move SEP and provide an SEP for loss of a dependent, or for no longer being considered a dependent due to divorce, legal separation, or death. Marketplaces can still provide either SEP, but implementation and the timing of that implementation are at the option of the Marketplace.

Six Types of SEP Circumstances

CMS included clarification, in separate guidance, that SEPs are only available in the six defined and limited types of circumstances listed below:

(1.) Losing other qualifying coverage

(2.) Changes in household size like marriage or birth

(3.) Changes in residence, with significant limitations

(4.) Changes in eligibility for financial help, with significant limitations

(5.) Defined types of errors made by Marketplaces or plans; and

(6.) Other specific cases like cycling between Medicaid and the Marketplace or leaving Americorps coverage.

To read the full details released by CMS regarding these changes, please click here to visit CMS.gov.