special enrollment

Insurers urge government to tighten rules for special enrollment

While insurance open enrollment periods have ended for the majority of Americans, those eligible to purchase coverage through HealthCare.Gov still have until the end of January before the clock runs out. Even after that, though, thousands of people are able to purchase policies in “special enrollment periods” each year. (Read our flipbook to learn more about the havoc this can wreak in admissions offices.)

Currently, there are 33 categories that allow for special enrollment on the federal exchange, ranging from typical issues like losing coverage through an employer, to unusual circumstances like missing the regular enrollment period due to a natural disaster.

This year, however, insurers are asking the government to tighten its rules. Critics claim that the existing categories are too flexible and enforcement is lax. This makes it easy for buyers to abuse the system and sign up for a policy only when they know they have a health issue that will require coverage. In feedback provided to the government, insurers offered examples including these:

  • The Blue Cross Blue Shield Association stated that individuals who enrolled through special enrollment periods utilized up to 55 percent more services than those who signed up through regular open enrollment.
  • Aetna wrote that its special enrollment customers keep their plans for an average of four months, as opposed to eight to nine months for regular enrollees.
  • UnitedHealth stated its special enrollment customers last year utilized 20 percent more care than regular enrollees.
  • Anthem reported that special enrollment customers are more than twice as likely to drop their plans after a short time than regular plan members.

The administration has already eliminated one of the top special enrollment drivers from last year, when it allowed signups through April—giving people the opportunity to enroll after they were hit with a tax penalty for not having coverage the previous year. While details have not yet been released, a CMS official has indicated that the government will go further in eliminating other special enrollment periods.

That may be tough news for the remaining pool of holdouts who are banking on staying healthy and paying the ACA fines as their cheapest way forward. Should they change their minds about this strategy, they will likely find no available options for special enrollment.