special enrollment

CMS announces special enrollment changes

The generous open enrollment window offered by health insurance marketplaces is now officially closed for the year, which means that admissions and billing professionals will soon have a somewhat firmer picture of patients’ coverage. It won’t be THAT firm, though, due to special enrollment periods (SEPs) that let some consumers make mid-year changes. (For more on this issue, check out our flipbook.)

As we’ve covered previously, insurance companies have been vocal about the problems caused by lenient SEPs on the marketplaces, stating that customers who enroll during these periods tend to use more care and keep their policies for shorter lengths of time. Now, CMS is responding to the issue, announcing three new ways it will tighten special enrollment periods:

  • Clarifying: CMS has updated its guidance to make it more clear that in cases where consumers cite a geographic move as their reason for special enrollment, that move must be permanent, as opposed to short-term.
  • Eliminating: Six SEPs have been eliminated after being deemed no longer necessary. These periods were largely for rare circumstances such as “consumers who were affected by an error in the treatment of Social Security Income for tax dependents.” Nonetheless, the elimination of these six periods lowers the number of possible SEPs from the previous total of 33, and may help eliminate confusion for consumers.
  • Enforcing: CMS’s new plan to conduct assessments and audits may be the change that goes furthest in addressing insurers’ complaints about special enrollment abuse. In its announcement, CMS writes that it will begin pulling samples of consumer records and validating that the policy buyers were properly qualified. The organization will also “emphasize more strongly to applicants that … they may be subject to penalties under federal law if they intentionally provide false or untrue information.”

“While there will continue to be special enrollment periods for people who lose coverage mid-year or experience other life changes, this channel for enrollment will not be available for the vast majority of consumers,” stated the announcement.

It seems that after several years of offering generous accommodations to enable people to enroll in plans, the government’s message is now growing sterner: If you don’t choose a plan during open enrollment, you may very well be locked out for the year.