New Exchange Special Enrollment Periods for Certain Individuals

Under the Affordable Care Act (ACA), each Exchange must have an initial open enrollment period, an annual open enrollment period and certain special enrollment periods. Individuals will only be able to enroll through an Exchange during one of the permitted enrollment periods. The initial open enrollment period is Oct. 1, 2013, through March 31, 2014.

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; and
• Limited Circumstance SEPs for individuals who were not able to enroll during the initial open enrollment period due to certain limited circumstances.

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

Overview of Special Enrollment in Exchanges

Individuals may be allowed an SEP in an Exchange following certain triggering events, such as marriage or birth of a child. SEPs permit individuals to enroll in a qualified health plan (QHP) outside of open enrollment.

The effective date of any coverage elected during an SEP follows rules similar to those applicable during initial enrollment. This means that coverage would generally be effective as of the first day of the month for elections made by the 15th of the preceding month, and on the first day of the second following month for elections made between the 16th and the last day of a given month. However, special rules apply when birth, adoption or placement of a child is the special enrollment triggering event.

For SEPs that are triggered by mistakes, contract violations, exceptional circumstances and misconduct, the Exchange may set an appropriate effective date.

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. This means that 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.

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.

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 paper applications received by April 7. These consumers will be able to select a plan through April 30, and coverage will be effective May 1.

This guidance applies in FFEs and state partnership Exchanges. State-based Exchanges have the option to offer similar SEPs.

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

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.
Generally, these SEPs will result in prospective coverage effective dates. Coverage effective dates may be based on either:
• The date of the event that triggered the SEP; or
• The regular prospective effective dates described in guidelines issued by HHS.

In cases where it is unknown when a consumer would have effectuated coverage, coverage should be provided according to the regular effective dates.

Exceptional Circumstances

An SEP will be provided in cases where a consumer faces exceptional circumstances as determined by CMS, such as a natural disaster, medical emergency and planned system outages that occur on or around plan selection deadlines.

CMS has provided the following examples:

• A natural disaster, such as an earthquake, massive flooding or hurricane
• A serious medical condition, such as an unexpected hospitalization or a temporary cognitive disability
• A planned Exchange system outage, such as Social Security Administration system outage

Misinformation, Misrepresentation or Inaction

An SEP will be provided in cases where misconduct by individuals or entities providing formal enrollment assistance (like an insurance company, Navigator, certified application counselor, Call Center Representative, or agent or broker) resulted in one of the following:
• A failure to enroll the consumer in a plan;
• Consumers being enrolled in the wrong plan against their wishes; or
• The consumer not receiving advanced premium tax credits or cost-sharing reductions for which they were eligible.

CMS has provided the following example:

• Representative enrolled a consumer in a plan that the consumer did not want to enroll in.

Enrollment Error

An SEP will be provided in cases where consumers enrolled through the Exchange, but the insurance company didn’t get their information due to technical issues.

CMS has provided the following examples:

• Consumer’s information is received by the insurance company and may be processed, but the enrollment file contains defective or missing data which makes the insurance company unable to enroll the consumer.
• Consumer’s application may have been rejected by the issuer’s system because of errors in reading the data.

System Errors Related to Immigration Status

An SEP will be provided in cases where an error in the processing of applications submitted by immigrants caused the consumer to get an incorrect eligibility result when he or she tried to apply for coverage.

CMS has provided the following example:

• Immigrants with income under 100 percent of the poverty line who are eligible for premium tax credits and cost-sharing reductions did not receive the proper determination.

Display Errors on Exchange Website

An SEP will be provided in cases where incorrect plan data was displayed at the time the consumer selected the QHP, such as plan benefit and cost-sharing information.

CMS has provided the following examples:

• Data errors on premiums, benefits or copay/deductibles
• Errors that resulted in the display of a QHP to applicants who were outside of the QHP’s service area or who were in ineligible enrollment groups
• Errors that didn’t allow consumers with certain categories of family relationships to enroll together in a single plan with their family members

Medicaid/CHIP—Exchange Transfer

An SEP will be provided for consumers who were found ineligible for Medicaid or CHIP and their applications weren’t transferred between the State Medicaid or CHIP agency and the Exchange in time for the consumer to enroll in a plan during open enrollment.

CMS has provided the following examples:

• Consumers who applied at the FFE, were assessed to be eligible for Medicaid or CHIP, were found ineligible for Medicaid or CHIP by the state agency and then weren’t transferred back in time for an FFE determination during open enrollment
• Consumers who applied at the state Medicaid or CHIP agency during open enrollment and ended up having their cases referred to the Exchange after a denial of Medicaid or CHIP

Error Messages

An SEP will be provided in cases where a consumer is not able to complete enrollment due to error messages. CMS has provided the following example:
• Error or box screen indicating that the data sources were down and the consumer could not proceed with enrollment

Unresolved Casework

An SEP will be provided in cases where a consumer is working with a caseworker on an enrollment issue that is not resolved prior to March 31. CMS has provided the following example:
• Consumers who began the casework process but it was not resolved prior to the end of open enrollment

Victims of Domestic Abuse

An SEP will be provided for consumers who are married and are victims of domestic abuse. Consumers who are in this category can apply and select a plan through

May 31, 2014

CMS has provided the following example:
• Prior to clarifying guidance from Treasury and HHS, consumer assumed or was informed that premium tax credits were unavailable to consumers who are married and not filing a joint tax return. Consumer may or may not have attempted to apply.

Other System Errors

Finally, an SEP will also be provided for other system errors, as determined by CMS, which hindered enrollment completion.

More Information

Please contact Robertson Ryan & Associates for more information on Exchange enrollment periods.

Source: Centers for Medicare & Medicaid Services