Fact Sheet: Pre-Enrollment Verification for Special Enrollment Periods

Centers for Medicare and Medicaid Service (CMS), December 2016

The Centers for Medicare and Medicaid Services (CMS) is committed to making sure that Health Insurance Marketplace special enrollment periods are available to those who are eligible for them, and equally committed to avoiding any misuse or abuse of special enrollment periods. Over the last year, we have taken a number of steps to balance these commitments. Today, we are announcing a pilot program starting in 2017 that will test the impact of pre-enrollment verification of special enrollment period eligibility through HealthCare.gov on compliance, enrollment, continuity of coverage, the risk pool, and other outcomes.

The Pre-Enrollment Verification Process:

• CMS will pilot pre-enrollment verification in all states and all counties served by the HealthCare.gov platform.

• All special enrollment period types will be subject to enhanced verification in some form, whether through the pilot or through other enhanced procedures. In particular, applications based on loss of minimum essential coverage will be included in the pilot.

• The pilot will begin in June 2017 and CMS anticipates basing future decisions about special enrollment period verification procedures on the results of the pilot.

• 50 percent of new applications with relevant special enrollment periods will be part of the pilot and applicants will be required to submit documents before their coverage begins. Applications will be randomly selected for the pilot.

• Consumers included in the pilot will still be able to submit their application and select a plan, with a coverage effective date determined by the date of plan selection. However, the Marketplace will “pend” the consumer’s enrollment until the consumer submits documents that establish their eligibility for a special enrollment period.

• Consumers will be given 30 days to provide document. They can upload documents into their account on HealthCare.gov or send their documents in the mail. The Marketplace Call Center will be able to provide consumers with information on the status of their documents.

• Once a consumer has submitted appropriate documents, the Marketplace will send their enrollment to the issuer. The consumer will be able to pay their premium, and their coverage will begin, generally with the original coverage effective date.

• CMS will evaluate the impact of pre-enrollment verification on the risk pool, using data on 2017 claims that will become available in the spring of 2018. CMS will also evaluate the impact of the pilot on enrollment and other metrics on an ongoing basis.

Prior Special Enrollment Period Program Integrity Actions:

Earlier this year, CMS added warnings to HealthCare.gov to discourage the inappropriate use of special enrollment periods. We have also eliminated several special enrollment periods that were no longer needed and tightened the eligibility rules for certain special enrollment periods.

We have begun to learn about how the Special Enrollment Confirmation Process is affecting the Marketplace. Since implementing this process in June, we have seen a 20 percent reduction in the number of consumers enrolling through special enrollment periods, compared to 2015, with every week since the implementation of the confirmation process in 2016 showing lower enrollment than the corresponding week in 2015.

The early results of the Special Enrollment Confirmation Process also suggest that younger consumers are disproportionately likely to fail to complete the verification process. A preliminary snapshot of consumers selected for review showed that 73 percent of applications with a household contact ages 55-64 submitted documents after initial outreach, but only 55 percent of those ages 18-24 did so.



New Special Enrollment Rules Will Shift Paperwork Burden To Consumers

By Michelle Andrews
Kaiser Health News, December 20, 2016

People who want to sign up for a policy on healthcare.gov after the annual open enrollment period ends Jan. 31 may have to produce a paper trail proving that they qualify for a “special enrollment period” before their coverage can begin, according to details of a pilot program described last week by federal officials. But the verification measures, long sought by insurance companies, may deter the very consumers the marketplace needs to attract: healthy people who may not bother signing up if doing so is a hassle.

The insurance needs of many of the shoppers who use the health marketplaces don’t fit neatly into the three-month annual open enrollment period. For example, nearly 30 million people — workers plus their families — lose employer-sponsored coverage every year outside of open enrollment, researchers at the Urban Institute found. But they estimated that only about 5 percent of those eligible for a special enrollment period signed up for marketplace coverage in 2015.

“We have a lot of experience that eligible consumers faced with [documentation requirements] will drop out of the process,” said (Stan Dorn, a senior fellow at the Urban Institute).


The policy community has gone out of its way to initiate studies that would enhance the business outcomes of the private insurers, almost regardless of any negative impact on patients. This study on special enrollment periods being initiated by CMS is no exception and may actually violate standards of ethics in research.

For most of the year individuals are prohibited from enrolling in ACA exchange plans in order to prevent individuals from signing up only when they need care and dropping out after receiving it. Obviously this is designed to protect insurers from excessive losses though it does so at a cost of reducing patients’ access to health insurance.

People do experience “life events” that require a change in their insurance. For this reason, special enrollment periods are offered on an individual basis. The insurers claim that many people “abuse” this process and simply wait until they need coverage. To reduce this “abuse,” one-half of special enrollment applicants will be required to submit documentation of the qualifying event or their pending coverage will be rejected. They will be compared with the other half who still have to meet the same requirements but will not have to provide documentation.

We already have a few facts at hand. Many people eligible for the exchange plans never apply for them, and some will remain uninsured. Since rules for the special enrollment periods were tightened earlier this year, the enrollment rate has dropped 20 percent. We know that people eligible for programs will drop out of the process when faced with sometimes burdensome documentation requirements. We do not need another study to show that those facing documentation requirements will enroll at a lower rate. Many of them will remain uninsured, with potential adverse health and financial outcomes.

This study will harm patients. It is a violation of medical and health policy ethics to institute a study in which harm to patients is an expected outcome.

Besides, we do not need this study. Instead, we need a health care financing system in which everyone is enrolled, automatically, for life.

We need a new ethical principle and that is that it is a violation of ethics to establish policies that benefit private insurers at a cost of the physical and financial well-being of patients. But under such a principle the business model of private insurers would fail because they would lose all of their patient-unfriendly innovations that have made the insurers such a business success.

That is why we need to replace them with our own single payer national health program – an improved Medicare for all. Such a public service model would eliminate the perversities of the insurers’ private business model. It’s a matter of ethics.