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Tuesday, May 9, 2017

What Enrollment Assisters Should Know about the New Marketplace Rules

Elizabeth Hagan

Associate Director of Coverage Initiatives

The recently finalized “marketplace stabilization” rule will have significant impacts for consumers by making coverage less affordable and making the process of enrolling more difficult. This blog will review the main implications of the rule for the enrollment process and policy, specifically focusing on changes to open enrollment periods, special enrollment periods, and rules for those who have missed premium payments. It will also provide ideas for how to minimize the potential consequences of this rule. 

For more information about this rule and how assisters are responding to it, register for our Enrollment Assister Webinar on May 11. 

The next open enrollment period will be shorter

The rule shortens the next open enrollment period to half the length of the recent open enrollment periods (OEP), with the next open enrollment period now running from November 1 to December 15, rather than November 1 to January 31. 

What Can You Do? 

Though this OEP is for all marketplaces, including state-based marketplace (SBMs), the rule does say that SBMs can tack on a special enrollment period (SEP) to the end of the official open enrollment period as a “transitionary measure.” Because SBMs may encounter difficulties when transitioning to a shorter OEP and many consumers will not know about the changes, this is being looked at as an appealing state option.    

This change means that there will be an even more significant need for outreach, education, and marketing to ensure consumers and partners know about enrollment timeframe. There is a role for any and all entities working on health care issues to market and message around the new OEP. It is also important that we ensure CMS and SBMs conduct outreach themselves. While CMS makes mention of this in the rule, we don’t have clarity or guarantees about plans. 

There is also the unfortunate reality that this OEP overlaps with many employer plans and Medicare, leading to less assistance available to help people enroll. Community organizations and interested people may want to consider whether they can become certified to help people enroll in coverage.  Organizations already offering assistance may want to consider altering their OEP plan, such as budgeting and planning for staff to work different hours during the 6-week OEP.  

Additional requirements for consumers signing up during special enrollment periods 

The rule also made a number of further changes to SEPs that will make it more difficult for consumers to enroll in coverage outside of the annual OEP. 

One of the most significant changes is that consumers enrolling through SEPs in the FFM will now have to prove their eligibility for all SEPs before they enroll in coverage. This is a change from what exists now where consumers have to prove their eligibility for SEPs after they enroll in coverage for the five most common SEPs (birth, adoption/placement for adoption, marriage, loss of coverage, and moving). 

People enrolling through a SEP in the FFM will have 30 days from the time they pick a plan and will have their coverage pending until their eligibility is verified. Coverage will be retroactive to the plan selection date unless the verification process takes two or more months, in which case the consumer can choose to not pay for coverage for the first month. 

We do not know yet how long CMS will take to verify eligibility and change someone’s coverage from pending to active. CMS notes that more specificity will be coming, but consumers will verify their eligibility either through providing documentation or through electronic means. State-based marketplaces will not have to do this pre-enrollment verification, although HHS notes in the rule that they encourage them to do so. 

The second major change will mean that most people enrolling through the marriage SEP will be required to have had prior coverage, like the change last year for the “permanent move” SEP. Previously, getting married triggered an SEP regardless of whether the couple had coverage previously, and this rule means that at least one spouse will have had to have coverage for one day in the prior 60 days in order to be eligible. This change applies to all marketplaces. 

Lastly, the other significant change limits SEPs for current enrollees. The rule largely prohibits people from upgrading metal levels when they become eligible for a SEP. So, for example, when someone already enrolled in coverage becomes eligible for the marriage SEP, that individual would generally not be able to change metal levels unless they are newly eligible for cost-sharing reductions.

These last two changes will also go into effect in the FFM in June and CMS asks that SBMs move quickly to implement them as well.  

What Can You Do? 

Pre-enrollment verification processes are not being required in SBMs but CMS is encouraging this and SBMs may also face pressure from issuers to move in that direction. Assisters and advocates can share their concerns with SBMs exploring whether to implement SEP verification. They can also share ideas about how to make these changes less burdensome for consumers if the SBM moves forward, such building systems to automate the process.  

Similar to the discussion about OEPs above, the need for outreach will be significant. Already, only about 5 percent of eligible SEP consumers actually enroll in coverage, and there is potential for that to be even less with these changes so it is important that consumers and partners know that certain events trigger SEPs and allow people to enroll outside of OEPs. 

It will also be critical to track any issues that consumers face, such as how long CMS takes to verify eligibility or delays on enrollment. Assisters have a unique perspective that CMS will benefit from learning about.  

Non-Payment of Premiums 

Lastly, as finalized in the rule, issuers will now be able to prohibit consumers from re-enrolling in their plan if they owe them premiums from the past 12 months. Issuers will not be permitted to block consumers from enrolling with them if they owe a different issuer back premiums. This will impact low-income consumers’ ability to maintain continuous coverage, especially those living in areas with a single issuer who may now be blocked from enrolling in any coverage. 

What Can You Do? 

There are options for states and issuers on this rule.  States can and do have laws prohibiting issuers from instituting this policy and they can also require issuers to accept installments for payments or threshold payments so that consumers are not on the hook for a large sum of money at once. The rule also does not create an appeal process, but states can create appeals procedures. 

Issuers are not required to institute this rule in states that allow it. If they do, they also can allow people to pay back premiums in installments or accept a specified threshold payment. However, many issuers have long advocated for this policy and may find the option appealing. Advocates and assisters can advocate for consumer-friendly policies in this area, both with issuers and their state’s policymakers. 

There is also a need for consumers to understand the difference between terminating a plan they no longer want to be enrolled in versus no longer paying their premiums; if a consumer wants to terminate coverage, they need to actively take steps to do so. This ensures that if they want to enroll at a later date with that issuer, they will not be prohibited from enrolling. 

For more information about this rule and how assisters are responding to it, register for our Enrollment Assister Webinar on May 11.