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New Special Enrollment Confirmation Process Announced

On February 24, 2016, CMS announced a new Special Enrollment Confirmation Process.

Once the new Special Enrollment Confirmation Process is implemented, all consumers applying through the most common HealthCare.gov special enrollment periods (SEPs) will be directed to submit documentation to verify their eligibly to use an SEP. CMS will then review the documents to ensure consumers qualify for an SEP.

On March 4, 2016, CMS updated the Marketplace application by:

  • Adding New Attestation Language: New language requires consumers to attest that they understand they may be asked to provide additional information, including proof of their eligibility for an SEP, and that, if they do not provide proof of eligibility, they may face penalties including the risk of losing their coverage. This box is on the privacy policy page of the application and must be checked prior to proceeding through a new or updated application and entering information that may qualify the consumer for an SEP.
  • Updates to Loss of Minimum Essential Coverage Questions: Both the recent loss of coverage and future loss of coverage questions have been updated to (1) specify that coverage must have been lost within the past 60 days or will be lost within the next 60 days; (2) provide examples of coverage that qualifies as minimum essential coverage (MEC); and (3) provide a link to a help page that provides a thorough discussion and explanation of MEC. In addition, new blue boxes have been added to clarify that losing coverage due to nonpayment of premiums does not qualify as loss of MEC for purposes of qualifying for this SEP.
  • Updates to the Permanent Move Question: The permanent move question has been updated to specify that the move must have occurred within the last 60 days and provide examples of which situations do and do not qualify as a permanent move for purposes of qualifying for this SEP.

Additionally, CMS updated text on the SEP Screener Tool to reflect these application updates. These application updates will be accompanied by other improvements to the SEP application process, which are described here and are part of the new Special Enrollment Confirmation Process.

Refer to this Fact Sheet for further information on how the Special Enrollment Confirmation Process will work and what else CMS is doing to improve the SEP process.

Marketplace vs. Insurance Company: Where to Report Life Changes

Some consumers may be unsure about where to report their life change or change in circumstance for their Marketplace coverage. Let consumers know that they should always report a life change or change in circumstance directly to the marketplace as soon as possible.

Below are a few examples of changes that must be reported to the Marketplace directly:

Marketplace vs. Insurance

Tax Season Spotlight

NOTE: This version of the assister newsletter revises the Tax Season Spotlight where the hyperlinks to resources were initially defective.

This tax season, the Marketplace and Internal Revenue Service (IRS) have told consumers that they must have had Minimal Essential Coverage (MEC) to avoid paying the penalty for the 2015 benefit year. If a consumer didn’t obtain coverage directly from the Marketplace, they may have a hard time figuring out if the coverage they had actually qualifies as MEC, if they qualify for an exemption from the requirement to have coverage, or if they have to pay the penalty. The resources below provides some helpful information to guide consumers through each scenario.

MEC Resources

Exemption Resources

Penalty Resources

As we approach the April 18th deadline, consumers will likely reach out to assisters for help in understanding how health care affects their taxes. While assisters are prohibited from helping consumers with filing their taxes (unless you are also a licensed tax professional), being able to refer a consumer to a tax professional is an excellent way to guide a consumer to the help they need. Where assisters are also licensed tax professionals, they might be in a position to assist clients with the tax filing components of the premium tax credit reconciliation process or claiming exemptions through a tax return, but should keep these duties separate and not perform any tax assistance within their capacity as an assister.

Coverage Gap SEP in Non-Medicaid Expansion States (Reminder)

Reminder: A consumer may qualify for the Medicaid Coverage Gap Special Enrollment Period (SEP) if the consumer:

  • Resides in a non-Medicaid expansion state;
  • Was previously ineligible for advance payments of the premium tax credit (APTC) solely because of a household income below 100% of the Federal Poverty Level (FPL);
  • Was ineligible for Medicaid during that same timeframe; and
  • Has experienced a change in household income that makes him/her newly eligible for APTC.

In April 2015, CMS added this SEP and removed the requirement for a consumers to receive the following documents before applying for Marketplace coverage through this SEP:

  • Medicaid denial notice from their state Medicaid agency,
  • Exemption Certificate Number (ECN) or,
  • Previous Marketplace Affordability Program (APTCs/CSRs) Denial

Currently to apply for this SEP, the consumer should call the Marketplace Call Center to attest that he or she was previously ineligible for Medicaid because they live in a non-Medicaid expansion state and were previous ineligible for APTC because their income was too low, but have now experienced an increase in household income that makes them newly eligible for APTC. =. The consumer has 60 days from the date that he or she experienced the change in household income that made him or her newly eligible for APTC to call  the Marketplace to report this change and enroll in coverage. This SEP is not available online, so consumers who want to request this SEP must call the Marketplace.

Here are answers to frequently asked questions from assisters about this SEP:

Q: I live in Georgia, a state that did not expand Medicaid. During open enrollment, I helped a consumer who had income below 100% FPL. She didn’t apply for Marketplace coverage during the open enrollment period and doesn’t have a Marketplace account. Now her income has gone above 100 percent of FPL. Is she eligible for this SEP even though she didn’t apply for Marketplace coverage during the annual open enrollment period? 

A: Yes, a consumer in this situation would be eligible to enroll under this SEP. For this SEP, the consumer is not required to have previously applied for Marketplace coverage during the open enrollment period.

Q: I understand that consumers in this situation don’t need to a Medicaid Denial Notice to apply for coverage under this SEP. Does this guidance also remove the requirement for consumers to obtain an Exemption Certificate Number (ECN) or previous Marketplace Affordability Program (APTCs/CSRs) Denial to apply for coverage under this SEP?

 A: Yes, eligibility for this SEP is not contingent upon being denied Medicaid, APTC/CSR or applying for an exemption. A qualifying consumer without any of these things can still apply for coverage under this SEP.

Q: I’m helping consumers in North Carolina and we aren’t sure about what supporting documents, if any, the consumer should provide when applying for coverage under this SEP. Will consumers have to provide documentation to the Marketplace to support claims of an increased income above 100% FPL? 

A: No, consumers do not need to submit documentation to prove an increase in household income in order to qualify for this SEP. Instead, consumers must attest that they previously weren’t eligible for Medicaid because they live in a non-Medicaid expansion state or for APTC because their income was too low, but experienced a change in income that makes them newly eligible for APTC.  Reminder: The Marketplace sometimes needs more information to verify consumers’ income, regardless of when they apply and enroll in coverage. In these cases, the Marketplace requests additional documentation to resolve what is known as a data matching issue (DMI). Click here to learn more about DMIs and how to help consumers resolve them. A list of documents consumers may be asked to provide to resolve the DMI is here.

Q: I’m an Assister in Texas and I’d like to provide enrollment assistance to consumers at job fairs whose income will likely rise above 100% FPL in the near future.  How soon after the qualifying increase in income will I be able to help the consumer apply for Marketplace coverage under this SEP?

A: The consumer has 60 days from the date that he or she experienced the change in household income that made him or her newly eligible for APTC to come to the Marketplace to report this change and enroll in coverage.

Q: I’m still unsure about how to help my consumer apply for this SEP? I don’t see the relevant questions on the application.

A: The consumer must call the Marketplace Call Center to request this SEP; however the SEP is not granted immediately. After the consumer attests to the information above, the call center representative (CSR) will forward the consumer’s request for this SEP to the Marketplace for review. The consumer will be notified by mail of their eligibility for this SEP. The letter will inform the consumer of the next steps he or she should take to enroll in coverage, if the consumer is found eligible.

Q: I am working with a consumer who was eligible for APTC during open enrollment but chose not to enroll. They are ineligible for Medicaid and would now like to enroll in Marketplace coverage. Does this consumer qualify for this SEP?

A: No. A consumer in this situation would not qualify for this SEP. Consumers must have previously had an income below 100% of the FPL that made them ineligible for Medicaid and APTCs through the Marketplace. Once the consumer experiences an increase in their household income that would qualify him or her for APTCs, he or she may become eligible for this SEP.

Marketplace Updates: EDN Changes and Future OE Dates

NEW: Disqualifying Income Now Listed on Eligibility Determination Notices

On April 1st, CMS updated the Marketplace Eligibility Determination Notice (EDN) sent to consumers who are found ineligible for advance payments of the premium tax credit (APTC), cost-sharing reductions (CSRs), Medicaid or CHIP. The notice will now include the household income that the Marketplace used to determine them as ineligible for APTC, CSRs, Medicaid or CHIP, as applicable.

The consumers’ disqualifying income will be listed under the “Why don’t I qualify for other programs?” section of the Eligibility Determination Notice (EDN).

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Marketplace Announces 2017-2019 Open Enrollment Dates

The next Marketplace open enrollment periods for the individual market are as follows:

  • For the 2017 benefit year: November 1, 2016 – January 31, 2017
  • For the 2018 benefit year: November 1, 2017 – January 31, 2018
  • For the 2019 benefit year and beyond: November 1, 2018 – December 15, 2018

NEW: Ending Special Enrollment Period (SEP) Retroactive Coverage

On April 1st,  the Centers for Medicare and Medicaid Services (CMS) issued guidance announcing that after March 31, 2016 the Marketplace will no longer be accepting new requests for Special Enrollment Period (SEP) for retroactive coverage back to 2015. All retro SEP requests received after this date will receive a max retro date of January 1, 2016.

For additional information, click here: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/ENR-GuidanceEnding2015-SEPs-FINAL-040116.pdf