HealthCare.gov plans systemwide eligibility-proofing test

The Affordable Care Act individual major medical open enrollment period runs from Nov. 1 through Jan. 31. (Photo: iStock)
The Affordable Care Act individual major medical open enrollment period runs from Nov. 1 through Jan. 31. (Photo: iStock)

HealthCare.gov managers say they hope to test a new strategy for screening people who apply for individual major medical coverage outside the normal enrollment period.

Related: New exchange screening rules slash sales

Starting in June, HealthCare.gov will require half of the people who are asking for special enrollment periods to provide documentation showing that they qualify for it, according to a new fact sheet on the Centers for Medicare & Medicaid Services (CMS) website.

The affected consumers will have to send in the documentation, through HealthCare.gov or through regular mail, before their exchange plan coverage will start.

Consumers who fail to submit documentation within 30 days may lose access to exchange plan coverage.

CMS, the arm of the U.S. Department of Health and Human Services that runs HealthCare.gov, says it wants to use a random process to put half of special enrollment period applicants in all markets it serves into the pilot program.

CMS will evaluate the effects of the pilot program throughout 2017, and it will conduct more evaluations in the spring of 2018, officials say.

CMS started HealthCare.gov to provide Affordable Care Act exchange services in states that were unable or unwilling to provide the services themselves. The pilot program would operate only in the states HealthCare.gov serves.

The ACA now requires insurers to sell and price individual major coverage without use of information about people’s health. They must charge the same price for people who are healthy and for people who are about to get lung transplants.

ACA exchange programs, insurance regulators and insurers developed the current open enrollment period system, or limits on when people can buy individual major medical coverage, to keep consumers from seeing the new restrictions on medical underwriting as a chance to wait until they get sick to pay for coverage.

The ACA open enrollment period runs from Nov. 1 through Jan. 31. Consumers who want to buy coverage at other times must show they have a good reason to qualify for a special enrollment period, which is called a “sep” in the industry, such as loss of access to group health coverage, or a move to a new town.

Some insurers have argued that some uninsured people who get sick are lying about qualifying for special enrollment periods to gain access to coverage.

Consumer groups have argued that few consumers know about special enrollment periods, that applying for it is already too hard, and that documentation requirements are more likely to hurt people who have a hard time with paperwork than to eliminate significant amounts of fraud.

CMS officials note in the new fact sheet that a much more limited special enrollment period screening program HealthCare.gov started, in June of this year, seems to have cut such enrollments about 20 percent. That program seems to be cutting sales to young adults much more than it has been cutting sales to older applicants, officials say. 

Republicans have said they hope to repeal Obamacare. The proposed special enrollment period eligibility verification pilot program is set to start after a new administration is in charge of CMS and HealthCare.gov.

Related:

Avalere shows how ‘special’ enrollees kill health insurers

3 must-have skills for finding ACA exchange liars

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