In an effort to make the Marketplace attractive for both consumers and insurance companies, CEO Kevin Counihan stated in a January 19 press release that CMS is eliminating “several unnecessary special enrollment periods” while clarifying the definitions of other SEPs. He also vowed that CMS will provide “stronger enforcement so that special enrollment periods serve the purpose for which they are intended and do not provide unintended loopholes.”

These changes are in response to complaints from health insurance companies that it is too easy for people to wait until they got sick to enroll in coverage, and with continued consolidation in the industry, the government wants to do everything it can to convince insurers to continue offering Marketplace plans.

Here’s an excerpt from the CMS press release:

The Marketplace must also be attractive to insurers, so that they make quality plans available at affordable prices and continue to drive innovation, and so consumers can find plans that meet their health and budget needs. Building an attractive Marketplace starts with establishing a predictable, stable set of rules that help to keep the risk pool balanced. As the Marketplace grows and evolves, we continue to analyze data to understand how our rules are impacting insurers and consumers and to make sure they are working to sustain a stable Marketplace. By having clear rules for how the Marketplace operates and making adjustments when needed, we are creating a more stable rate environment with more affordable plan choices for consumers.

Special Enrollment Periods that have been eliminated

The press release announced that the below special enrollment periods will no longer be available beginning this year:

  • Consumers who enrolled with too much in advance payments of the premium tax credit because of a redundant or duplicate policy
  • Consumers who were affected by an error in the treatment of Social Security Income for tax dependents
  • Lawfully present non-citizens that were affected by a system error in determination of their advance payments of the premium tax credit
  • Lawfully present non-citizens with incomes below 100% FPL who experienced certain processing delays
  • Consumers who were eligible for or enrolled in COBRA and not sufficiently informed about their coverage options
  • Consumers who were previously enrolled in the Pre-Existing Condition Health Insurance Program

Additionally, the tax filing SEP, which allowed taxpayers who first learned about the individual mandate when they were filing their 2014 taxes to special enroll between March 15 and April 30, 2015, will not be repeated in 2016.

Finally, CMS clarifies that, while moving to a new area creates a special enrollment opportunity, “this special enrollment period cannot be used for a short-term or temporary move where the consumer doesn’t plan to stay in their new location, including situations in which a consumer is admitted to a hospital for treatment in a different area.”

Remaining Special Enrollment Opportunities

Special enrollment opportunities do serve a purpose: “to make sure that people who lose their health insurance during the year or who experience a major life change…have the opportunity to enroll in coverage through the Marketplaces.” And they’re not all going away. A quick review of the website reveals that consumers still have plenty of special enrollment opportunities, including marriage, having or adopting a child and the loss of job-based coverage. Here are some other situations that would result in a special enrollment period:

  • Moving to a new state
  • Changes in your income that affect the coverage you qualify for
  • Gaining membership in a federally recognized tribe or status as an Alaska Native Claims Settlement Act (ANCSA) Corporation shareholder
  • Becoming a U.S. citizen
  • Leaving incarceration
  • Change of dependency status of someone on your plan
  • Death of a covered member of your household
  • Turning 26 or older and aging off your parent's plan
  • AmeriCorps members starting or ending their service

In Summary

Long story short, there will be fewer opportunities in 2016 to enroll clients and prospects outside of the open enrollment period, but that’s not necessarily a bad thing. The special enrollment periods that are being eliminated aren’t very common, and—ultimately–this action by CMS will help to strengthen and stabilize the individual health insurance market. Many of the carriers offering Marketplace plans are losing money, and some are reconsidering their decision to provide individual coverage. Anything CMS can do to reduce their risk and convince them to continue to offer options to consumers is a good thing.

One last thing: While it’s great to help clients get health insurance twelve months of the year, you probably shouldn’t focus too heavily on these sales in the nine months between open enrollment periods. There are plenty of other products you can sell such as short-term medical and supplemental plans that more people will qualify for and that can make you a lot more money. Contact AHCP to learn more.