Each Exchange must have an initial open enrollment period, an annual open enrollment period, and certain special enrollment periods, under the Affordable Care Act (ACA). During one of the permitted enrollment periods individuals will only be able to enroll through an Exchange. The initial open enrollment period is Oct. 1, 2013, through March 31, 2014.
The Centers for Medicare & Medicaid Services (CMS) issued two separate pieces of guidance providing the following special enrollment periods (SEPs) in the federally-facilitated Exchange (FFE), on March 26, 2014:
• SEP for “In Line” Individuals—those who have begun the enrollment process but haven’t finished—as of March 31; and
• Limited Circumstance SEPs for individuals who were not able to enroll during the initial open enrollment period due to certain limited circumstances.
These SEPs allow individuals to enroll in Exchange coverage after the initial open enrollment period closes if certain conditions are met.
Overview of Special Enrollment in Exchanges
Following certain triggering events, such as marriage or birth of a child, individuals may be allowed an SEP in an Exchange. SEPs permit individuals to enroll in a qualified health plan (QHP) outside of open enrollment.
Similar to those applicable during initial enrollment, the effective date of any coverage elected during an SEP follows rules. This means that coverage would generally be effective as of the first day of the month for elections made by the 15th of the preceding month, and on the first day of the second following month for elections made between the 16th and the last day of a given month. Special rules apply when birth, adoption or placement of a child is the special enrollment triggering event, however.
The Exchange may set an appropriate effective date, for SEPs that are triggered by mistakes, contract violations, exceptional circumstances and misconduct.
SEPs for “In Line” Individuals
Despite efforts to meet the deadline, CMS has expressed concern over whether high consumer traffic leading up to the March 31 enrollment deadline could potentially keep consumers from completing the enrollment process.
CMS will provide an SEP for consumers in the PPF who are “in line” as of March 31, should this occur. This means that consumers who tried to enroll during the open enrollment period, but did not complete the process by March 31, will be allowed a limited amount of additional time to finish the application and enrollment process.
As long as consumers who were “in line” pay their first month’s premium on time, it is anticipated that enrollments made in the limited time after March 31 will have a May 1 coverage effective date. This is the coverage effective date that consumers would have had it they were able to complete enrollment by March 31, and is the normal effective date for enrollments between March 16 and April 15.
CMS will process paper applications received by April 7, for consumers who were “in line” with paper applications (or whose applications were pending submission or review of supporting documentation) on March 31. These consumers will be able to select a plan through April 30, and coverage will be effective May 1.
This guidance applies in FFEs and state partnership Exchanges. State-based Exchanges have the option to offer similar SEPs.
For more information please contact The Benefits Firm.
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