Each year, Centers for Medicare & Medicaid Services (CMS) issues the Notice of Benefit and Payment Parameter (NBPP), proposed rules and regulations that will guide the Affordable Care Act individual insurance market for the upcoming plan year. In our second blog post on the plan year 2024 NBPP, we set out to simplify the proposed rules for Special Enrollment Periods (SEPs). A special enrollment period is an enrollment window outside of the Open Enrollment period in which you can enroll in a qualified health plan due to a qualifying life event such as getting married, having a baby, losing access to your employer sponsored coverages, etc.   

Special Enrollment Period (SEP) Changes 

The COVID pandemic created an urgent need for Exchanges to create substantive changes to ensure that Americans were able to access and maintain affordable health insurance coverage throughout the pandemic period. Exchanges acted by extending the Open Enrollment Period (OEP) and adjusting ways in which individuals could access Special Enrollment Periods (SEPs). These actions served as a lesson on how Exchanges can eliminate barriers for consumers to access enrollment through an SEP. CMS is seeking to build on this momentum, while also providing State-Based Exchanges (SBEs) autonomous options to adjust operations that best fit the needs of their consumers. 

CMS proposes several changes to SEPs in the 2024 NBPP that are focused on eliminating gaps in coverage, as well as general technical clarifications for offering SEPs to qualified individuals.  

  • The proposed rule better defines which members of a tax household qualify for an SEP. The proposed language indicates that even if only one member of a tax household is eligible for an SEP, the whole family is eligible. This will allow families to make enrollment decisions to best suit their needs holistically. Families who choose to change plans during the plan year should consider how the change will impact their existing cost-sharing spends, such as the amount they have already paid towards their deductibles.
  • The proposed rule suggests allowing Exchanges the flexibility to offer an earlier effective date of coverage when a consumer is reporting a future loss of minimum essential coverage (MEC).   Under current regulations the consumer’s effective date is the first of the month after plan selection. This proposed change is targeted to help consumers seamlessly transition between plans without a gap in their coverage.
  • Ahead of the upcoming end of the Public Health Emergency (PHE) CMS is proposing a new special rule to allow individuals transitioning off Medicaid or CHIP a longer shopping window. Currently under SEP regulations all SEPs are granted a 60-day shopping window from the date of the event. This proposal would allow individuals who are losing Medicaid/CHIP coverage to be eligible for a shopping window of 90-days after the loss of Medicaid/CHIP. This change will allow the influx of individuals who are losing Medicaid/CHIP due to the end of the PHE to make the best plan choice for their specific needs.
  • The 2024 NBPP proposes streamlining SEPs by accepting consumer attestations of income when the tax data is not available from the IRS. Under current rules a consumer’s subsidy eligibility is determined from the income on file with the IRS, however if the subsidy provided by the consumer is not compatible with the IRS’ data, or there is no data available, the Exchange generates a data matching issue (DMI) requiring the consumer to provide proof of income. CMS proposes that in the scenario where the IRS has no information on the consumer’s income the Exchange should use the income attestation of the consumer to determine subsidy eligibility.  

Should all, or even some of the proposed changes to SEPs be finalized, consumers across the country will be able to access SEPs in a more streamlined fashion minimizing the administrative burdens on both the consumer and the Exchange.