The exchanges (or marketplace) will essentially run with two different opportunities to enroll. Like many plans today, this will include the open enrollment period and special enrollment periods. The exchanges will also have their own rules for when coverage may be cancelled.
It is important to note that these periods will not match other plans outside of exchanges or other plans from large employers. This may be confusing for participants as they learn these new rules and sometime move in and out of exchange coverage.
In the first year of operation, the marketplace (or exchanges) will allow an enrollment period from October 1, 2013 through March 31, 2014. This essentially is a 6 month window for open enrollment. In the years that follow, the marketplace open enrollment period will run from October 15th through December 7th, essentially a 2 month window for open enrollment.
- Recent guidance extended this date from November 15th to January 15 and then again in the form of a CMS Bulletin in March 2014 extended the enrollment period for 2015 coverage from Nov. 15, 2014 until Feb. 15, 2015, one month longer than previously scheduled.
If you meet certain conditions outside of open enrollment, the regulations allow for the following special enrollment periods:
(1) A qualified individual or dependent loses minimum essential coverage;
(2) A qualified individual gains a dependent or becomes a dependent through marriage, birth, adoption or placement for adoption;
(3) An individual, who was not previously a citizen, national, or lawfully present individual gains such status;
(4) A qualified individual’s enrollment or non-enrollment in a QHP is unintentional, inadvertent, or erroneous and is the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Exchange or HHS, or its instrumentalities as evaluated and determined by the Exchange. In such cases, the Exchange may take such action as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction;
(5) An enrollee adequately demonstrates to the Exchange that the QHP in which he or she is enrolled substantially violated a material provision of its contract in relation to the enrollee;
(6) An individual is determined newly eligible or newly ineligible for advance payments of the premium tax credit or has a change in eligibility for cost-sharing reductions, regardless of whether such individual is already enrolled in a QHP. The Exchange must permit individuals whose existing coverage through an eligible employer- sponsored plan will no longer be affordable or provide minimum value for his or her employer’s upcoming plan year to access this special enrollment period prior to the end of his or her coverage through such eligible employer-sponsored plan;
(7) A qualified individual or enrollee gains access to new QHPs as a result of a permanent move;
(8) An Indian, as defined by section 4 of the Indian Health Care Improvement Act, may enroll in a QHP or change from one QHP to another one time per month; and
(9) A qualified individual or enrollee demonstrates to the Exchange, in accordance with guidelines issued by HHS, that the individual meets other exceptional circumstances as the Exchange may provide.
Unless specifically noted, the marketplace will allow many of the events listed above to provide a 60 day window to change their election.
The events will also have special rules for when the events must be effective. Some are retroactive as is the case for birth or adoption, and some have their own rule dependent on what part of the month the election is made in. These effective dates will not coincide with non exchange coverage, which may result in some gaps in coverage.
Please note, several forms of subsequent guidance also applied to the enrollment periods for individuals attempting to sign up for coverage.
First, in February 2014 a CMS Bulletin on Marketplaces provided an additional special enrollment feature for retroactive tax credits and cost sharing subsidies.
Second, in March 2014, a separate CMS letter provided guidance on complex cases which allow late enrollment after the initial open enrollment period. This includes examples like exceptional circumstances, misinformation, enrollment error, system error, display errors, domestic abuse, and other errors. http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/complex-cases-SEP-3-26-2014.pdf
Third, CMS released another letter in March 2014 providing guidance on people “In Line” for the Federally-facilitated Marketplace at the end of the Initial Open Enrollment Period. http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/in-line-SEP-3-26-2014.pdf
Fourth, in August 2014, CMS announced two additional situations where special enrollment periods (SEP) may apply for "exceptional circumstances." This includes those attempting to apply for coverage by March 31, 2014 and could not due to system errors until April 1-15th, met the "in-line" but completed application by April 15th, transferred to state Medicaid or CHIP, and denied Medicaid or CHIP by the state. This also includes situations where individuals in a state that did not expand Medicaid applied for coverage when their income was under 100% of poverty (thereby not eligible for premium tax credits) but later had income over 100% poverty level so they became eligibe for premium tax credits.
Some of these special enrollment complex cases may be viewed at the following link:
The following events will allow an enrollee to cancel coverage:
(1) The enrollee is no longer eligible for coverage,
(2) Non-payment of premiums for coverage of the enrollee,
(3) The 3-month grace period required for individuals receiving advance payments of the premium tax credit has been exhausted,
(4) Any other grace period [described by regulation] has been exhausted;
(5) The enrollee’s coverage is rescinded,
(6) The plan terminates or is decertified, or
(7) The enrollee changes from one qualified health plan to another during an annual open enrollment period or special enrollment period.
To view these rules: 45 CFR 155-157
If you need help understanding these rules or the ACA generally, please contact Kinney & Larson.