Feds want proof for ACA exchange special enrollment windows

AP News
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Posted: Feb 24, 2016 4:23 PM

The federal government is tightening loopholes that let customers on the Affordable Care Act's public insurance exchanges buy coverage outside the law's annual enrollment window.

That could ease a major concern health insurers have about the exchanges.

The Centers for Medicare and Medicaid Services said Wednesday that it will start requiring documentation or proof from people who say they need to buy a plan or change coverage outside that window for reasons like marriage, a permanent move or the birth of a child.

Millions of people have used the ACA's state-based exchanges to buy health insurance over the past few years. The vast majority do so during an open enrollment window that starts every fall and runs into January.

The law established that window to prevent people from waiting until they become sick to buy insurance. It also created special enrollment periods in case a life-changing event causes a customer's insurance needs to change outside of open enrollment.

UnitedHealth Group Inc. and other insurers have said they get a lot of expensive customers through these special enrollment periods. They suspect that some customers were waiting until they become sick to buy insurance since no one was asking for proof that they qualified for a special enrollment period.

Such proof can come in the form of a birth certificate or a marriage license, and insurers require it for coverage purchased off the ACA's public exchanges. But they aren't allowed to ask for that proof from their exchange customers.

The special enrollment documentation will be required in the 38 states that use the federal, HealthCare.gov website for their exchange. The new requirement will unfold over the next several months.

A CMS spokesman said the government has to notify customers about the new requirement, get documentation from them and then verify it.

HealthCare.gov executives said in a blog post that the government is committed to making sure these sign-up windows are still available to those eligible for them, but "it's equally important to avoid misuse or abuse of special enrollment periods."

Insurers like Aetna Inc. have recently questioned the sustainability of the exchanges, and the Blue Cross-Blue Shield insurer Anthem Inc. has said it was paying close attention to how the government deals with special enrollment periods.

The industry trade group America's Health Insurance Plans on Wednesday called the new documentation requirement a "much-needed step in the right direction."