Here are some of the key changes spelled out in the new regulations:
HealthCare.gov’s 2018 open enrollment will run from November 1–December 15, 2017 (45 days instead of 3 months)
The new rule says a special enrollment period for people not already covered through HealthCare.gov will be granted only after the consumer verifies they are eligible for one. HealthCare.gov will begin phasing this in in June.
People seeking a special enrollment period for new coverage will be able to apply for coverage and select a plan, but will not be enrolled until their eligibility for the SEP is verified.
Consumers will have 30 days after requesting the SEP and applying for coverage to submit proof they are eligible for the SEP. They may receive a retroactive coverage start date based on the date they selected a plan.
If verification of their information takes long enough that they would have to pay for two or more months of retroactive coverage, they will be permitted to forgo one month of the retroactive coverage and premium.
For couples newly enrolling though HealthCare.gov outside of open enrollment, a special enrollment period will be granted based on marriage only if one member of the couple had minimum essential coverage on at least one of the previous 60 days.
A consumer who already has a qualified health plan and gets a special enrollment period to enroll a spouse will generally be allowed to add the spouse to their existing plan, but not shop for an entirely new plan. Alternatively, the new spouse may choose his or her own new plan from among all available plans.
As an exception, both spouses may move into a new silver-level plan if marriage makes them newly eligible for cost-sharing reductions.
Birth or adoption:
A consumer who already has a qualified health plan and gets a special enrollment period to enroll a new baby or adopted child will generally be allowed to add the child to their existing plan, but not shop for an entirely new plan. Alternatively, the parent may choose any new plan for the child only.
As an exception, the family may move into a new silver-level plan if adding the child to the family makes them newly eligible for cost-sharing reductions.
Other special enrollments:
Permanent move. People applying for a special enrollment period based on a permanent move will have to show evidence of prior coverage during the previous 60 days. In the past, people had to only attest they had coverage in the previous 60 days. Current Marketplace enrollees granted a special enrollment period will be permitted to choose a new plan only in the same "metal tier" they already have.
Exceptional circumstances. HealthCare.gov will be stricter in evaluating applications for "exceptional circumstances" special enrollment periods. Applicants seeking these special enrollments will have to demonstrate that something truly exceptional happened in their lives (such as an illness or a natural disaster) that prevented them from enrolling during open enrollment. CMS will provide in the future more specific guidance on this type of SEP.
Loss of Minimum Essential Coverage. HealthCare.gov will begin screening enrollees who apply for this special enrollment period to ensure the enrollee was not recently terminated from Marketplace coverage for failing to pay premiums.
Tribe members are exempt from the new SEP restrictions and will continue to have the right to enrollment in any month of the year for any reason.
Consumers’ outstanding premium debt:
The regulation permits insurers to apply the premium payments made by a returning enrollee to past-due premiums from the prior 12 months. This means that people who were terminated from coverage for nonpayment of premiums in the previous 12 months and who still owe a premium for that time will be required to pay the previous amounts plus one additional full month of premium to re-start coverage with the same insurer. This rule applies to individual insurance companies as well as any parent, subsidiary, or affiliated insurance companies.
The regulation allows states to set their own rules around this issue, and those rules can vary from the description above. Oregon may choose to implement its own approach to consumer and carrier rights when it comes to unpaid premiums, and we will keep partners and stakeholders updated as that develops.