Feds may go after some 'special' PPACA exchange plan enrollees

Officials at the Centers for Medicare & Medicaid Services (CMS) imply that they could prosecute some consumers for exchange plan application fraud in an answer to a question about special enrollment period (SEP) enforcement measures.

See also: Health market gets special

CMS officials announced Tuesday in a blog entry and a pair of informal guidance documents that they will try to do a better job of verifying whether consumers really qualify for special enrollment periods (SEPs) in the Patient Protection and Affordable Care Act (PPACA) open enrollment period system.

Officials will look especially hard to consumers who obtained SEPs based on assertions that they lost access to minimum essential coverage (MEC) or moved permanently to a new location, officials say in one batch of guidance.

CMS program integrity investigators will “sample consumer records nationally and may request additional information from consumers or take other actions to validate that they properly accessed coverage using those SEPs,” officials say.

Officials note that, “Responses to questions that trigger a special enrollment period are made subject to penalty of perjury.”

Officials go on to say they will try to improve HealthCare.gov and it’s call center scripts to ensure that consumers understand that they may be subject to penalties under federal law if they intentionally provide false or “untrue” information as part of the enrollment process. Officials appear to be leaving behind the possibility that they will bring criminal charges against some consumers who lied on SEP applications open to interpretations.

CMS also has eliminated some obsolete SEP types, such as SEP types related to the launch of PPACA-based programs.

PPACA now blocks insurers from using personal information other than location when they are deciding whether to issue coverage, and it prohibits use of information other than location, age, and — in some cases — tobacco use, when insurers are pricing individual coverage.

Regulators developed the open enrollment period system to give insurers some protection against moves by healthy consumers to wait until they get sick to pay for coverage. By letting consumers buy health coverage only a few months a year, the system exposes non-buyers to the threat that they might get sick, and run up huge bills, at a time when they cannot buy coverage.