The federal agency that runs HealthCare.gov has just given insurance agents and brokers more information about how the tough new special enrollment period verification process will really work.

(Related: Trump’s HealthCare.gov Explains Enrollment Changes)

The agency, the Center for Consumer Information and Insurance Oversight, has posted a slidedeck giving blow-by-blow examples of how the new pre-enrollment verification process is supposed to work. CCIIO officials used the slidedeck to brief agents who attended a semiprivate webinar on the process earlier this month.

The open enrollment period for 2017 ended Jan. 31 in most of the country. Anyone who buys individual coverage now is supposed to have what a state’s exchange sees as a good excuse to qualify for a special enrollment period, or SEP.

CCIIO is now rolling out SEP pre-enrollment verification requirements in two phases, with one phase taking effect June 23 and the other in August.

During the recent webinar, CCIIO officials focused mainly on what agents will need to do to help clients with the verification requirements taking effect this month.

Here’s a look at three secrets from the webinar, based a copy of the slidedeck obtained by ThinkAdvisor Life Health and other sources.

1. CCIIO may have some trouble getting anyone to help consumers with the eligibility verification process.

CCIIO is an arm of the Centers for Medicare and Medicaid Services. The agency helps its parent enforce Affordable Care Act rules and run health-law programs.

One of CCIIO’s biggest, most visible programs is HealthCare.gov. HealthCare.gov enrolls people in Affordable Care Act public exchange plans in states that are unable or unwilling to do that. HealthCare.gov also manages consumers’ exchange accounts in those states.

HealthCare.gov decides whether exchange plan users qualify for government subsidies, and whether they qualify for special enrollment periods, or SEPs.

The SEP process is supposed to push healthy people to pay for coverage even when they feel fine, by reducing their ability to get coverage immediately the day they need a heart transplant. Insurers offer an annual open enrollment period every year. The period for 2018, for example, is set to run from Nov. 1 through Dec. 15. At other times of the year, consumers are supposed to show they have lost their old coverage, moved, married or gone through some other major life or coverage change.

HealthCare.gov started the open enrollment period for 2017 with more than 60,000 registered agents of brokers, but many have stopped making active efforts to sell individual major medical coverage, inside or outside the exchange market. Some agents are giving up on individual major medical because of uncertainty in Washington, insurer decisions to stop paying commissions, and problems with getting insurers to pay the commissions already earned.

Woman with a very long nose (Image: Thinkstock)

(Image: Thinkstock)

Nonprofit exchange helpers in many areas have faced their own problems with funding and red tape.

In spite of the problems, thousands of insurance agents, brokers and nonprofit exchange helpers are still trying to help clients cope with the individual major medical insurance application process.

Other financial professionals face the new individual major medical application process mainly when they’re getting coverage for themselves or their loved ones.

2. CCIIO will introduce the new SEP verification requirements in two phases.

HealthCare.gov has been letting most consumers qualify for SEPs by swearing upon penalty of perjury that they qualify for SEPs. Some insurers have argued that lack of verification has encouraged consumers to lie.

HealthCare.gov began testing a verification pilot program a year ago.

This year, CCIIO dramatically expanded the SEP verification program. The agency made the change in the same packet of regulations that shifted the end of the 2018 open enrollment period to Dec. 15, from Jan. 31, 2018.

CMS provides a detailed flowchart showing what a consumer might have to do to clear up a SEP verification problem. (Image: CMS)

CMS has provided a detailed SEP verification problem-solving flowchart. (Image: CMS)

HealthCare.gov will start the first phase of eligibility verification June 23.

During Phase 1, HealthCare.gov will ask for documentation from consumers who say they are buying coverage because they lost their old coverage involuntarily or are moving.

In August, when the second phase starts, HealthCare.gov will begin asking for documentation from consumers who are buying coverage due to marriage, adoption or Medicaid application denials.

3. The new SEP verification process could be complicated for any agent trying to help a client, or loved one, through it.

CCIIO is using these acronyms to run the eligibility verification program:

  • SEPV: Special enrollment period verification, or SEP verification.

  • SVI: Special enrollment period verification issue, or SEP verification issue.

  • DMI: Data matching issue.

  • PPS notice: Pended plan selection notice.

  • EN: Eligibility notice.

Suppose an agent has a client named Jane Doe.

In July, if she needs coverage because she’s moving across the country and losing her coverage, she’ll get one SVI, or SEP verification issue, for losing her coverage and one for moving. The exchange will “pend” her plan, or show that she’s chosen a plan without yet officially qualifying for coverage, for 30 days after she’s selected the plan, while she’s coming up with documentation of her move.

If HealthCare.gov checks with the Internal Revenue Service and thinks she’s lied about her income, she’ll have a DMI, or data matching issue. She’ll have 90 or 95 days to clear up the DMI. The deadline for providing the documentation will appear on her EN, or on the eligibility notice page in her HealthCare.gov account file.

CCIIO provides a flow chart that shows each step a consumer may have to take to resolve SEP verification issue. The agency also provides a chart showing how the timing works for a consumer who is applying for a special enrollment period, trying to document eligibility for SEP, or trying to clear up a data matching issue.

Other slides in the slidedeck give detailed descriptions of the kinds of changes that let people qualify for SEPs.

CCIIO notes that a consumer can have two or more SVIs.

An appendix lists the types of documents a consumer can use to document a move or loss of coverage.

If, for example, Jane Doe has moved to Phoenix, from Chicago, and is homeless, she can document the move by submitting a reference letter from a friend, family member or caseworker who lives in Arizona, along with another document confirming that she had coverage in Chicago.

— Read CMS Draft Attracts Few Enrollment Abuse Stories on ThinkAdvisor.