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What If Your Client, Daniel, Is Sick Now?

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The Trump administration may not love the Affordable Care Act public exchange system, but managers are still trying to keep their web-based health insurance supermarket up and running. team members recently gave agents and brokers a webinar on how to handle individual health insurance clients who may, or may not, qualify for special enrollment periods (SEPs), or opportunities to sign up for coverage outside the usual enrollment period.

(Related: Trump’s Explains Enrollment Changes)

The team is part of the Center for Consumer Information & Insurance Oversight (CCIIO), which, in turn, is part of the Centers for Medicare and Medicaid Services.

CCIIO and CMS workers have been offering many webinars aimed at insurance plan providers and at producers. Earlier this month, for example, CMS staff members gave insurance company workers a tutorial on how to feed 2019 health plan data into

During the SEP webinar, the team rolled out a number of new characters, and vignettes, to help producers understand SEP rules.

The team’s latest characters are:

  • Alex and Lisa, who got married June 9 and now have to figure out whether they qualify to buy exchange plan coverage.
  • Jacob, a man who recently moved to Virginia, from Maryland, and is not sure how to prove that he’s just moved.
  • Daniel, who voluntarily dropped his coverage, is sick, and wants an agent to help him forge the documents needed to show that he qualifies for a SEP.

The team uses Daniel’s story to drive home the point that producers must understand SEP rules, and help clients comply with the rules.

Regulators, insurers and Affordable Care Act public exchange program managers created the current individual major medical insurance enrollment period calendar in an effort to push healthy people to pay for coverage even when they feel healthy.

Consumers can sign up for coverage without providing any reason from Nov. 1 through Dec. 15 each year. If consumers try to sign up at other times of the year, with SEPs, they are supposed to show they have what the government classifies as a good excuse to be shopping coverage, not just buying coverage because they are sick and wish they had health coverage. Insurers say that approach stabilizes the market and holds down premiums, by encouraging healthy people to stay in the risk pool.

The team provides a multiple choice question about how an agent serving Daniel should proceed.

One response is, “Agree to help him so you earn a commission on the enrollment; you may also be able to establish a long-term relationship to help Daniel with his future insurance needs.”

That’s the wrong answer, the team says.

The team encourages producers to refuse to help Daniel, and to tell Daniel that submitting false information to, which the team calls “the Marketplace,” would be a form of fraud.

“If you assisted Daniel in this scenario, you would be subject to civil money penalties for failure to provide correct information to the Marketplace and/or knowing and willful provision of false or fraudulent information…and would face suspension or termination of your Marketplace agreement(s) with CMS,” the team warns.

Agents and brokers can learn more about the webinars for agents and brokers here.

— Read Avalere Shows How ‘Special’ Enrollees Kill Health Insurerson ThinkAdvisor.

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