CMS Quietly Creates New Enrollment Window For Those With Unresolved Inconsistencies

Although CMS says it is sticking to the Friday (Sept. 5) deadline for consumers with unresolved immigration-related inconsistencies to submit necessary documents -- or lose their coverage at the end of the month and potentially be forced to repay subsidies -- the agency has also quietly established two 60-day special enrollment periods for those unable to get the documents in on time.

One special enrollment period applies to consumers who can attest that they tried to submit their documents by the deadline and for whom eligibility can be verified. People falling under that category have 60 days to select a plan, and coverage would be retroactive to the date after their plan was terminated. A second window is available for those who cannot attest that they attempted to send in documents by Sept. 5, but who do submit the needed documentation within the two-month window. For those consumers, coverage would be prospective, meaning it would go in effect the first day of the month following plan selection, according to CMS guidance sent to issuers on Aug. 13.

The guidance says the special enrollment periods are intended to accommodate time lags due to the mailing and processing of documents. The guidance also addresses situations in which the terminated individual is a member of a family plan, but the remaining members are eligible.

The message went to insurers as the agency was making a strong public push for enrollees to provide documentation to avoid losing coverage. CMS announced Aug. 12 that it would be sending letters to 310,000 consumers whose citizenship or immigration status could not be verified through data sources. CMS says that as of Aug. 28, it had received responses from only 70,000 consumers, a number that advocates find highly concerning.

While the deadline is Friday, it is unclear exactly when termination notices will be sent or what message the notices will contain. CMS also would not provide information on when it will begin pursuing coverage terminations for those with income-related inconsistencies. Consumer advocates are anxiously awaiting CMS' next move, one advocate says, as the examples they have seen of individuals with income inconsistencies are very complicated and CMS in some cases is asking people for documents that don't really exist. At the end of the day, CMS could just leave those people alone because there is a reconciliation process already built into the law, the source says, and it's already September.

As of the end of May, 1.2 million enrollees had income inconsistencies in their applications. An agency spokesperson did not provide updated figures and would only say more on income inconsistencies would be provided in the “near future.”

Judy Solomon of the Center on Budget and Policy Priorities -- which has been working with other groups and beneficiary advocates to ensure that people understand the importance of responding to HHS -- says the creation of the special enrollment periods for people that have tried to resolve immigration issues is critically important. But she says it is also important to see what HHS will be communicating in their termination letters.

A Treasury Department spokesperson last week said that people found ineligible for coverage may be responsible for paying back subsidies, but up to a limit (see related story).

The agency in its Aug. 13 guidance says that during the special enrollment period beneficiaries will have the option of selecting their existing coverage. In cases where a member chooses that coverage or a corresponding self-only plan, CMS says, issuers are expected to apply any amounts paid toward deductibles and out-of-pocket costs.

In order to terminate the status of an individual who no longer qualifies for their plan, the marketplace will send an 834 notice to the issuer. CMS says it is expected that in most cases when one person is terminated from a plan, the remaining members would still be eligible and would generally constitute a valid enrollment group. In these cases, CMS would send the 834 transaction to the issuer, which would reflect any changes to the premium tax credits or cost-sharing subsidies, and the remaining group members would be automatically re-enrolled in their existing coverage. If the remaining members would like different coverage from the plan in which they were auto-enrolled, they have to option to go the federal exchange's “report a life change” function to apply for a special enrollment period.

CMS earlier this year told issuers that they had the option of contacting their members about application inconsistencies, but also said plans would not be told the exact nature of the information discrepancies due to privacy concerns. One industry source says even though CMS has given plans information listing members with inconsistencies, up until this point plans have not known how many are related to income and how many are citizenship issues. As a result, the plans are having difficulty doing outreach to members, and the situations are so different that it is difficult to do broad outreach across all members that need to submit additional documentation, the source says.

After Sept. 5 -- when the marketplace will begin sending the 834 notices for terminations -- it will be clear to plans how many people have immigration issues versus inconsistencies in other areas, the source adds. -- Amy Lotven (alotven@iwpnews.com), Rachana Dixit Pradhan (rdixit@iwpnews.com)