On April 13, The Centers for Medicare and Medicaid Services (CMS) issued the highly anticipated final rule, referred to as the Marketplace Stabilization rule. The press release and summary can be found here. Arkansas Blue Cross and Blue Shield Consumer and Retail Markets would like to address a few of the rule’s key changes, and how they will impact your daily processes and procedures.
Changes in open enrollment period dates
The 2018 open enrollment period (OEP) will be significantly shorter, lasting from November 1, 2017, until December 15, 2017. You will receive much more information regarding the upcoming OEP in the coming months.
Pre-enrollment verification of special enrollment period eligibility
You’ll see the most immediate impact in how you facilitate special enrollment periods (SEP). CMS said they plan to implement the necessary system changes in late June 2017, when they’ll adopt an “enroll and pend” process for SEPs. The applicable SEPs are: loss of minimum essential coverage, permanent move, Medicaid/CHIP denial, marriage and adoption or birth.
Your clients will have 30 days to provide documentation to prove eligibility. Instructions on how to send documentation will be listed on the “eligibility results PDF” provided at the completion of each SEP eligibility application. The methods are the same for any unresolved inconsistency, but instead of 90 days, the applicant has 30 days. Also, as noted above, the enrollment will be pended until verification is proven.
Please note: We can assume the system changes are currently being developed to support the above. Additionally, there is guidance stating some flexibility will be given to applicants if there is a delay in pre-enrollment verification. There is optional relief that can be taken to start their coverage one month later if the delay caused owing two or more months of retroactive premium. This sounds like a positive for the applicant, but we will have to wait and see more information from the Federally Facilitated Marketplace (FFM) as to how you and your clients can request this effective date change.
Guaranteed availability of coverage
Unlike before, this change allows insurers to require past due, delinquent premiums with prior coverage to be paid to effectuate new coverage. There is flexibility given to each insurer as how to implement, but the look-back period for delinquent premium cannot exceed 12 months from the effective date of new policy.
We’ll be sharing much more information on this rule change in the coming months, and in our annual agent trainings. But, we want agents to be aware of this change, and advise clients appropriately. Here are some highlights of the Arkansas Blue Cross plan to operationalize this new rule.
Off-exchange metallic policies:
- Not impacted; neither are Arkansas Works members.
- Because we do not pay claims for any months without full payment, there is no application of the rule to this line of business. If an off-exchange metallic policy cancels because of delinquent premium, any paid claims during grace period are recouped.
On-exchange metallic policies:
- Impacts members who receive an advance premium tax credit (APTC).
- When an on-exchange metallic policy is canceled for non-payment and/or delinquent premium, Arkansas Blue Cross still pays claims for the first month of delinquency.
|January 2017||February 2017
Initial Grace Period
|March 2017||April 2017|
|New policy effectuated with member premium (premium minus APTC)||Member doesn’t pay premium||Since 30 days elapsed, claims are pended||Member does not pay|
|Marketplace pays APTC||APTC received from Marketplace||Member does not pay||Policy termed back to the end of February|
|Claims paid for this month|
- Beginning June 19, 2017, the delinquent balance for the previous month’s premium (in the above example, this would be February’s premium minus APTC) will no longer be written off.
- If the policyholder returns with another on-exchange policy, any delinquent balance due for the past 12 months starting June 2017 will be owed in addition to the new premium. This 12-month look-back will also apply during OEP.
Please note: This will be enforced at the contract level, not the member level. In other words, if a dependent of a delinquent policy returns to Arkansas Blue Cross with his/her own newly assigned on-exchange policy, they would not be impacted and required to pay the delinquent payment because this would be a different contract number.
Additional SEP changes
We’ll have more details to SEP changes after we see how the CMS systems will enforce/accommodate the changes, but there is the option for Marketplace to provide limitations on the types of plan changes resulting from an SEP. As we understand it, this is intended to mitigate people who may be “gaming” the system to change between metallic tiers (Bronze-to-Gold, Bronze-to-Silver, etc.), which is another form of adverse selection. Arkansas Blue Cross is currently reviewing our options, but we do not initially plan to make any changes to our off-exchange plans.
- As the FFM implements their system changes related to stricter SEP plan changes, this will carry over to direct enrollment through Blueprint for Agents. We will share more as information is released.
- If using “marriage” as the SEP, applicants must demonstrate that either spouse was enrolled in minimum essential coverage in the last 60 days prior to date of marriage.
- More verification is needed and required to validate “permanent move” as an SEP.