Last Friday, NAHU sent a letter to the Centers for Medicare and Medicaid Services (CMS) regarding the verification of Special Enrollment Period (SEP) Pilot Program for marketplace SEPs. Our comments focused on the four areas of concern for the program: testing; program focus; minimizing consumer burden and coverage disruptions; and measuring the program’s impact. Our letter noted our support of efforts by CMS to prevent adverse selection and abuse of the SEP process through greater verification of an individual’s eligibility for a SEP and noted how the pilot program can best work to achieve these end goals.

Targeting of the Pilot Program

• Program should be geographically targeted. Isolating by geography can help those involved understand the program’s parameters.
• We recommend selecting a large city, a rural area and a few more densely populated suburban counties in different parts of the country.

Focus of the Pilot Program

• Program should not be limited to any particular qualification for a SEP, but should address and evaluate a pre-enrollment verification process for all six of the SEP qualification events for which CMS began requiring greater document verification last spring.
• This will allow program participants to fully test pre-enrollment verification and accurately determine if the process works well for each qualifying event on a distinct basis.

Minimizing Consumer Burden and Coverage Disruptions

• Program should have a dedicated source of customer support for the pilot program participants and other involved entities, so that everyone knows where to go if any type of problem occurs.
• To minimize coverage disruption, pilot program consumers should be allowed to enroll in coverage immediately and begin paying premiums, even if they do not have all required documents to submit at the time of initial enrollment. If all documents are not immediately available for verification, the consumer should be placed in a “pending” status by the FFM and health plan. Once documentation is received and verified by the FFM, then the pending status should be lifted and claims incurred be paid retroactively to the date of enrollment.

Measuring the Impact of the Pilot

• Program should be transparent and share data. We suggest CMS release data points by month for each month of the pilot program’s duration, and then also release a comprehensive report and analysis of the program following its conclusion.
• We recommend that CMS solicit feedback on the process from the consumer, certified assisters, agent or brokers, navigators, and issuers involved in the enrollment and SEP coverage process.
• We recommend CMS collect data on:
  1. The number of individuals who initiate the special enrollment process during the pilot program duration;
  2. The number of individuals who complete the pre-enrollment verification process;
  3. The point of entry these individuals utilized to access the marketplace;
  4. If the individual utilized any type of certified agent or broker, navigator, assister, call center operator or other form of direct assistance;
  5. Which forms of directed assistance were utilized;
  6. The length of time it took the individual to complete the pre-enrollment certification process;
  7. Stumbling blocks experienced by the consumer;
  8. Stumbling blocks experienced by the marketplace;
  9. The type of SEP qualification being used by the consumer; and
  10. The documentation provided by the consumer, so as to assess the most common types used.