Helping Consumers with Complex Cases Enroll in Special Enrollment Periods in the Health Insurance Marketplace

CMS issues tips for assisters in complex cases

A PDF of the guidance for enrollers is available here.

Consumer information is available here.

March 26, 2014 - Open enrollment for 2014 Marketplace coverage will end on March 31, 2014. A Special Enrollment Period allows a consumer to enroll in health coverage outside of the open enrollment period and have it be effective for that coverage year. For instance, if a consumer has a qualifying life event like having a baby or getting married, they can enroll in or change coverage outside of the open enrollment period. Visit to learn more about these qualifying life events.
This fact sheet describes other limited circumstances, beyond qualifying life events, which consumers may experience related to system errors which make them eligible for an SEP. Depending on a consumer’s situation they may be eligible for a Special Enrollment Period in specific circumstances that blocked them from enrolling in coverage.
Limited Circumstances Special Enrollment Period Descriptions
There are several systems issues that may have prevented timely application submission, produced incorrect eligibility determinations, or hindered enrollment in the Marketplace during the initial open enrollment period. A consumer’s problem may not have been resolved in time to allow enrollment before March 31. Special Enrollment Periods for these issues will ensure that consumers will have an opportunity to get Marketplace coverage for 2014.
If a consumer experiences any of these circumstances, the Marketplace may be able to provide a Special Enrollment Period allowing the consumer to enroll in coverage through the Marketplace. Circumstances that may allow for a Limited Circumstance Special Enrollment Period includes:
Limited Circumstance Special Enrollment Periods Description Examples
Exceptional Circumstances
A consumer faces exceptional circumstances as determined by CMS, such as a natural disaster, medical emergency, and planned system outages that occur on or around plan selection deadlines.
· A natural disaster, such as an earthquake, massive flooding, or hurricane.
· A serious medical condition, such as an unexpected hospitalization or a temporary cognitive disability
· A planned Marketplace system outage, such as SSA system outage
Misinformation, Misrepresentation, or Inaction
Misconduct by individuals or entities providing formal enrollment assistance (like an insurance company, Navigator, certified application counselor, Call Center Representative, or agent or broker) resulted in one of the following:
· Representative enrolled a consumer in a plan that the consumer did not want to enroll in
· A failure to enroll the consumer in a plan
· Consumers being enrolled in the wrong plan against their wish
· The consumer did not receive advanced premium tax credits or cost-sharing reductions for which they were eligible.
Enrollment Error
Consumers enrolled through the Marketplace, but the insurance company didn’t get their information due to technical issues.
· Consumer’s information is received by the insurance company and may be processed, but the enrollment file contains defective or missing data which makes the insurance company unable to enroll the consumer.
· Consumer’s application may have been rejected by the issuer’s system because of errors in reading the data.
System errors related to immigration status
An error in the processing of applications submitted by immigrants caused the consumer to get an incorrect eligibility result when they tried to apply for coverage.
· Immigrants with income under 100% of the poverty line who are eligible for premium tax credits and cost-sharing reductions did not receive the proper determination.
Display Errors on Marketplace website
Incorrect plan data was displayed at the time the consumer selected the QHP, such as plan benefit and cost-sharing information.
· Data errors on premiums, benefits, or co-pay/deductibles.
· Errors that resulted in the display of a QHP to applicants that were outside of the QHP’s service area or that were in ineligible enrollment groups.
· Errors that didn’t allow consumers with certain categories of family relationships to enroll together in a single plan with their family members.
Medicaid/CHIP - Marketplace transfer
Consumers who were found ineligible for Medicaid or CHIP and their applications weren’t transferred between the State Medicaid or CHIP agency and the Marketplace in time for the consumer to enroll in a plan
· Consumers, who applied at the FFM, were assessed eligible for Medicaid or CHIP, were found ineligible for Medicaid or CHIP by the state agency and then weren’t transferred back in time for an FFM determination during open enrollment.
during open enrollment.
· Consumers who applied at the state Medicaid or CHIP agency during open enrollment and ended up having their cases referred to the Marketplace after a denial of Medicaid or CHIP.
Error messages
A consumer is not able to complete enrollment due to error messages.
· Error or box screen indicating that the data sources were down and they could not proceed with enrollment.
Unresolved casework
A consumer is working with a caseworker on an enrollment issue that is not resolved prior to March 31st.
· Consumers who began the case work process but it was not resolved prior to the end of open enrollment.
Victims of domestic abuse
A consumer who is married, and is a victim of domestic abuse. Consumers who are in this category can apply and select a plan through May 31, 2014.
· Prior to clarifying guidance from Treasury and HHS, consumer assumed or was informed that APTC were unavailable to consumers who are married and not filing a joint tax return. Consumer may or may not have attempted to apply.
Other system errors
Other system errors, as determined by CMS, which hindered enrollment completion.
Process to Initiate a Limited Circumstance Special Enrollment Periods
1. In general, a consumer who wants a Limited Circumstance Special Enrollment Period based on the circumstances outlined above must call the Marketplace Call Center at 1-800-318-2596 and ask the Call Center to request the Special Enrollment Period. TTY users should call 1-855-889-4325. 2. The Call Center will ask the consumer a variety of questions to help understand if the consumer is eligible for a Special Enrollment Period. o The Call Center will forward cases that need additional review to CMS caseworkers. The consumer’s situation will be evaluated by a caseworker to determine whether to grant a Special Enrollment Period.
§ The consumer will be notified if the Special Enrollment Period was approved or denied. If approved from a case worker, the consumer will have to call the call center to “activate” the Special Enrollment Period. 3. If the Special Enrollment Period is granted, the Call Center will activate the Special Enrollment Period and allow the consumer to complete enrollment. 4. The consumer should receive information from the issuer once they are enrolled. 5. If the Special Enrollment Period is denied, the consumer can appeal the decision, as described below.
· Please note that for some circumstances, the Marketplace or issuer may reach out to the consumer to tell them about their potential Special Enrollment Period.
o Please note that for benefit display errors, the consumer may also receive a notice from the insurance company informing the consumer that there was a display error and they are eligible for a Special Enrollment Period.
· Please note that for any system defects that hinder the completion of enrollment, assisters and consumers should be vigilant in monitoring when the defect is resolved and to call the call center to request the appropriate Special Enrollment Period. Consumers and assisters can monitor the status of defect fixes by continuing to try to reprocess their applications. Consumers will then have 60 days from the time the defect is fixed and the call center approves of the Special Enrollment Period.
If a consumer is enrolling through their state’s Marketplace and wants to request a Special Enrollment Period, the consumer should contact that state. Visit to get information for state-based Marketplaces.
Plan Selection for Limited Circumstance Special Enrollment Period
After following the process above, in most cases consumers will have 60 days to select a plan from the date they are granted the Special Enrollment Period, which could be one of the following:
- The date that the consumer receives a letter informing them that they are eligible for a Special Enrollment Period;
- The date that the consumer contacts the call center and is found eligible for a Special Enrollment Period; or
- The date that the caseworker finds an individual eligible for a Special Enrollment Period.
If a consumer experienced any of these limited circumstances, or others deemed by the Marketplace, prior to the end of open enrollment they may be able to complete their enrollment for the first time. If a consumer has already enrolled in coverage and then receives a Limited Circumstance Special Enrollment Period, they have the option to change plans or stay in their current plan, depending on what is offered to them on the Marketplace.
Limited Circumstance Special Enrollment Period Coverage Effective Dates
Coverage effective dates will generally follow the regular effective dates.
Filing an Appeal
If a request for a Special Enrollment Period is denied, a consumer has the right to file an appeal. A consumer has 90 days to request an appeal with the Marketplace from the date of a Special Enrollment Period denial notice or 90 days from the date of the eligibility determination. Each Special Enrollment Period appeal request will be reviewed on a case-by-case basis, in accordance with the regulations governing appeals, 45 C.F.R., Sections 155.500-155.545, and decisions will be promulgated ordering coverage retroactive to the date of the incorrect determination if appropriate, see 155.545(c)(1)(ii). If the determination to deny a request for a Special Enrollment Period is found to have been incorrect on appeal, the consumer has the option to get coverage retroactive to the date of the incorrect determination. The consumer can file an appeal in one of these ways:
· Visit to find and complete the appeal request form for the consumer’s state.
· Mail appeal documents to:
Health Insurance Marketplace
465 Industrial Blvd.
London, KY 40750-0061
Additionally, when possible, it is preferable but not required, that consumers requesting an eligibility appeal to include a copy of the Special Enrollment Period denial notice and of any other eligibility determination documentation the consumer may have received.
When mailing the appeal request to the Health Insurance Marketplace, it is preferable, but not required, that consumers include the last four digits of the London, KY zip code (40750-0061) to ensure efficient processing of the appeal request.