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HHS Interim Final Rule Amends Certain Special Enrollment Period Eligibility Requirements

May 20, 2016

HR360, Inc.
May 10, 2016

Separate Guidance Outlines Six Special Enrollment Periods

The U.S. Department of Health and Human Services (HHS) has announced an interim final rule which tightens the requirements for certain special enrollment periods (SEPs). Separate guidance also makes clear that SEPs in the Health Insurance Marketplace are only available in six defined and limited types of circumstances.

Special Enrollment Periods
The new guidance clarifies that SEPs are only available in the following circumstances:

  1. Loss of other qualifying coverage (e.g., employer-based coverage);
  2. Change in household size (e.g., due to marriage or birth);
  3. Change in residency;
    • Effective July 11, 2016 and subject to certain exceptions outlined in the interim final rule, individuals requesting a SEP as a result of a change in his or her residence must have minimum essential coverage for one or more days in the 60 days preceding the change in residence.
  4. Change in eligibility for Marketplace coverage or for financial help to purchase such coverage;
  5. Enrollment errors made by the Marketplace or a health plan; or
  6. Other special circumstances which apply to, among others, victims of domestic abuse or natural disasters.

Availability of SEPs
The interim final rule also removes a January 1, 2017 implementation deadline by which Marketplaces would otherwise have had to provide advance availability (which provides qualified individuals with 60 days before or after a triggering event to select a qualified health plan) of the residency SEP. The rule also removes the requirement that SEPs for the loss of a dependent or for no longer being considered a dependent due to divorce, legal separation, or death be offered by January 1, 2017. Marketplaces can still provide either SEP, but implementation and the timing of that implementation are now at the option of the Marketplace.  

For more information about the new guidance, please review the HHS Fact Sheet.

Be sure to check out our section on Health Insurance Exchanges for information regarding employer eligibility requirements to participate in the federal SHOP Marketplace.

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