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The government is trying to make some changes to the Affordable Care Act, also known as Obamacare, to try to weed out those gaming the system.
In a release Tuesday, the Centers for Medicare and Medicaid Services said it plans to roll out a pilot program to assess the effect of more stringent requirements for people signing up for insurance through the ACA’s public exchanges outside of the open enrollment period.
In theory, only those in special situations – such as people losing employer-based coverage or leaving their parents’ insurance when they turn 26 years old – are supposed to enroll in the exchanges outside of the designated time period. (For example, the open enrollment period for 2017 runs from November 1, 2016, to January 31, 2017.)
The concern is that patients sign up outside of the designated window only when they are sick and need coverage.
Since the ACA does not allow insurers to deny coverage based on preexisting conditions, this means that people who are already sick cannot be denied. This adds to costs for insurers and distorts the risk pools of the exchanges.
“We also noted the concerns we have heard about how these actions are affecting the exchange risk pools,” the CMS release said. “Some have said that additional changes are needed to prevent individuals from misusing special enrollment periods to sign up for coverage only after they become sick.”
In order to discourage this sort of behavior, CMS has added confirmation steps to the special enrollment periods; added warnings to the exchanges’ website, Healthcare.gov, about consequences from abusing special enrollment; and eliminated some of the special enrollment windows.
This, in turn, has lowered the number of people signing up during these periods.
“In the seven weeks prior to implementation of the confirmation process, special enrollment period plan selections in 2016 were about the same as during the same weeks in 2015,” the release said.
“In the seven weeks after implementation, special enrollment period plan selections in 2016 were almost 15 percent lower than during the same weeks last year, although why enrollments are falling in response to the new confirmation process is unclear.”
In order to better quantify the effect of these changes on the market, the CMS will launch a pilot project for 2017 to determine whether it is helping insurers control risks and if it is discouraging people who should be signing up from doing so.
Additionally, the release said, the program will allow the CMS to determine what further measures may be necessary to ensure that people aren’t abusing the special enrollment periods.
“Our intent in conducting such a pilot would be to evaluate the impact of pre-enrollment verification of special enrollment period eligibility on compliance, enrollment, continuity of coverage, the risk pool, and other outcomes. The scope of the pilot is still being determined,” the release said.
The pilot has not been finalized, and the CMS is taking open comment until September 20 before determining the final framework.