Editor’s note: This post was updated on August 12, 2014 to discuss steps by the federal government to resolve inconsistencies in immigration and citizenship status for some enrollees in qualified health plans offered in the federally facilitated marketplace, and on August 15 as reflected immediately below.
August 15, 2014 update: On August 13, 2014, CMS released Bulletin 11, which informs qualified health plan insurers in the individual market federally facilitated marketplace how to handle individuals who are determined not qualified to enroll in qualified health plans because of data matching issues. If individuals from whom documentation has been requested to verify information on their applications fail to submit this documentation on time (by September 5), their eligibility will be determined based on information that CMS has available in trusted electronic data sources. This may result in termination of qualified individual status if the issue is citizenship or lawful residence status, since an unlawful resident does not qualify for marketplace coverage.
In these cases, marketplace coverage will end on the last day of the month during which CMS determines that the individual is not qualified. The individual will be directed to its QHP insurer to request coverage outside the marketplace without premium tax credits or cost-sharing reduction payments. He or she will qualify for a special enrollment period based on loss of coverage or change in eligibility for premium tax credits. The insurer is encouraged to work with the individual to avoid gaps in coverage and to credit any amounts paid toward deductibles or out-of-pocket limits for the individual’s coverage outside the marketplace.
If some members of an enrollment group remain eligible for coverage (for example, because one member of a family is determined ineligible but the remaining members are qualified), marketplace coverage should continue for the remaining family members. Any amounts previously paid by the member who is removed should be credited toward the deductible and out-of-pocket limits of those members remaining. If the members of the family that remain eligible do not qualify for the QHP in which they were enrolled, they must be given a special enrollment period to enroll in a QHP for which they are eligible.
If individuals are determined not to be qualified individuals because requested documentation was not received in a timely manner, they can reenroll with retroactive coverage within 60 days if they attest that they in fact submitted documentation on time and are in fact subsequently determined eligible. They will not be penalized due to time lags in mailing or processing of documents. If an individual does not submit documentation on time, but does so within 60 days after termination, and the individual is subsequently determined eligible, the individual will be given a special enrollment period to reenroll, although coverage will not resume until the first day of the month following plan selection. The insurer is expected to apply any amounts previous paid toward the deductible and out-of-pocket limits of the coverage in which the individual enrolls during the special enrollment period.
Original post. On August 1, 2014, the Centers for Medicare and Medicaid Services released a set of frequently asked questions on the relationship between Medicare and the marketplaces. This is not the first guidance CMS has published on this topic, and much of the information in the FAQ was already available. The FAQ is also quite repetitive, as it answers the same questions under different headings, such as “general enrollment FAQs” and “consumer messaging,” but does contain useful information. This post briefly summarizes the FAQ.
The FAQ emphasizes the fact that Medicare and marketplaces operate independently, with little overlap. The marketplaces do not enroll individuals in Medicare or in Medicare Advantage plans and do not sell Medicare supplement plans. Indeed, exchanges cannot legally sell coverage to Medicare beneficiaries. Read the rest of this entry »