On August 25, 2015, the Centers for Medicare and Medicaid Services (CMS) released on its REGTAP website a guidance for insurers on reenrollment of 2015 enrollees through the federally facilitated marketplace (FFM) for 2016. The guidance is quite technical and includes little non-technical information that has not already been released, in particular in CMS’s April 22, 2015 reenrollment guidance. The August 25 guidance, however, presents a particularly detailed roadmap of how the 2016 open enrollment period will work for qualified health plan (QHP) insurers, and is thus worthy of a description here.
Defining Reenrollment
First, some definitions. Reenrollment is the process though which the FFM ensures that an insurer continues an enrollee’s QHP coverage from one plan year to the next. Reenrollment may be in the same product or in a different product if the original product in which an enrollee was enrolled is no longer available. Renewal is reenrollment in the same product. Active enrollment occurs when an enrollee returns to the FFM to submit an application and select a plan for the next year. Passive enrollment or auto-enrollment is reenrollment initiated by the FFM for current enrollees who do not return to the FFM to submit an application and select a plan by December 15, 2015.
Enrollees who do not actively reenroll by December 15, 2015 will have their eligibility redetermined for 2015 based on the most recent income information available on the FFM regarding the enrollee and on updated Federal Poverty Tables and benchmark plan premium information. The FFM will send current 2015 enrollees not scheduled for termination a notice prior to the open enrollment period describing the annual redetermination and reenrollment process, their obligation to update their information with the FFM, and the process the FFM will follow to update advance premium tax credit and cost-sharing reduction (CSR) eligibility for those who fail to actively reenroll.
Enrollment Notices
Particular notices will be sent to three groups of individuals:
- The Opt-Out Group who have not authorized the FFM to access their tax data, for whom eligibility updating will not be possible unless they actively return to the FFM;
- The Special Notice group whose tax information reflects an income of more than 500 percent of the federal poverty level, who must reestablish eligibility with the FFM for APTC or CSR; and
- The Failure to Reconcile Group, who have did not file taxes or reconcile their 2015 advance tax credits for 2014, and who must be terminated from coverage if they fail to do so before the end of 2015.
The third group promises to be quite large. Individuals in these groups will generally be reenrolled in coverage for 2016, but will not receive tax credits or cost-sharing reductions unless they actively reenroll, and for the failure to reconcile group, file their taxes and reconcile their 2014 tax credits.
Guidance For Insurers
Insurers will get a list of their enrollees that fall into one of these three groups, although it will just be a single list not broken down into the three categories. The guidance includes talking points that insurers can use to reach out to the enrollees on this list, advising them how to address each of the potential issues that may affect them. Of particular importance is getting individuals who have not yet filed form 8962 to reconcile their 2014 tax credits to file their taxes and the form. Once they have done so, they must return to the FFM after open enrollment begins on November 1, 2015, to update their 2016 application, as the FFM will not have a record of their filing their taxes if they have only just done so.
The FFM will passively auto-enroll 2015 enrollees who continue to be eligible for coverage for 2016 and do not actively enroll, if their QHP insurer has provided the FFM with a 2016 reenrollment crosswalk template to indicate in what plan the 2015 enrollees will be reenrolled. 2015 enrollees may also actively reenroll for 2016 between November 1, 2015 and December 15, 2015 for coverage beginning January 1, 2016, even if their 2015 coverage was terminated prior to December 31, 2015, for instance for non-payment. The FFM will provide returning 2015 enrollees with a pre-populated application that they can use to update their eligibility.
The FFM will send passive reenrollment transactions to insurers in two waves, one beginning around October 15, 2015 and the other beginning around December 16, 2015. Most reenrollees will be included in the first round, giving insurers time to prepare reenrollment notices to those who are passively reenrolled. Enrollees will not be given any indication that they are being reenrolled, however, until December 16, 2015 to encourage them to return to the FFM before that date to actively reenroll. Insurers will not inform enrollees that they have been passively reenrolled until the insurer sends out the January billing notice.
The second wave of passive reenrollments will include newer enrollees who began enrollment after the first wave of passive reenrollments were executed as well as enrollees who for whatever reason, including pending data-matching issues, needed additional time to complete an action before they could be reenrolled. Enrollees who are still in the 90/95 day grace period for resolving data-matching issues at the end of the 2015 plan year will be reenrolled passively for 2016, with a set date in 2016 for their coverage to expire if the issue is not resolved.
The guidance describes in detail the transactions that will be exchanged between the FFM and insurers and the codes that will be used for those transactions during the reenrollment period. Active reenrollments that result in a plan change will result in an 834 transaction being sent both to the losing and gaining plans. Most 2015 enrollees will be passively reenrolled by the start of open enrollment, so active enrollments that result in changes of plan will result in a cancellation by the plan in which the individual has been passively reenrolled. Active reenrollment in the same plan will also result in an active reenrollment transaction.
If an individual actively reenrolls after December 15, 2015, the FFM will terminate the passive reenrollment the day before the actively selected plan becomes effective. Agent/broker National Producer Numbers (NPNs) will be sent on passive reenrollments and pre-populated for 2016 reenrollment, but can be removed or edited by the applicant and will be superseded by any NPN entered through a reenrollment application. Information on assisters who are not agents or brokers will not be included for passive reenrollments but will be sent on active reenrollments.
Beginning in early November and daily through December 22, 2015, the FFM will send insurers “switch files,” which will cumulatively list the insurer’s current subscribers who have switched to another insurer but were not passively reenrolled. It will not include subscribers who were passively reenrolled and then switched (who will be covered by a cancelled passive reenrollment 834 transaction) or enrollees who actively reenroll in a 2016 plan offered by their 2015 insurer.
Passive Reenrollment
In exceptional circumstances, a passive reenrollment may be cancelled because the enrollee’s coverage terminates before the end of 2015, for example for nonpayment. A passive enrollment may also be cancelled if a current enrollee actively reenrolls opening a new account rather than using the FFM’s pre-populated application, thus creating a duplicate enrollment.
At any time during open enrollment (up until January 31) an enrollee can change plans, resulting in a cancellation of any plan in which the enrollee is actively or passively reenrolled. If an enrollee reports a life change, such as the addition of a baby or spouse, before December 15, it will be reflected in a passive reenrollment. An individual passively reenrolled in the October 15 wave may be reenrolled again passively in the December 16 wave if life changes are reported in the interim.
Enrollees who are passively reenrolled during the first wave will have pre-populated application forms available at Healthcare.gov if they choose to update their eligibility information and reenroll. Their account will not reveal their passive reenrollment prior to December 15, but the plan in which they are passively reenrolled will be in “saved plans” in Plan Compare. The 2015 tobacco rating status will remain the same for 2016 passive reenrollments unless it is changed by the enrollee.
If an insurer receives neither an active nor passive reenrollment for a current year enrollee, and the enrollee is not on the switch file and does not have a late current year termination, the insurer should search to see if the enrollee has enrolled with a new FFM-assigned identification or as a dependent of another enrollee. If the enrollee cannot be found enrolled under a different number, the insurer should attempt to contact the enrollee. If the insurer locates the enrollee and the enrollee wishes to continue coverage, or if the enrollee continues to pay his or her premium, the insurer should advise the enrollee to contact the FFM to straighten things out and in the interim the insurer should continue coverage based on the most recently available information as to tax credit and cost-sharing reduction eligibility.
Insurers are not required to collect a binder payment from enrollees who are reenrolled in the same product or in a new product because the original product is no longer available. If an enrollee fails to pay the premium for the first month of 2016, the reenrollee is entitled to a 90-day grace period before termination. Binder payments are required to effectuate coverage for enrollees who change products, for new enrollees, and for returning enrollees who did not have continuous coverage with the insurer.
After December 15, 2015, the FFM will send 2015 enrollees information about their 2016 enrollment, indicating if they were passively reenrolled and whether financial assistance was applied. If the individual was not passively reenrolled, the FFM will encourage him or her to contact the FFM to actively reenroll. Insurers must also send enrollees notice as to products they are discontinuing or renewing in accordance with earlier guidance.
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