CMS: Special Enrollment Confirmation Process

The Centers of Medicare & Medicaid Services (CMS), the agency that oversees the Federal Marketplace Exchange is buckling down on special enrollment periods (SEP) in an effort to minimize adverse selection for insurers. In the past, the rules have been fairly loose, and as a result many individuals were able to enroll on a medical plan through the Exchange outside of the annual open-enrollment period with no proof of their said circumstances. I encourage you to read the new SEP standards that are being implemented now.

From CMS:

Special enrollment periods (SEPs) are an important way to make sure that people who lose health insurance during the year or who experience major life changes like getting married or having a child have the opportunity to enroll in coverage through the Health Insurance Marketplaces outside of the annual Open Enrollment period. SEPs are a longstanding feature of employer insurance, and without them many people would lack options to maintain continuous coverage. But it’s equally important to avoid SEPs being misused or abused.


Document Submission by Consumers: Beginning in the next several months, all consumers who enroll or change plans using an SEP for any of the following triggering events will be directed to provide documentation:

  • Loss of minimum essential coverage,
  • Permanent move,
  • Birth,
  • Adoption, placement for adoption, placement for foster care or child support or other court order, or
  • Marriage.

These SEPs represented three quarters of consumers who enrolled or changed plans using an SEP in the second half of 2015.

We will provide consumers with lists of qualifying documents, like a birth or marriage certificate. Consumers will be able to upload documents to their account or mail them in.

Document Verification by CMS: CMS will institute a verification process for consumers who enroll or change plans using an SEP in 2016. The Special Enrollment Confirmation Process is modeled after approaches used by the Internal Revenue Service. We will review documents to ensure consumers qualify for an SEP and will follow up with consumers if there is a question or problem. Consumers need to be sure to provide sufficient documentation. If they don’t respond to our notices, they could be found ineligible for their SEP and could lose their insurance


Centers for Medicare & Medicaid Services. (2016). Fact Sheet: Special Enrollment Confirmation Process [Data file]. Retrieved from