Proof Needed to Enroll in Health Plan Post-Deadline

By Robert Pear, The New York Times

WASHINGTON — People who want to buy health insurance in the federal marketplace outside the annual open enrollment period will now have to provide documents to show they are eligible, the Obama administration announced on Wednesday.

In the last two years, insurers say, many people went without coverage and then signed up under the Affordable Care Act when they became sick and needed care. Insurers say that people who sign up after the deadline tend to generate more claims and more costs, raising premiums.

The National Association of Insurance Commissioners, representing state officials, complained recently that “consumers are not required to provide documentation to substantiate their eligibility for a special enrollment period.”

The new policy requires people to submit documents like a birth or marriage certificate if they want to sign up after the deadline using any of the most common special enrollment periods. These are available after a marriage or the birth or adoption of a child. They are also available when people move permanently to a new address or lose coverage provided by an employer, a government program or other source.

The administration has created more than 30 special enrollment categories and sent emails to millions of Americans last year urging them to see if they might be able to sign up after the open enrollment deadline.

It is unclear how rigorous the government will be in checking eligibility. Consumers who appear to qualify for a special enrollment period will be allowed to obtain insurance while the government tries to confirm eligibility based on the documents provided, federal officials said.

Kevin J. Counihan, the chief executive of the federal marketplace, said Wednesday that the new requirements would apply to people who want to enroll or change health plans midyear in the 38 states that use the federal website, HealthCare.gov.

“We are committed to making sure that special enrollment periods are available to those who are eligible,” Mr. Counihan said. “But it’s equally important to avoid misuse or abuse.”

If consumers do not provide the required documents, he said, “they could be found ineligible to enroll in marketplace coverage and could lose their insurance.”

Insurers welcomed the new policy. Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a trade group, said the documentation requirements were “a much-needed step in the right direction.”

Justine G. Handelman, a vice president of the Blue Cross and Blue Shield Association, said the policy could help stabilize the federal insurance marketplace. The insurer Aetna said that, on average, people who signed up in a special enrollment period kept their coverage for about half of the time of regular enrollees.

Consumer advocates who usually support the White House denounced the administration’s action. Rachel Klein, the director of organizational strategy at Families USA, a consumer group, said, “We should be making it easier for people to sign up for health insurance, not harder.”

Consumers, she said, are still learning how to navigate a complex enrollment process, so the administration should not be putting “bureaucratic roadblocks” in their path.

Judith Solomon, a vice president at the Center on Budget and Policy Priorities, a liberal-leaning research and advocacy group, said she was disappointed because the government was imposing the new requirements without clear evidence of abuse.

“There is evidence that special enrollment periods are underutilized,” Ms. Solomon said. “We fear that requiring more paperwork will exacerbate that trend and keep people out of coverage.”

The new policy was announced a few hours after the Government Accountability Office, an investigative arm of Congress, questioned another aspect of HealthCare.gov.

In a report to Congress, the investigators said that the Centers for Medicare and Medicaid Services “has assumed a passive approach to identifying and preventing fraud” by people who bought insurance and obtained subsidies through HealthCare.gov.

The Obama administration waived certain document filing requirements, did not always verify income and citizenship, and thus “allowed an unknown number of applicants to retain coverage, including subsidies, they might otherwise have lost,” the report said.