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Covered California Begins Special Enrollment Verification

Posted: September 01, 2016

by Wendy Barnett

Covered CA gets serious with Qualifying Life Events

Beginning the week of August 1st, Covered CA’s Office of Consumer Protection (OCP) will start a new Special Enrollment verification process. They will select a random sample of their members who enrolled during the Special Enrollment Period (SEP) to verify their Qualifying Life Event (QLE). Additionally, Covered CA has added notices and fraud warnings to their application signature pages. Furthermore, Certified Enrollment Counselors and Certified Covered CA Agents have been cautioned that they must also ensure their clients are able to provide proof of a QLE.  These steps are being taken to ensure SEP guidelines are being followed properly with Covered CA enrollments and are in addition to any QLE verification processes that insurance carriers may take.

Special Enrollment Period (SEP) Verification Process

  • Every week Verification Request Notices will be sent out to a random sample of consumers who self-attested that they had a QLE which qualified them to enroll in a Special Enrollment Period
  • The notices give members 30 days to provide a proof of  QLE document
  • A reminder to submit QLE proof will be given 15 days from the date of the notice by phone or e-mail
  • Documents can be submitted to Covered CA by electronic upload, mail, or fax (be sure to include your case number and cover sheet when submitting documents):Covered California Submitting Documentation

 

  • If acceptable QLE document is submitted on time, then consumer will receive an Acceptable Document Notice stating that their coverage will continue
  • If a QLE document is submitted on time, but is not acceptable, an Unacceptable Document Notice will go out to consumer giving them a little more time to submit correct document
  • If no acceptable QLE document is submitted on time, a Special Enrollment Termination Notice will go out to the consumer informing them that their plan will end on the last day of that month
  • Extensions
    • If consumers demonstrate a good faith effort to provide verification documents, they may request an extension
    • Contact the Covered California OCP and provide your case number and reason for request
      • Phone:  888-217-9311
  • Appeals
    • If consumer believes they were terminated unjustly, they can request an appeal within 90 days of their termination notice
    • Contact the OCP at 888-217-9311 to request an appeal

U.S. Department of Health and Human Services (HHS) Fraud Waste and Abuse Regulations

  • HHS has updated regulations for consumers submitting documentation to prove QLE
  • Consumers may be fined by HHS for giving false information on their application as stated by Covered CA :
    • “You may be fined up to $25,000 if you negligently or with intentional disregard for the rules provide false information in your application”
    • “You may be fined up to $250,000 if you knowingly lie on your application”