Last week, CMS finalized the market stabilization regulations. One of the main areas addressed in the rules is the process for Special Enrollment Periods (SEPs). Beginning in June, consumers attempting to enroll through a SEP will be required to provide documentation to verify they are entitled to the SEP. Additionally, consumers enrolling through a SEP will be restricted from changing metal levels. This last restriction was one of the provisions we addressed in our comment letter submitted about the proposed regulations. In our comments, we stated “for those consumers who have a child born with a disability or adopt a child with a disability, they may realize that their current metal level is not the best fit for them given the special health care needs of the child.” The concern is parents may have enrolled in a plan where the premium was low but cost-sharing was high as they did not anticipate any significant medical needs. However, a new child with a disability could change this in a dramatic and previously unforeseen way.

While CMS may not have changed the rules when they finalized them, they did respond to our comments and provided guidance for what families may want to consider if they are in this situation. On page 56 of the final rules, CMS states that “new dependents could enroll in a new QHP at any metal level, if they enroll in a separate QHP from other existing enrollees.” In other words, parents with a newborn that has a disability and significant medical needs could enroll the child in his or her own plan rather than adding them to the parents’ plan. While this would mean that they would have to pay a separate premium for this plan, it could still save considerable costs if the child could be enrolled in a higher metal level with significantly lower out-of-pocket costs. Navigators assisting families with a new child with significant health care needs should help the family do a cost analysis to determine whether this would be an appropriate solution for the individual family’s situation.