Highmark ACA Individual Market Newsletter: Marketplace SEP Verification in Effect Now

Marketplace SEP Verification Changes Now in Effect

Please be aware of the recent changes to Marketplace Special Enrollment Period (SEP) verification, which went into effect on May 16, 2025.

Key Change: When individuals claim Loss of Minimum Essential Coverage (MEC), documentation may be required before they can use their plan if the loss cannot be automatically verified. This will trigger a Special Enrollment Period Verification Issue (SVI).

Impact: Enrollees will have 30 days to resolve an SVI with acceptable documentation. Failure to do so will prevent them from using their coverage.

Your Role:

• Understand which documents verify Loss of MEC.
• Advise individuals to submit documents as soon as possible to avoid coverage delays.
• Familiarize yourself with the SEP Verification process and SVIs.

Submitting Documents: Those applying for a Special Enrollment Period (SEP) may need to submit documents to confirm eligibility. These documents must be sent before coverage can be used, and a Marketplace Eligibility Notice will provide instructions.

Enrollees have 30 days to submit documents after selecting a plan. Coverage begins the first day of the month after plan selection, pending eligibility confirmation and premium payment.

• Losing or Lost Coverage: Advise individuals to select a plan within 60 days (90 for Medicaid/CHIP) of losing coverage, and to submit documents within 30 days of plan selection.
• How to Submit: Documents can be uploaded or mailed.

For more detailed information, please visit healthcare.gov.

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Network Update: Suburban Community Hospital Closure on July 1, 2025 (SEPA)

Prime Healthcare recently announced that Suburban Community Hospital will cease providing acute care and emergency room services on July 1, 2025. The facility will be converted into a 15 bed, geriatric psychiatry hospital. It will be renamed Suburban Behavioral Health Campus of Roxborough Memorial Hospital.

Additional in-network hospitals near Suburban Community Hospital:

• Temple University Hospital, Inc. 1-800-836-7536
• Abington Memorial Hospital 1-800-533-3669
• Albert Einstein Medical Center 1-215-456-7890
• Einstein Medical Center Montgomery 1-484-622-1000

Approximately 72 Highmark members have used services at Suburban Community Hospital in the last year. Highmark plans to notify members who have accessed services at Suburban Community Hospital in the last year and will assist in coordinating care with other local providers.

Members can find alternative in-network doctors and hospitals by logging in to the member portal online or through the MyHighmark app.

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2025 Agent FIeld Guide and Product Guide

Two of our most comprehensive resources:

2025 Agent Field Guide: Your complete guide to doing business with Highmark, including technical processes, commissions, compliance, agent oversight, and detailed product information across all lines of business (MA, D-SNP, and ACA). To download the most current version, Click Here.

2025 Agent Product Guide: Everything you need to know about our plans: updated coverage maps, benefit grids, regional highlights, and supplemental benefits for MA, D-SNP, and ACA plans. To download the most current version, Click Here.

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