Overview of the CMS 2018 Enrollment Manual

Overview of the CMS 2018 Enrollment Manual

On June 25, 2018, the Centers for Medicare and Medicaid Services (CMS) released its 2018 Enrollment Manual. The manual offers 15 key highlights relating to several processes including auto reenrollment and non-renewal, reports such as the Batch Auto-Reenrollment (BAR) Progress Report, as well as updates on Enhanced Direct Enrollment (EDE), Marketplace premiums, and Medicaid.

In this blog, we examine these highlights and their potential impact:

FFE Enrollment

Five of the fifteen reportable changes include:

  • Increase or decrease in projected annual household income for the coverage year or change to current month’s household income
  • Add or remove applicant or non-applicant household member listed on application (such as whenever there is a birth, death, or marriage)
  • Change in full-time student status for 18-22-year-olds (could affect eligibility for Medicaid under applicable state rules)
  • Change in tax filing status (e.g., will or will not file, joint or separate filer) or change in tax dependents that will be claimed
  • Became disabled or in need of long term care (or is no longer in need of long term care)

Files and Transactions with Auto-renewal

The FFE communicates the vast majority of renewals (both active and passive) and new enrollment to issuers via 834 enrollment transactions. Because of the unique data architecture of the Exchange, additional files and transactions are also sent to issuers to inform the issuer of the FFE enrollment. For example, the Switch File (2.6.4.1) tells the current year issuer to end coverage December 31, letting the issuer know that no auto-reenrollment should be expected, while the Passive Cancel File (2.6.4.2) eliminates duplicate coverage created in error.

Passive Cancel Job

When enrollees or their assisters fail to access their existing pre-populated future year application and create a new application for future year coverage, a duplicate policy is created. The FFE will cancel passive reenrollments that duplicate active enrollments for future year coverage via the Passive Cancel Job. This job is scheduled to run periodically in November and December.

Cancel Carry Forward Job

During OE, an enrollee or issuer may terminate (or even cancel) the current year coverage after the FFE has sent the passive reenrollment for future year coverage, such as terminations for nonpayment. The Cancel Carry Forward Job cancels auto-reenrollments (policy origin of 11) that are linked to a prior year enrollment that has been cancelled or terminated after auto-renewal. Since the passive reenrollments were created based upon the prior year coverage that has subsequently ended, the Cancel Carry Forward job “carries forward” the termination (or cancel) to cancel the future year’s enrollment.

Batch Auto – Reenrollment (BAR) Progress Report

Prior to and throughout the OEP, the FFE will send QHP and QDP issuers that are expecting renewals (i.e., continue to offer QHPs through the Exchange) a daily report that totals the auto-renewals sent to them as of midnight the night before the report’s generation via EFT MISC.

The report compares the count of “BAR-eligible” policies (current year policies in good standing as of that incremental run of BAR, updated periodically throughout the OEP) with the actual BAR enrollments sent by the FFE. Issuers can use the report to track progress and report problems.

Medicare Enrollment and Non-renewals

Section 1882(d) of the Social Security Act prohibits issuers, agents, and brokers from selling or issuing individual market coverage that duplicates Medicare to a Qualified Individual (QI) that it knows is enrolled or entitled to Medicare. The anti-duplication provisions apply even if the beneficiary has only Part A or only Part B Medicare, and are intended to protect Medicare beneficiaries from fraudulent or abusive practices leading to the purchase of excessive or unnecessary coverage. Employer sponsored coverage, such as plans sold in the FF-SHOP, is explicitly exempted from the anti-duplication prohibition.

FF-SHOP Enrollment

Direct Enrollment (DE) is an enrollment process that allows new applicants and existing. Beginning with plan year 2018, enrollment into FF-SHOPs and SBE-FP for SHOPs (for convenience, referred to collectively as FF-SHOPs) QHPs and QDPs will occur through a SHOP-registered agent or broker or through an insurance company. Employers will no longer use Healthcare.gov to enroll in FF-SHOP coverage. Groups enrolled in FF-SHOP QHPs and QDPs that began prior to January 1, 2018 will continue to manage their accounts and pay their premiums through the FF-SHOP and Healthcare.gov.

Direct Enrollment Supersized

New for 2019, Enhanced Direct Enrollment (EDE) will be available   The EDE option, unlike classic DE, does not require a   to be redirected to the FFE. DE Partners are able to provide a complete enrollment experience on their website, including hosting the eligibility application.

Softheon’s Software Architect Jonathan Stein says, “this year, we are proud to be working more closely with CMS on the EDE alpha team. CMS’ decision to open and allow their technical resources to companies like Softheon and allowing a deeper level of collaboration should lead to an easier and more fluid enrollment experience.”

Special Enrollment Periods (SEP)

While SEP verification does not impact the individual’s Exchange-generated effective date, which is typically determined by the applicable triggering event and the date of QHP selection. CMS has made changes to the availability and length of SEPs, SEP triggering events and coverage effective dates, and SEPs accessed outside of the application process and plan display errors.

Premiums

The five changes include:

  • Information on the effectuation of coverage with a retroactive effective date or associated with a verified or non-verified SEP (Section 6.1.1) and examples of Binders pursuant to 155.400(e)(1)(iii).
  • Information on the Binder payment extensions directed by the Exchange or State Authority.
  • Updates related to the issuer option to condition new enrollment on payment of past due premium.
  • Information on the enrollment transactions received for a Subscriber whose coverage is being terminated.
  • Updates on the APTC grace period rules and the claims pended during the grace period.

Terminations

A termination is the end of an enrollee’s coverage or enrollment in a QHP or QDP through an Exchange occurring after their coverage effective date. A termination may be either voluntary (i.e., initiated by the enrollee or the employer) or involuntary (i.e., initiated by the QHP/QDP or the FFE). Issuers must notify the Exchange of involuntary terminations. If an enrollee’s coverage or enrollment through an Exchange is terminated, the QHP or QDP must provide coverage from the coverage effective date through the termination date. Three key changes include: enrollee requested terminations, terminations of an enrollee’s coverage in the FFEs due to death and aging-off terminations.

Reinstatements

A reinstatement is the undoing of a termination or cancellation to correct an issuer or Exchange

error or to reflect an Exchange Appeals decision, and results in restoration of an enrollment to the

original coverage effective date with no break in coverage. The reinstatement process requires a HICS case for policies terminated because the Exchange determined the enrollee was no longer eligible for Exchange coverage. Some common permitted reasons for reinstatements are:

  • Erroneous Termination/Cancellation of an Enrollment by an Issuer;
  • Erroneous Termination/Cancellation of an Enrollment Initiated by an Agent/Broker;
  • Erroneous Death Notification;
  • Exchange Error;
  • Assister Error;
  • Directive to Reactivate Individual Coverage Through Granted Appeal.

Enrollment Data Alignment

Pursuant to 45 CFR §155.400(d), the FFE is required to reconcile enrollment records with all participating issuers on a monthly basis. Reconciliation ensures that QHP issuers, QDP issuers, and the Exchanges have equivalent enrollment information. Accurate enrollment information allows CMS to make correct payments for APTCs and CSR, and to assess FFE user fees. It also prevents multiple enrollments by one individual and ensures that the data used for analytics and metrics are accurate. Key changes include: inbound 834, enrollment reconciliations and pre-audit files, resolution of enrollment and payment discrepancies (disputes), payment disputes, enrollment disputes, and HICS direct dispute process.

1095-A

Throughout January each year, the FFE generates and sends initial Forms 1095-A to tax filers who enrolled in a QHP through the FFE during the prior year. The Form 1095-A provides enrollees with information about their health coverage so that application tax filers can: file their taxes, reconcile advance payments of the premium tax credit (APTC), and claim the premium tax credit (PTC). Key changes include: 1095-A initial generation process, how issuers should answer enrollee questions about the form, basics for assisting QHP enrollees, form corrections, and reprints and impact of prior year appeals.

QHP Coverage and Minimum Essential Coverage

Exchange enrollees aren’t eligible for financial assistance such as advance payments of premium tax credits (APTC) and Cost Sharing Reductions (CSR) if they are eligible or enrolled in other minimum essential coverage (MEC), such as coverage provided by Medicare Part A or Part C, Medicaid, or certain coverage provided by an employer plan. While an issuer should not end financial assistance if it believes the enrollee is eligible for MEC, the issuer is encouraged to reach out to the enrollee suspected of being eligible for MEC to urge the enrollee to report the eligibility for other coverage to the Exchange so that the enrollee’s eligibility can be redetermined, and financial assistance removed prospectively, if appropriate. Key changes include: periodic data matching, Medicaid/CHIP periodic data matching, Medicare periodic data matching, and Medicare anti-duplication.

Fraud

The Federally-facilitated Exchanges (FFEs) and State-based Exchanges using the federal platform (SBEs-FP) receive complaints alleging fraud and/or misrepresentations from both individuals and issuers regarding suspect enrollments into Qualified Health Plans (QHP) offered through the FFE or SBE-FP. CMS, as administrator of the FFEs and of the federal platform for the SBE-FPs, takes each complaint seriously, and the Center for Consumer Information & Insurance Oversight (CCIIO) works closely with the Center for Program Integrity (CPI) to review and respond to these complaints through two distinct processes. Key changes include: individual complaints alleging unauthorize enrollments, operational process for cancelling unauthorized enrolments, reporting fraudulent enrollments, and bases for a rescission.

Appeals

Individuals have the right to appeal Federally-facilitated Exchange (FFE) eligibility determinations. The FFE provides written notification to enrollees advising them of their right to appeal when they receive an eligibility determination, including an explanation that an appeal must be requested within 90 days of the date of the notice of the FFE’s eligibility determination. In addition, when enrollees appeal an eligibility redetermination made by the FFE, they have the right, pursuant to 45 CFR 155.525, to request continued eligibility pending appeal. A key change to this section is the impact of appeals on reconciliation.

HICS

The Health Insurance Casework System (HICS) is the official tracking system for Exchange casework and is used by Issuers that participate in the FFEs and State Based Exchanges on the Federal Platform (SBE-FPs). The HICS system is the means by which the Marketplace Call Center routes cases to issuers that require investigation and resolution.

Data Matching Issues (DMI)

When individuals apply for coverage through the Exchanges, including through Healthcare.gov, the applicable Exchange verifies information that is provided by the individual on his or her application. Most applicants’ information is immediately verified by the Exchange, however, in some cases, the information the applicant provided does not match up immediately with existing records or the applicant may not have provided enough information to match with the Exchange trusted data sources. Key changes include: data matching issues outreach schedule and process and late submission of documentation for data matching issues.

The ’19 Open Enrollment Period will begin on November 1st and will conclude on December 15th.

Sources

  1. https://www.regtap.info/uploads/library/ENR_2018EnrollmentManualHighlights_5CR_071218.pdf
  2. https://www.regtap.info/uploads/library/ENR_ENRManual_5CR_062618.pdf
  3. https://www.medicareresources.org/glossary/
  4. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Enrollment/Enrollment%20Dashboard.html

 The views and opinions expressed by the authors on this blog website and those providing comments are theirs alone, and do not reflect the opinions of Softheon. Please direct any questions or comments to marketing@softheon.com.

Amanda Wolfer

Amanda is the Senior Digital Strategist at Softheon. She works closely with the Marketing team to develop and maintain Softheon’s blog and social media presence. She received her bachelor’s degree in English Language & Literature and Organizational Communication from SUNY New Paltz in New Paltz, New York.

Leave a Reply

Close Menu