Open Enrollment for the Health Insurance Marketplace Begins: Issuers and Enrollees Forge Onward with the Chaos

Beginning next week, consumers will start actively enrolling in the Health Insurance Marketplace for the fourth year of the Affordable Care Act (ACA). The open enrollment period for the Marketplace begins November 1, 2016, and runs through January 31, 2017. Consumers who would like to actively enroll for January 1 coverage are encouraged to enroll through healthcare.gov by December 15 to ensure they will have coverage in their selected plan the first of the year.

Specific to Qualified Health Plan (QHP) Issuers in the Marketplace, the Centers for Medicare & Medicaid Services (CMS) will once again challenge Issuers with navigating through a multitude of enrollee stressors this season. Here are just a few challenges:

1. Redistribution of Enrollees to an Alternate QHP Issuer:Based on a number of QHP Issuers either exiting the Marketplace in specific counties/states or exiting altogether, 2016 enrollees are left to identify a new plan for next year en masse. As a means to encourage consumers to choose a new plan, CMS has targeted November 16 as the next notice date to urge consumers to actively select a new 2017 plan because their current plan will not be available through the Marketplace. Unique to other notices consumers have received, this notice will be the first time CMS will communicate an “Alternate Plan Option” by defining the health plan name CMS has matched to the enrollee for each member currently enrolled in the household. Included in the notice is language related to how the alternate plan will communicate with the consumer through a welcome letter and a bill for the first month of coverage if they choose to activate. Enrollees are encouraged to either select a new plan altogether or activate the alternate plan to avoid a gap in coverage.Issuers have the opportunity to gain membership in this scenario, but there is no way to predict consumer behavior, especially for consumers who have been inundated by communications regarding this shift.

2. Renewals to 2017 Coverage Year:A week leading up to the opening of enrollment on November 1, QHP Issuers are receiving state-by-state files detailing current enrollees who are being passively re-enrolled into 2017 plans. As the renewal process is a constant challenge for Issuers and CMS, ensuring the right members are being rolled into the correct plan is critical. A major component of the renewal process is to pause and identify inaccurate renewal data and ensure membership is updated within both systems (Issuer and CMS). This also includes recalculated eligibility for Advanced Premium Tax Credit (APTC) and Cost Sharing Reduction (CSR).

   Now that policy-based payments (PBPs) are in place, errors generated from inaccurate Batch Auto Renewal (BAR) processing will create an immediate financial impact to the Issuer for January 2017 payment. Financial impacts based on bad membership data were not realized in previous Q1 periods, but with operationalized PBPs, CMS now pays Issuers based on the Federally-Facilitated Marketplace (FFM) system. In other words, if CMS passively enrolls a member but the Issuer does not, it will automatically generate a non-member payment to the plan.

3. Unaffiliated Issuer Enrollments (UIEs) or Issuer Orphans:Based on comparing Marketplace membership data between the Issuer system and the FFM system through the reconciliation process each month, UIEs are identified which represent members who are present on the Issuer system but not found on the FFM.  Understanding UIEs represent enrollees who would not receive an initial 1095A notice for coverage nor would the Issuer receive payment from CMS for providing the benefit, CMS has acknowledged a solution needs to be extended to all interested parties this year.  While guidance is still pending, CMS has assured the industry 2016 members will receive a manual 1095A, and Issuers will receive a payment adjustment through an undefined process.

   As for the good news, CMS is addressing the fix prior to year-end, but it is yet to be seen whether the solution includes a front-end fix to end the generation of UIEs altogether.

4. Periodic Data MatchingOn a periodic basis, CMS uses data criteria to identify individuals who are receiving financial assistance by enrolling in the Marketplace but at the same time are eligible or are enrolled in other Minimum Essential Coverage (MEC) such as Medicare, Medicaid, or the Children’s Health Insurance Program (CHIP). If enrollees choose to stay dually-enrolled in a Marketplace plan, they will no longer receive APTCs or income-based CSRs per the regulation.

   Issuers continue to receive files from CMS to aid in outreach efforts to elicit action by the consumer and ensure they understand the loss of financial assistance before receiving a bill. Part of the process is helping consumers understand they are eligible for other coverage and to determine the appropriate MEC for them.

With the interim processes that are all too common for QHP Issuers, one fact is evident with managing membership – the data always tells the truth. Issuers will commit to working through the requirements as detailed above, support all open enrollment functions, and diligently work to resolve immediate membership issues that arise with January coverage. As with every new challenge that impacts enrollment, Issuers who have a robust reconciliation process to detect and resolve issues will be best positioned to measure and respond.

In parallel, the member experience leading into 2017 will be reacting to the some of the same challenges and a few more, including a 25 percent rise in premiums as stated by Health and Human Services (HHS) this week. Some enrollees will need a new plan, receive a manual 2016 tax notice, or be confused by notifications regarding their re-enrollment or other data matching issues.  Others may receive a welcome kit and bill from a plan they did or did not select. When you review all the consumer touchpoints, it is evident the work ahead is a shared responsibility between the Marketplace, the member, and the QHP Issuer to ultimately get the member record right on all fronts. Collectively, the industry has made great progress this year, but we are still dealing with the chaos of a new government program.

Gorman Health Group’s proprietary tool, Valencia^™, which currently reconciles 45 percent of the 11.1 million Marketplace enrollees, supports clients’ reconciliation processes with a comprehensive approach. Aside from managing enrollment and payment reconciliation, Valencia^™ provides compliant and transparent workflow to ensure your operational processes – and the resulting payment – are as accurate as possible. Our goal is to help Issuers manage the chaos and be audit ready.

Resources

To learn more about our Valencia^™ product, reconciliation services, and how they support enrollment and payment reconciliation for Issuers, please contact ghg@ghgadvisors.com.

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