A service of Maryland Health Benefit Exchange

Enrollment and Billing Policy Update

Exchange Board of Trustees Briefing

August 13, 2013

Individual Marketplace: Enrollment Flow

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Tax Credit Eligibility

Plan Shopping

Initial Payment

Collection

Application Eligibility

Determination

Confirmed Coverage

Notify Carriers

Consumer completes online application for insurance coverage. Streamlined application to allow for a “no wrong door” approach.

If not eligible for Medicaid, Consumer is evaluated and notified of eligibility for tax credits.

Consumer is able to select from available plans based on personal preferences.

Consumer is able to make the initial premium payment directly through Maryland Health Connection.

Maryland Health Connection will display a message to the consumer for coverage start date.

Maryland Health Connection will send data files to carriers to notify them of enrollment information and of premiums collected

Individual Marketplace Administration • Initial Premium billing

• Carrier payment

• On-going eligibility / enrollment management

• Enrollment and funds flow reconciliation

Individual Enrollment - Payment Types

Consumers can make their initial premium payment

on Maryland Health Connection as part of the plan

selection process

Accepted payment types include:

– Credit card

– ACH

– Check

– Money Orders

Maryland Health Connection: Initial Payment Collection

Individual Enrollment Transactions

Carriers must receive several transactions from Maryland Health Connection: – 834 – Enrollment file with demographic, plan selection info

– 820 – Payment file with information on payment collected

– Cash Disbursement – Payment from State to carrier

Carriers will receive a daily 834 file to immediately begin enrollment procedures

Carriers will receive the 820 files and cash disbursements on a weekly basis

Carriers will generate enrollment materials (e.g. ID card)

Initial Payment: Maryland Health Connection

Individual Enrollment Cut Off Schedule

Effective Date of Coverage

October 1 – December 18 Payments posted during this period will have coverage effective January 1, 2014. December 19 – January 18 Payments posted during this period will have coverage effective February 1, 2014. January 19 – February 18 Payments posted during this period will have coverage effective March 1, 2014. February 19 – March 18 Payments posted during this period will have coverage effective April 1, 2014. March 19 – March 31 Payments posted during this period will have coverage effective May 1, 2014.

Initial Payment: Maryland Health Connection

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Individual Enrollment: Paying Carriers Directly

Consumers can opt to pay carriers directly for the initial payment. – Maryland Health Connection will allow the customer to select ”Pay

Carrier Directly”

– MHBE Sends Informational Enrollment (834) Record to Carrier

– MHBE Does NOT Create an Invoice

– Carrier Invoices Customer Directly

– Carrier Begins Coverage Based Upon Carrier Payment Posting Rules

– Carrier Returns Enrollment (834) Record When Customer Enrollment Complete

MHBE is working with carriers to identify whether or not a standard cut-off should apply to all carriers when consumers opt to pay the carrier directly

Initial Payment: Paying Carriers Directly

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Individual On-Going Billing

Carriers will be responsible for on-going billing and

collection of premiums and provision of healthcare

services

On-Going Billing

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Appendix

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TERMS

EFFECTUATION – The process of the carrier issuing

membership/enrollment material; to occur upon

receipt of the daily 834 enrollment file from the MHBE

EFFECTIVE DATE – The date when coverage starts

POSTED – Premium Payments Credited to Customer

Account and Deposited in MD Bank Account

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BASIC MHBE FINANCIAL POLICIES

1. When Premium Payment is Posted to the MHBE by the 18th of the Month the Daily Enrollment Record (834) is Sent to the Carrier

• Coverage Must be Effective by the 1st of the Following Month (or 1/1/2014)

– Does Not Apply to Pay Direct to Carrier

2. There are to be No Changes to Plans Once Coverage Has Started

3. Carriers Will Be Paid Weekly

4. Carriers Will be Invoiced Monthly for Individual Credit Card Fees

– Fees Will be Allocated Based Upon Percentage of Premiums Paid by Credit Card to the Carrier

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DAILY PROCESS

Create Enrollment (834) File (MHBE)

Pick Up Enrollment (834) File (Carrier)

– Contains Enrollment Detail by Customer

• New Enrollments, Changes, Cancellations, Terminations, Carrier

Direct Payment Option

• Sent Only When Full Premium Payment Posted to Customer’s

Account

Effectuate Coverage (Carrier) • Issue Membership Materials/Enrollment Information

• Customers Who Opt to Pay Carrier Directly are Effectuated

Upon Receipt of Payment by the Carrier

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WEEKLY PROCESS

Carrier Disbursement

– Print Disbursement Report (MHBE)

– Create and Send Payment File to State Financial System

(MHBE)

– Create and send weekly 820 File (MHBE)

• By Customer: Premium Payments and Adjustments

(Cancellations, NSFs, Credit Card Disputes)

– Pick Up Payment (820) File (Carrier)

• Report Payment (820) File Problems (Carrier)

– Using 820 Error Process

– Reconcile Daily 834s to 820 to Report (MHBE)

– Review and Approve Payments (MHBE)

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WEEKLY PROCESS (CON’T)

Carrier Disbursement

– Release Batch for State Review (MHBE)

– Send Disbursement Report to Treasurer’s Dept. (MHBE)

– Review Disbursement (State Treasurer)

– Disbursement Released (State Treasurer)

• EFT to Carrier Account by Thursday AM; Check in the Mail

• Equal to Total of “PREM” amounts on 820

Research Payment Discrepancy Issues (MHBE) • POC – Billing Manager (Jody Hartzell)

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MONTHLY PROCESS

Reconciliation

– Send Monthly 834 Reconciliation File to Carrier on 21st of the

Month (MHBE)

• Full Monthly File

• Reconciliation Problems Follow 834 Error Process

– Send Monthly APTC File to CMS on 26th of the Month

(MHBE)

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NSF PROCESS

Customer Pays by Paper Check or ACH (electronic

check)

– Check is processed by the bank

– Funds are deposited in MD Cash Account

– Customer Invoice is updated as paid

– 834 sent to carrier (daily)

– 820 sent to carrier (every Monday); payment to carrier (every

Thursday)

Check (or ACH) is Returned to Lockbox for NSF (est.

3-5 business days)

– Check (or ACH) is re-submitted

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NSF PROCESS CONT’D

Check (or ACH) is Returned again as NSF (est. 3-5

business days)

– MD Cash Account debited

– Customer Invoice updated to unpaid

– 834 cancellation sent to carrier

– Carrier Cancels Coverage

– 820 sent to carrier with negative adjustment

• Potential for both positive and negative to be on the same day

Last Posting Date is 18th of the month

– 6-10 business days to process NSFs

– Process allows enough time for carrier to cancel coverage

– Notification to customer

• Pay by Money Order or Credit/Debit Card

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CANCELLATIONS AND TERMINATIONS

Cancellations (Prior to Effective Date)

– NSFs, CC Disputes, Customer Cancel

• Included on Daily 834 Enrollment File

• Reflected on Weekly 820 as a Negative Amount

• MHBE Refunds Premium for Customer Cancellation

Terminations (After Effective Date)

– Non-Payment (Subsequent Payments to Carrier)

• Carrier to Send 834 Record of Termination

– Customer Initiated (Change in Circumstances)

• MHBE to Send 834 to Carrier

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SPECIAL ENROLLMENT

Special Enrollment (After Effective Date)

– Change in Circumstances

• ACA Qualifying Events

• Can Occur Any Time During Year

– May Result in a Customer Initiated Termination

• Daily 834 to Indicate Termination of Old Plan/Carrier

• Daily 834 to Indicate Enrollment in a New Plan/Carrier

• MHBE to Generate a New Invoice

• Weekly 820 to Carrier

– Conforms to Standard Payment Schedule (posted by the18th

of the month)

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PAYING THE CARRIER DIRECTLY

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SCHEDULE – OCTOBER 2013

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Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date

Reconciliation 834 to Carrier

10/01-10/06 10/01-10/06 10/10 01/01/2014

10/07-10/13 10/07-10/13 10/17 01/01/2014

10/14-10/20 10/14-10/20 10/24 01/01/2014 10/21

10/21-10/27 10/21-10/27 10/31 01/01/2014

10/28-11/03 10/28-11/03 11/07 01/01/2014

SCHEDULE – NOVEMBER 2013

Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date Reconciliation 834 to Carrier

11/04-11/10 11/04-11/10 11/14 01/01/2014

11/11-11/17 11/11-11/17 11/21 01/01/2014

11/18-11/24 11/18-11/24 11/28 01/01/2014 11/21

11/25-12/01 11/25-12/01 12/05 01/01/2014

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SCHEDULE – DECEMBER 2013

Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date

Reconciliation 834 to Carrier

12/02-12/08 12/02-12/08 12/12 01/01/2014

12/09-12/15 12/09-12/15 12/19 01/01/2014

12/16-12/22 12/16-12/22 12/26 01/01/2014 (<or=18th) 02/01/2014 (>18th)

12/21

12/23-12/29 12/23-12/29 01/02 02/01/2014

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SCHEDULE – JANUARY 2014

Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date

Reconciliation 834 to Carrier

12/30-01/05 12/30-01/05 01/09 02/01/2014

01/06-01/12 01/06-01/12 01/15 02/01/2014

01/13-01/19 01/13-01/19 01/23 02/01/2014 (<or=18th) 03/01/2014 (>18th)

01/20-01/26 01/20-01/26 01/30 03/01/2014 01/21

01/27-02/02 01/27-02/02 02/06 03/01/2014

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SCHEDULE – FEBRUARY 2014

Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date Reconciliation 834 to Carrier

02/03-02/09 02/03-02-09 02/13 03/01/2014

02/10-02/16 02/10-02/16 02/20 03/01/2014

02/17-02/23 02/17-02/23 02/27 03/01/2014 (<or=18th) 04/01/2014 (>18th)

02/21

02/24-03/02 02/24-03/02 03/06 04/01/2014

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SCHEDULE – MARCH 2014

Payment Posted/ Deposited

Daily 834 to Carrier

Payment to Carrier

Effective Date

Reconciliation to Carrier

03/03-03/09 03/03-03/09 03/13 04/01/2014

03/10-03/16 03/10-03/16 03/20 04/01/2014

03/17-03/23 03/17-03/23

03/27 04/01/2014 (<or=18th) 05/01/2014 (>18th)

03/21

03/24-03/30 03/24-03/30 04/03 05/01/2014

03/31 03/31 04/10 05/01/2014

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