August 28 update: On August 27, 2015 the Centers for Medicare and Medicaid Services (CMS) published a notice that it is seeking emergency clearance from the Office of Management and Budget (OMB) for modifications to an information collection request currently approved by the OMB for collecting information from insurers under the medical loss ratio and risk corridor programs.
CMS claims that additional and more detailed information is necessary to validate data that insurers have already submitted to CMS, to resolve significant discrepancies in the 2014 benefit-year submissions, and to address a number of common errors that may lead to submissions that do not comply with CMS guidelines. Without this information, CMS states that it will be unable to verify the accuracy of submissions and validate the data needed to operate the risk corridor program.
All qualified health plan insurers that submitted risk corridor data will be required complete a risk corridor checklist that will be available at the CMS Paperwork Reduction Act website. If a company cannot verify the accuracy of its submitted MLR/risk corridor data on the checklist, it must resubmit accurate data by September 8 or 14 as instructed by CMS.
In addition, companies that are requested to do so by August 31, 2015 must complete a risk-corridor discrepancy worksheet. Both reports must be submitted online. The discrepancy reporting worksheet relates to discrepancies between the MLR/risk corridor report and the reports that were submitted for the reinsurance program.
One issue that CMS seems to be focused on is companies that had an unusually high number of claims that were submitted in 2014 but not paid by March 31, 2015. Dollar figures submitted by insurers with respect to premiums and claims are expected to be accurate to one quarter of one percent.
It is perhaps not surprising that implementation of a program as complex as the risk corridor program would have led to complications in its first year of operation. The final deadline for approval of qualified health plan rates by state insurance departments, however, was August 25, 2015, and without information on the risk corridor contributions and payments of particular insurers, states cannot be certain that the rates they are approving are appropriate.
CMS has not yet to my knowledge publicly announced how it will deal with this issue.
August 27 update: On August 24, 2015, the Centers for Medicare and Medicaid Services (CMS) released a Guidance Regarding Training, Certification, and Recertification for Navigator Grantees and Certified Application Counselors (CACs) in the Federally Facilitated Marketplaces (FFMs).
CMS regulations require all navigators in FFMs to complete Department of Health and Human Services (HHS)-approved training and pass a certification examination before being certified, and to be certified or recertified on an annual basis, Navigators must also meet permissible state licensure or certification standards.
Certification for navigator staff and volunteers who completed training during the 2014-2015 grant period expires on September 15, 2015. In order to continue to perform as a navigator after September 15, FFM navigators must either complete the entire 2016 navigator training program or, depending on the circumstances, the 2016 recertification training program.
Navigators working for organizations that received a no-cost extension continuing after September 15, 2015, but are not awarded a navigator grant for the 2015-2018 project, will lose their certification when the no-cost extension ends and may not hold themselves out as navigators after that point. Navigators with programs that have applied for a 2015-2018 grant, but do not have a no cost-extension from 2014-2015, are advised to hold off until navigator program awards are announced early in September.
Navigators who were certified for 2014-2015 and not decertified and who are still with the same organization can be recertified by taking an abbreviated 2016 training program consisting of two modules, one on “SHOP Marketplace Assistance” and the other on “Privacy, Security, and Fraud Prevention Standards.” These modules are updated from last year.
Recertified navigators may continue to perform their duties if their organization receives a 2015-2018 grant or a no-cost extension. Navigators who have not yet been certified or who were certified during the 2014-2015 period, but were either decertified or have become affiliated with a different organization than the one with which they were affiliated for 2014-2015, must take the entire 2016 certification training program, which consists of 15 modules and takes about 20 hours to complete.
Certified application counselors must also take marketplace-approved training programs, pass the CAC certification examination, and meet permissible state licensure or certification requirements. The CAC training consists of six modules and takes five to 10 hours to complete. CACs may also complete additional navigator training modules if they choose to do so.
CACs are certified by their organizations for one year and must be recertified by their CAC organization within one year of their initial certification. CAC organizations are encouraged to have their CACs complete the 2016 training before the 2016 open enrollment period begins even if the CAC is not due for recertification.
CACs must take the full CAC certification training — there is no abbreviated CAC recertification training available. CAC training was not available between June 15, 2015 and August 26, 2015 so CAC organizations with CACs who were not recertified during this time period will not be considered out of compliance with HHS requirements if they complete training by September 30, 2015.
CAC organization agreements renew automatically each year unless the organization or CMS terminates or fails to renew the agreement. CACs are not required to enter into new agreements with their CAC organization, but CAC organizations must ensure that all their CACs are in compliance with HHS requirements and that the certification of their CACs is current.
CAC organizations must disclose to their CACs any non-disqualifying conflicts of interest that they have so that the CACs may further disclose the conflict to consumers. CACs are not required to inform CMS as to which CACs they have or have not certified or recertified.
New Guidance On Reenrollment Of 2015 Enrollees
Original post: On August 25, 2015, the Centers for Medicare and Medicaid Services (CMS) released on its REGTAP website a guidance for insurers on reenrollment of 2015 enrollees through the federally facilitated marketplace (FFM) for 2016. The guidance is quite technical and includes little non-technical information that has not already been released, in particular in CMS’s April 22, 2015 reenrollment guidance. The August 25 guidance, however, presents a particularly detailed roadmap of how the 2016 open enrollment period will work for qualified health plan (QHP) insurers, and is thus worthy of a description here.
Defining Reenrollment
First, some definitions. Reenrollment is the process though which the FFM ensures that an insurer continues an enrollee’s QHP coverage from one plan year to the next. Reenrollment may be in the same product or in a different product if the original product in which an enrollee was enrolled is no longer available. Renewal is reenrollment in the same product. Active enrollment occurs when an enrollee returns to the FFM to submit an application and select a plan for the next year. Passive enrollment or auto-enrollment is reenrollment initiated by the FFM for current enrollees who do not return to the FFM to submit an application and select a plan by December 15, 2015.
Enrollees who do not actively reenroll by December 15, 2015 will have their eligibility redetermined for 2015 based on the most recent income information available on the FFM regarding the enrollee and on updated Federal Poverty Tables and benchmark plan premium information. The FFM will send current 2015 enrollees not scheduled for termination a notice prior to the open enrollment period describing the annual redetermination and reenrollment process, their obligation to update their information with the FFM, and the process the FFM will follow to update advance premium tax credit and cost-sharing reduction (CSR) eligibility for those who fail to actively reenroll.
Enrollment Notices
Particular notices will be sent to three groups of individuals:
- The Opt-Out Group who have not authorized the FFM to access their tax data, for whom eligibility updating will not be possible unless they actively return to the FFM;
- The Special Notice group whose tax information reflects an income of more than 500 percent of the federal poverty level, who must reestablish eligibility with the FFM for APTC or CSR; and
- The Failure to Reconcile Group, who have did not file taxes or reconcile their 2015 advance tax credits for 2014, and who must be terminated from coverage if they fail to do so before the end of 2015.
The third group promises to be quite large. Individuals in these groups will generally be reenrolled in coverage for 2016, but will not receive tax credits or cost-sharing reductions unless they actively reenroll, and for the failure to reconcile group, file their taxes and reconcile their 2014 tax credits.
Guidance For Insurers
Insurers will get a list of their enrollees that fall into one of these three groups, although it will just be a single list not broken down into the three categories. The guidance includes talking points that insurers can use to reach out to the enrollees on this list, advising them how to address each of the potential issues that may affect them. Of particular importance is getting individuals who have not yet filed form 8962 to reconcile their 2014 tax credits to file their taxes and the form. Once they have done so, they must return to the FFM after open enrollment begins on November 1, 2015, to update their 2016 application, as the FFM will not have a record of their filing their taxes if they have only just done so.
The FFM will passively auto-enroll 2015 enrollees who continue to be eligible for coverage for 2016 and do not actively enroll, if their QHP insurer has provided the FFM with a 2016 reenrollment crosswalk template to indicate in what plan the 2015 enrollees will be reenrolled. 2015 enrollees may also actively reenroll for 2016 between November 1, 2015 and December 15, 2015 for coverage beginning January 1, 2016, even if their 2015 coverage was terminated prior to December 31, 2015, for instance for non-payment. The FFM will provide returning 2015 enrollees with a pre-populated application that they can use to update their eligibility.
The FFM will send passive reenrollment transactions to insurers in two waves, one beginning around October 15, 2015 and the other beginning around December 16, 2015. Most reenrollees will be included in the first round, giving insurers time to prepare reenrollment notices to those who are passively reenrolled. Enrollees will not be given any indication that they are being reenrolled, however, until December 16, 2015 to encourage them to return to the FFM before that date to actively reenroll. Insurers will not inform enrollees that they have been passively reenrolled until the insurer sends out the January billing notice.
The second wave of passive reenrollments will include newer enrollees who began enrollment after the first wave of passive reenrollments were executed as well as enrollees who for whatever reason, including pending data-matching issues, needed additional time to complete an action before they could be reenrolled. Enrollees who are still in the 90/95 day grace period for resolving data-matching issues at the end of the 2015 plan year will be reenrolled passively for 2016, with a set date in 2016 for their coverage to expire if the issue is not resolved.
The guidance describes in detail the transactions that will be exchanged between the FFM and insurers and the codes that will be used for those transactions during the reenrollment period. Active reenrollments that result in a plan change will result in an 834 transaction being sent both to the losing and gaining plans. Most 2015 enrollees will be passively reenrolled by the start of open enrollment, so active enrollments that result in changes of plan will result in a cancellation by the plan in which the individual has been passively reenrolled. Active reenrollment in the same plan will also result in an active reenrollment transaction.
If an individual actively reenrolls after December 15, 2015, the FFM will terminate the passive reenrollment the day before the actively selected plan becomes effective. Agent/broker National Producer Numbers (NPNs) will be sent on passive reenrollments and pre-populated for 2016 reenrollment, but can be removed or edited by the applicant and will be superseded by any NPN entered through a reenrollment application. Information on assisters who are not agents or brokers will not be included for passive reenrollments but will be sent on active reenrollments.
Beginning in early November and daily through December 22, 2015, the FFM will send insurers “switch files,” which will cumulatively list the insurer’s current subscribers who have switched to another insurer but were not passively reenrolled. It will not include subscribers who were passively reenrolled and then switched (who will be covered by a cancelled passive reenrollment 834 transaction) or enrollees who actively reenroll in a 2016 plan offered by their 2015 insurer.
Passive Reenrollment
In exceptional circumstances, a passive reenrollment may be cancelled because the enrollee’s coverage terminates before the end of 2015, for example for nonpayment. A passive enrollment may also be cancelled if a current enrollee actively reenrolls opening a new account rather than using the FFM’s pre-populated application, thus creating a duplicate enrollment.
At any time during open enrollment (up until January 31) an enrollee can change plans, resulting in a cancellation of any plan in which the enrollee is actively or passively reenrolled. If an enrollee reports a life change, such as the addition of a baby or spouse, before December 15, it will be reflected in a passive reenrollment. An individual passively reenrolled in the October 15 wave may be reenrolled again passively in the December 16 wave if life changes are reported in the interim.
Enrollees who are passively reenrolled during the first wave will have pre-populated application forms available at Healthcare.gov if they choose to update their eligibility information and reenroll. Their account will not reveal their passive reenrollment prior to December 15, but the plan in which they are passively reenrolled will be in “saved plans” in Plan Compare. The 2015 tobacco rating status will remain the same for 2016 passive reenrollments unless it is changed by the enrollee.
If an insurer receives neither an active nor passive reenrollment for a current year enrollee, and the enrollee is not on the switch file and does not have a late current year termination, the insurer should search to see if the enrollee has enrolled with a new FFM-assigned identification or as a dependent of another enrollee. If the enrollee cannot be found enrolled under a different number, the insurer should attempt to contact the enrollee. If the insurer locates the enrollee and the enrollee wishes to continue coverage, or if the enrollee continues to pay his or her premium, the insurer should advise the enrollee to contact the FFM to straighten things out and in the interim the insurer should continue coverage based on the most recently available information as to tax credit and cost-sharing reduction eligibility.
Insurers are not required to collect a binder payment from enrollees who are reenrolled in the same product or in a new product because the original product is no longer available. If an enrollee fails to pay the premium for the first month of 2016, the reenrollee is entitled to a 90-day grace period before termination. Binder payments are required to effectuate coverage for enrollees who change products, for new enrollees, and for returning enrollees who did not have continuous coverage with the insurer.
After December 15, 2015, the FFM will send 2015 enrollees information about their 2016 enrollment, indicating if they were passively reenrolled and whether financial assistance was applied. If the individual was not passively reenrolled, the FFM will encourage him or her to contact the FFM to actively reenroll. Insurers must also send enrollees notice as to products they are discontinuing or renewing in accordance with earlier guidance.
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