October 30 update: On October 24, 2014, CMS released a Guidance for Issuers on the Termination of a Consumer’s Enrollment in the Federally-facilitated Marketplace due to death. When a individual enrolled in a qualified health plan through the FFM dies, coverage terminates effective on the date of death. The FFM and insurer must learn of the death, however, to terminate coverage.
A death can be reported by the individual who filed the application for marketplace coverage covering the deceased or any member of the deceased’s coverage household who is at least 18 years of age. The death can be reported through Healthcare.gov or through the call center, but if it is reported online, it should also be reported through the call center to establish the date of death and terminate coverage retroactively to the date of death. Alternatively, someone who was not a member of the coverage household or the application filer can report the death, but then it must be documented with, for example, a death certificate, obituary, power of attorney, proof of executor, or proof of estate. The documentation must be mailed to the FFM’s London, Kentucky center
If the death is reported to the insurer rather than the FFM, the insurer should direct the person who reports the death to the FFM. The remaining qualified individuals or enrollees may need to update their information with the FFM. The FFM will then conduct a redetermination of eligibility of the remaining members of the household. These changes may qualify the remaining enrollees for an special enrollment period if they result in loss of minimum essential coverage.
When coverage is terminated due to death, the FFM will instruct the insurer to terminate coverage prospectively through an 834 transaction. The call center will then open a case through the Health Insurance Casework System to terminate coverage retroactively to the date of death. It will also re-enroll qualified individuals in the household in coverage where appropriate. Insurers should process premium refunds or adjustments in accordance with state law and industry practice.
CMS also announced on October 27, 2014 that it is making access to the FF-SHOP exchange early in Delaware, Illinois, Missouri, New Jersey and Ohio. Small businesses in those states can establish a Marketplace SHOP account, assign a SHOP agent/broker to their account, complete an employer SHOP eligibility application, obtain an eligibility determination from the FF-SHOP, and upload an employee roster. They will be able also to see information on available plans in the near future. The early release will give CMS a further opportunity to ensure that the SHOP exchange website is working properly prior to its formal launch on November 15, 2014.
October 24 update: The Affordable Care Act requires HHS to establish a federal process for hearing and deciding appeals from marketplace determinations regarding eligibility to enroll in a qualified health plan through the marketplace, eligibility for advance premium tax credits and cost-sharing reduction payment, and exemptions from the individual responsibility requirement. An appeal process is also supposed to be available to employers who are notified that they may be liable for employer responsibility payments. HHS has promulgated a final regulation establishing standards governing these appeals, as well as eligibility appeals for employers and employees for determinations involving the SHOP program. This regulation provides state-operated exchanges flexibility to establish their own appeal procedures in accordance with federal requirements.
Under the final regulation, appeals entities were allowed to conduct a paper-based appeals process through December 31, 2014, after which they were to use an electronic process. Under a guidance released October 23, 2014, HHS has extended the permissibility of paper-based appeals through December 31, 2015 because of difficulties in implementing the electronic process. HHS has also stated that the federally-facilitated marketplace will continue to use a paper-based process for the 2015 benefit year. State-operated marketplaces may choose whether to use paper or electronic processes. The flexibility extends to all electronic requirements included within the final regulation, including appeal requests, transfer of records, and notifications.
Original post: CMS continues to put the pieces into place that are needed for the launch of the 2015 coverage year. On October 16, 2014, the Centers for Medicare and Medicaid Services released at its REGTAP.info website the certification agreement and privacy and security agreement that qualified health plan (QHP) insurers must sign with CMS to access the federally facilitated exchange (FFE), the federally facilitated SHOP (FF-SHOP), and CMS Data Services Hub. The agreement focuses primarily on obligations that the QHP insurer undertakes to protect personally identifiable information and to ensure secure communications with CMS, although it also addresses the effective date and termination of the agreement and a few other issues. Most of the terms of the agreement are unremarkable, and this post will only comment on a few.
QHP insurers undertake under the agreement to protect personally identifiable information and to ensure secure communications with CMS in conformity with applicable laws, regulations, and standards. They must also ensure that their contractors and downstream entities comply with these requirements. QHP insurers agree to report any personally identifiable information incidents or breaches to CMS within 72 to 96 hours. This is a far cry from the one-hour breach reporting requirement proposed by CMS last year but never finalized, but perhaps recognizes the difficult of identifying and assessing a security breach.
The agreement expressly recognizes that QHP insurers have developed their products based on the assumption that advance premium tax credits and cost-sharing reduction payments will be available through the marketplace and that QHP insurers could have cause to terminate the agreement if this assumption ceases to be valid. This could be interpreted as a reference to the Halbig/King litigation which currently threatens the availability of tax credits and cost-sharing reduction payments through the FFE, but could also have been included in recognition of the likely Republican takeover of the Senate and the possibility that the Republicans may accomplish through budget reconciliation or otherwise their longstanding goal of repealing the ACA. As the agreement is renewable from year to year, this clause may contemplate contingencies in the indefinite as well as the near future. Read the rest of this entry »