Transcript Document

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Confidential
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Copyright © 2014 TriZetto Corporation
Healthcare Reform:
Exchange Experience
Facets™
Mikesh Patel Facets Product Manager
[email protected]
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Agenda
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Exchange Communication
Facets™ Enrollment & EDI
Membership, APTC, Rating, and Delinquency
Age Calculation for Premiums
Cost Share Reduction
Essential Health Benefits
Enhancement Requests under Review
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Reform Communication Overview
 FERW
 Customer Exchange
 Community > User Group > TriZetto Customer Group >
Subcommittees > FERW
 Reviewing requirements from Facets community
 Health Care Reform Council
 Change Pack Reviews
 Support
 For enhancements in the field
 Design Review Webinars
 Customer Exchange
 Community > Webinars > Facets Webinars
 Contact me [email protected]
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Facets™
Enrollment & EDI
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Facets™ Enrollment
HIPAA Gateway,
834 subsystem
Batch Enrollment –
MMS Standalone
• Support for APTC/Subsidy, QHPID, Exchange ID
and Member ID
FXI – Membership
Services updated
• Add, Change, Get family
• Enrollment Source (MEES), Subsidy billing
(MESU), TEG Data (SBTD)
FXI - Add Group
Services
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• Support for APTC/Subsidy, QHPID, Exchange and
Member ID
• Leverages Qualified Health Plan Definition
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• Create everything required for a group in Facets
Facets™ HIPAA Gateway for 834 X12 and
the 834 Subsystem
 Support individual enrollment through Exchanges
 Capture Exchange Member ID, Exchange ID, QHP ID,
Enrollment Channel
 Capture Advance Payment of Premium Tax Credit
 Capture and store agent/broker/navigator info
 Mapping exchange enrollment data to QHP definitions tables
 Creation of pediatric dental and vision enrollments
 Capture member and subscriber level smoker indicator
 New alternate indexes for inquiry on Exchange IDs
 New configuration options for Trading Partners to support
exchange 834 transactions
 Separate ini setting for SHOP enrollments
 CSR amount storage, no functionality
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Facets™ Qualified Health Plan Definition
• Link Channel and Submitter ID to:
• Group
• SubGroup
• Class
• Billing Profile
• Subsidy Billing Group
• Link a QHP to
• Plan ID
• Auto assign Plan IDs for Pediatric
Dental and Vision
• Based on Max Age
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Facets™ HIPAA Gateway
 306 HIX 820 is used to communicate remittance on:
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Premium Payments
Advance Payment of Premium Tax Credit (APTC)
Risk Adjustments
Advance Cost Share Payments
Reconciliation Payments
 Storage and compliance check of the 306 HIX820
 Creation of receipt keywords
 Clients need to customize a method to assign these keywords to
appropriate billing entities
 Demo on CX > Community > UserGroups > Change Pack
Review > Videos > 5.10 R5 HIX 820
 https://cx.trizetto.com/community/usergroup/groupportal/vide
o.cfm?g=43
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Advanced Premium
Tax Credit,
Delinquency Grace
Period, Rating
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APTC- Advanced Premium Tax Credit
 The federal government will pay a portion of the
premium for members who are within the certain
income levels
 Based on % of Federal Poverty Level
 Communicated as monthly dollar amount
 Can be at subscriber or member level
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Solution Overview
 Capture Exchange ID, QHPID, & Exchange Member ID
 Store subsidy dollar amount at the
Subscriber/Member level
 Support Subsidy billing
 Calculate amount for subsidy and net remaining to be billed to
subscriber
 Uses separate billing group for subsidy amounts
 Need to mark billing group for use in expanded split billing
 Does not require a billing group
 Can be used to store values that do not reduce premium
 For example CSR amount
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Enrollment Source Data
QHP ID & Member ID
9876123
Exchange & Channel
must match Exchange
Rules Prefix
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Must be Y to get
APTC grace and
delinquency
Subsidy Billing
• Subsidy amount entered as $ value
• Billing Group ID entered will be used
for split billing
• Available on CMC/CDS table for
reporting
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Delinquency for members with APTC:
 During first month of delinquency
 Health Plan must continue to pay claims
 After 1 month
 Member must be given 2 months to become current
 During this 2 month period Health Plans can Pend claims
 Member must become paid in full for all outstanding
due amounts before the delinquency period resets
 partial payments do not reset the delinquency period
 applies only to subsidized coverages the member purchases
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Definition of APTC configuration
 Must be in place before billing
 Enrollment Source Records for every member and
category contain:
 APTC Eligible Indicator
 Valid Exchange and Channel
 Exchange Rules Product Prefix
 For each possible product all valid Exchange ID and Channel ID
combinations are setup, with a claims grace period (1 month)
 Delinquency Definition
 The billing entity connected to the member has a delinquency
definition with the total number of eligible months for a category
(3 months)
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Member Set for APTC Eligible
QHP ID & Member ID
9876123
Exchange & Channel
must match Exchange
Rules Prefix
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Must be Y to get
APTC grace and
delinquency
Configure Exchange Rules
• Exchange & Channel must
match Member
• If no match exists standard
delinquency/grace period
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How long to pay claims
Delinquency Definition Option E
When using ‘E’
value is in
Months
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Delinquency Solution Overview
 Split billing and APTC delinquency are completely
independent
 During Billing Batch
 Update the APTC Delinquency Date
 Delinquency Batch
 Calculates the Bill’s APTC status
 Unpaid, Paid, Paid late not subject to termination, Paid late subject to
termination, etc.
 Billing Entity APTC extended Grace Period Through Date is updated
 Date that claims will pay through for APTC coverage
 Processes category based termination for the ‘E’ value
 Claims Payment
 Updated to check if a claim is for an APTC coverage
 Reads new system parameter to define pending claims for APTC members
when delinquent
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APTC Status Override
• Recalculate ATPC Delinquency
Status – When bill is a status 5
• Override an APTC status of paid
late subject to termination
• Reverse a bill that has been
overridden
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Issues In the Field
 All config must be in place before billing and it is
fragile
 Clients are not completing config during enrollment
 Retroactive changes by the exchange
 Retro changes to subsidy amount with unpaid bills
 Jan billed $100 unpaid
 Feb billed $100 unpaid
 March retro subsidy -$300 paid
 Because Jan and Feb are unpaid APTC delinquency thinks
the entity is delinquent
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Coming in 5.2
 Supporting fully subsidized members
 Currently a billing entity with a $0 bill is considered unpaid
 Supporting the APTC tolerance regulations
 Currently we require paid in full for our APTC delinquency logic
 Recalculating an APTC status after the bill has run
 Goal is to ease the burden when config is missing
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Rating
Enhancements
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Facets™ Rating Requirements and
Enhancements
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Rates can vary only by Age, Area and Smoker status
Rates must be per member
Only the 3 oldest children under age 21 can be rated
Changes to the rating/billing calculation
 Max number of children rated
 Max child age rating
 Changes to the Premium Rate Table application
 Based on the 3 oldest children
 Currently based on date added
 Only for column structure where rating each family member separately
 Column structure G and D
 New Age Basis
 Age, Gender, and Smoker
 Allow clients to rate without needing to use any rate factors
 Use Tier Modifier Types of Rating Area, State and County or State
 New Age basis, M – Use Age, Gender and Smoker status of Each Member
 Tier Column Structure of D or G
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Rates vary by Age, Smoker and Area
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New Age Calculation
Method (R6 Delivery)
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Requirement
 For members who are effective in a QHP before the
plan year, the plan year start date must be used for
premium age calculation
 For members who are effective in a QHP after the
plan year, the effective date in that QHP must be
used for their premium age calculation
 When member comes up for renewal the plan year start date
must be used for premium age calculation
 For SHOP business the premium renewal period may
be on a different date than the plan year
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New option for “Age as of enrollment, policy
issuance, or renewal”
 Planned for R6 Delivery
 When used enter a Policy Issuance or Renewal date
 Changing age calculation method is discouraged, will result in a large
amount of retroactivity.
 A new generation should be added for the coming billing cycle.
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Example – Mid year addition and
re-enrollment
Subscriber
effective in QHP
on 4/1/2014
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Renews in QHP
on 1/1/2015
4/1/201412/31/2014 age
calc based on
4/1/2014
Once re-enrolled
age calc based
on renewal date
of 1/1/2015
Example – Members Added to Coverage
Subscriber was
enrolled before
the plan year
start, 1/1/2014
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CIC- gets
married, adds
spouse and
dependent to
coverage
effective 4/1/2014
Subscriber’s age
Calc based on
1/1/2014
Spouse and
dependent age is
based on there
MEPE effective
date, 4/1/2014
Example - Change in CSPI
Subscriber
enrolled into CSPI
“Silver1” before
plan year start,
1/1/2014
Effective 3/1/2014
subscriber
changes CSPI to
“Gold1”
*The functionality will look for a change in the CSPI
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1/1/2014-2/28/2014
“Silver1” Age Calc
based on 1/1/2014
3/1/2014 12/31/2014
“Gold1” Age Calc
based on 3/1/2014
Example – Addition of a new Plan
Subscriber
enrolled into
CSPI “Silver1”
before plan year
start, 1/1/2014
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Subscriber
enrolls into an
additional CSPI
“Dental1” on
3/1/2014
Age Calc for
“Silver1” based
on renewal date
of 1/1/2014
Age Calc for
“Dental1” based
on MEPE
Effective date in
the new CSPI,
3/1/2014
Example - Gap in coverage
Subscriber
enrolled into
CSPI
“Silver1”
before plan
year start,
1/1/2014
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On 3/31/2014
the
Subscriber
terminates
coverage
On 6/1/2014
the
subscriber
re-enrolls
into CSPI
“Silver1”
1/1/20143/31/2014
Age Calc
Based on
1/1/2014
6/1/201412/31/2014 is
based on
6/1/2014
CSR Requirement
and Solution Design
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CSR- Cost Share Reduction
 The federal government will share the out of pocket costs for
members who are within the certain income levels
 Different cost share brackets exist based on % of Federal Poverty Level
 Cost Share Reduction is only required for Essential Health
Benefits(EHB)
 Pediatric vision and dental EHB included
 Plans can only differentiate based on Co-pay, Co-insurance, deductible,
out of pocket max
 Health Plans need to track/report OOP costs for the member as if Cost
Share had not been in place
 Compared to the base Silver Plan
Silver
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Silver CSR Variation
Smith Family CSR Example
 Jane Smith Benefits Summary
Plan
Deductible
Coinsurance after
Deductible met
Standard Silver Plan (Shadow Plan)
$1500
10%
Silver CSR Band 1 (Actual Plan)
$750
10%
 Jane has rheumatoid arthritis, and get infused with medication
 Claim = $600 (medicine jcode + infusion procedure code)
Before Claim
After Claim
Jane’s out of
pocket
$750 Deductible
accumulator value
$1350 Deductible
accumulator value.
Coverage pays $0
$600
$750 Deductible Met
$750 Deductible limit
met.
Coverage pays $540
Standard Silver Plan:
(Shadow Plan)
Silver CSR Band 1
(Actual Plan)
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$540
$60
Approach for Cost Share Reduction
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Partially re-adjudicate claims under a different set of “benefit
parameters”
Enroll members in the actual plan for which they will process (Cost
share reduction built in)
 Class plan indicator for ‘shadow’ adjudication
 Shadow calculation will occur in a separate batch
Configuration of Shadow Product Variable Components:
 ‘Shadow Service Payment’ (medical)
 ‘Shadow Deductible Rules’
 ‘Shadow Limit Rules’ prefixes
 ‘Shadow Dental Category Payment’
 ‘Shadow Dental Procedure Payment’
Configure specific accumulator suffixes as ‘shadow’
Process claims marked for Cost Share Reduction using Shadow
Components via a new batch process
 New claim tables to store the results of the ‘shadow’ adjudication
 Results will be displayed in Claims Inquiry
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Product-Variable Components Section
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Product-Business Info Section
• Designation of specific Accumulator Suffix
to use the ‘Shadow Accumulators’
• Differentiating ‘actual’ vs ‘shadow’
accumulations
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CSR Example
 4 claims for service “OV”
 Actual set up for $10 Copay with a $150 deductible
 Shadow setup for $20 Copay with a $300 deductible
Actual
$150
deductible
Sub:CSR
SBSB01
CSR0000
00100
OV
CSR0000
00200
OV
CSR0000
00300
OV
CSR0000
00400
OV
Shadow
$300
deductible
Charge Copay
$150.00 $10.00
$140.00
$150.00 $10.00
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Charge Copay Deductible
Paid
$150.00 $20.00
$130.00
$150.00
$0.00
$10.00
$20.00 $130.00 OV
$150.00 $20.00
$130.00
$150.00
$0.00
$150.00 $10.00
$0.00
$10.00 $140.00 OV
$150.00 $20.00
$40.00
$60.00
$90.00
$150.00 $10.00
$600.00 $40.00
$0.00
$150.00
$10.00 $140.00 OV
$190.00 $410.00
$150.00 $20.00
$600.00 $80.00
$0.00
$300.00
$20.00
$380.00
$130.00
$220.00
Copyright © 2014 TriZetto Corporation
$150.00
Paid
Mem
OOP
$0.00 OV
Actual
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Deductible
Mem
OOP
Shadow
Cost Share Reduction
 ITS Claims Targeted for 5.2 R1 (Nov 2014)
 New data elements are being sent via the APC2 process
 TriZetto started receiving these amounts earlier in 2014
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Essential Health
Benefit Enhancement
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Essential Health Benefit Enhancement
 New support application, Medical Product, List of Essential
Health Benefit IDs and Descriptions
 New Medical Plan application (product component prefix)
 Allow the user to indicate, for each Facets Service ID, which Essential Health
Benefit ID it is assigned
 Modify the Limit Rules application to allow for selection of a
new Essential Health Benefits
 Add a new Subsection/Tab to Limit Rules application
 For entry of configured Essential Health Benefits to be Included or Exclude
 Medical claims adjudication routine, batch, and services will:
 Derive and store the Essential Health Benefits ID for the Service ID
 Apply limits based on the new Essential Health Benefit 'Type'
 Claims processing and Claims Inquiry to display the Essential
Health Benefit ID and Description at the line level
 Demo on CX > Community > UserGroups > Change Pack
Review > Videos > 5.10 R5 HIX 820
 https://cx.trizetto.com/community/usergroup/groupportal/video.cfm?g=43
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Enhancement
Requests under
Review
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Enhancement Requests
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Storage of Member Level Rates on the bill level
New GPAI Age out Parameter to support market rules
Void at the Member level
APTC Delinquency
 Separate letters for new APTC delinquency
 Input receipt date, rather than rely on system date
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Member on hold eligibility status
Rebill multiple months
Exchange Policy ID
Qualified Health Plan Definition
 Introduce more flexibility into mappings
 Auto-assignment of Pharmacy Shell product
 Outbound 834
 Pay commissions on gross premium
 FARM
 Shadow calculation for encounter data
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Questions?
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Thank you
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Appendix
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CSR Solution High
Level Design
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Shadow Adjudication
 Pre-Adjudication Steps
 Facets™ will mark claims for Shadow Adjudication when
 Claim is not pre-priced
 New Class/Plan Shadow Adjudication indicated
 Claims Adjudication (for status 01) will write trigger row and initial
data in Shadow Claim line item tables
 Claim ID, Sequence number, Member info, Consider Charge,
Allowable, Units, and Price
 Shadow prefixes: Adjustments will be backed out
 Assumption: no CSR for COB
 Payment Batch will update trigger rows to mark for inclusion in new
Shadow Adjudication batch process
 Shadow Adjudication Batch
 Processes through Shadow Components and updates Shadow Claim
Tables
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Shadow Adjudication
 Obtain Shadow Service Payment
 If no SEPY claim with error
 Utilization Edits
 Leverage current utilization edit routine to apply alternate service
rule
 Read pricing info stored in Shadow table
 Price will reflect all overrides on the actual claim*
 Back out accumulators for adjusted claims
 Deductibles
 Limits
*Include run book option to exclude/include Copay,
Coinsurance, Deductible, and Service Rule Overrides
 Not selective, all 4 include or exclude
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Shadow Adjudication
 Shadow processing
 Based on Service Tiers determine:
 Max allowed, Max counter, Deductible Accumulator, Copay
and coinsurance
 Read/Apply Service Related Parameter copay per day or
variable period limit logic
 Read/Apply Limit routine to appropriate rows
 Read/Apply Deductible routine to appropriate rows
 Based on the Shadow processing
 Accumulators will be updated
 Out of Pocket amounts calculated and populated on Shadow
Line Item tables
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Workshop Survey
We would like to extend you an opportunity
to provide candid feedback.
During the workshop you should have received an e-mail
notification for you to take an on-line survey.
If you could take a few minutes to complete at this time ,
we would greatly value your feedback. For your convenience,
the survey will be available throughout the remainder of the conference
should you not be able to complete immediately.
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