Eligibility and Enrollment Management

The Determine Member Eligibility business process is responsible for the operational aspects of determining if an applicant is eligible for Medicaid or potentially eligible for other insurance affordability programs (e.g., Advance Premium Tax Credits through the Health Insurance Marketplace (HIX) commonly referred to as the Marketplace. Children’s Health Insurance Program [CHIP], and/or Basic Health Program [BHP]). An applicant submits an application or a member updates account information via online, in person, over the phone, by mail, or by other commonly available electronic means. The business process checks for status (e.g., new, resubmission, redetermination, duplicate, or referral from the Health Insurance Marketplace or other agencies administering insurance affordability programs) and verifies applicant information in accordance with the policies established. The business process determines eligibility based on modified adjusted gross income (MAGI) or on a basis other than MAGI methods including group/category (e.g., parents/caretaker relatives, pregnant women, children under 19 year of age). The business process also assigns a Medicaid ID, associates the benefit packages, and produces notifications for coordinated communications. When required, the State Medicaid Agency (SMA) submits applicant or member eligibility information and/or eligibility determination to other agencies administering insurance affordability programs and CMS information systems. This business process could be a Shared Eligibility Service between the Medicaid Agency, the Health Insurance Marketplace, and other State-based insurance affordability programs such as CHIP or BHP. NOTE: Applications and Accounts: An individual seeking eligibility for enrollment in an insurance affordability program completes and submits an application on-line, in person, over the phone, by mail, or paper application for verification and eligibility determination. Accepted application data is managed in an “electronic account” (as defined in 42 CFR 435.4) by the receiving program to enable access to this information during the verification and eligibility determination processes, as well as after the conclusion of the process to support change reporting and for other purposes.

The Disenroll Member business process is responsible for the termination of a member’s enrollment in a health plan or health benefit. An enrollment termination may occur due to: • A member is no longer eligible based on redetermination of Medicaid eligibility either on an annual basis or as a result of change reporting during the coverage year. • Upon receipt of a notification of incarceration, SMA may suspend eligibility (if State policy indicates to do so). • A member is no longer eligible based on change in residence. • The denial of eligibility for a or benefit that is based on a technical factor or non-financial characteristic. • A member submits a disenrollment request. • Disenrollment request from a provider or contractor due to issues with the member such as moving out of service area, fraud and abuse, disruptive behavior, non-compliance, or death. • Member is deceased. • Receive disenrollment request from Manage Compliance Incident Information business process for continued failure to make payments. • Receive disenrollment request from Determine Adverse Action Incident due to fraudulent or abuse activity. • The provider or contactor has a change of status or termination that requires a mass disenrollment of members. • A health plan or health benefit has a change that requires a mass disenrollment of members. • A member modifies their Manage Care Organization (MCO), Primary Care Case Manager (PCCM), or waiver provider: - Member changes information during Open Enrollment period. - As permitted by State rules, such as the following: ✓ Change in member’s residence. ✓ A provider whom the member has chosen no longer contracts with current program or MCO. ✓ Medicaid terminates the contract with the member’s MCO or PCCM. ✓ Member successfully appeals auto-assignment. ✓ The member has issues with the MCO, PCCM, or waiver provider that may affect quality of care. NOTE: Enrollment brokers may perform some of the steps in this business process.

The Enroll Member business process receives eligibility information from the Determine Member Eligibility business process, the Health Insurance Marketplace, or any insurance affordability program (e.g., Children’s Health Insurance Program [CHIP] or Basic Health Program [BHP]). It determines additional qualifications for enrollment in health benefits for which the member is eligible, and produces notifications for coordination of communications to the member, provider, and to the insurance affordability programs. The Marketplace, Agency or enrollment brokers may perform some or all of the steps in this business process. NOTE: There is a separate business process for Disenroll Member. NOTE: Applications and Accounts - An individual seeking eligibility for enrollment in a qualified health plan through the Health Insurance Marketplace, advance premium tax credits, cost-sharing reductions, Medicaid, CHIP or BHP completes and submits an on-line, telephone, in-person, or paper application for verification and eligibility determination. The Health Insurance Marketplace or insurance affordability program accepts application data and manages information in an “account” by the receiving program to enable access to this information during the verification and eligibility determination processes, as well as after the conclusion of the process to support change reporting and for other purposes.

The Inquire Member Eligibility business process receives requests for eligibility verification from Health Insurance Marketplace, authorized providers, programs or business associates; performs the inquiry; and prepares the Eligibility, Coverage or Benefit Information response. The response information includes but is not limited to benefit status, explanation of benefits, coverage, effective dates, and amount for co-insurance, co-pays, deductibles, exclusions and limitations. The information may include details about the Medicaid health plans, health benefits, and the provider(s) from which the member may receive covered services. NOTE: This business process does not include Member requests for eligibility verification. Member initiated requests are handled by the Manage Member Information and or Manage Applicant and Member Communication business processes.

The Determine Provider Eligibility business process collects enrollment application from Health Care Provider, or collects re-enrollment or revalidation information from existing Provider. The business process verifies syntax and semantic of information, checks status tracking (e.g., initial, modification, duplicate, cancelation), requests additional information when necessary, determines screening level (i.e., limited, moderate or high), verifies applicant information with external entities, collects application fees, and notifies Health Care Provider or Provider of enrollment eligibility determination (e.g., accepted, denied, or suspended). Determine Provider Eligibility business process sends enrollment determination alert signals to subscribing business processes Enroll Provider and Manage Provider Communication. Determine Provider Eligibility sends alert signal to Manage Accounts Receivable Funds business process to collect application fee. The Determine Provider Eligibility business process works in conjunction with Medicare and the processing of dual eligibles. Medicare agency conducts provider screening activities, application fee collection, and revalidation for those providers who are dual eligible. Determine Provider Eligibility business process is responsible for the provider screening activities, application fee collection, and revalidation for only Medicaid providers. NOTE: External contractors such as quality assurance and credentialing verification services may perform some of these steps.

The Disenroll Provider business process is responsible for managing disenrollment in the Medicaid Program. This business process covers the activity of disenrollment including the tracking of disenrollment requests and validation that the disenrollment meets state’s rules. Medicaid sends notifications to affected parties (e.g., provider, contractor, business partners) as well as alerts to other business processes to discontinue business activities.

The Enroll Provider business process is responsible for enrolling providers into Medicaid that includes: • Determination of contracting parameters (e.g., Provider taxonomy, type, category of service that the Provider can bill). • Establishment of payment rates and funding sources, taking into consideration service area, incentives or discounts. • Alert sent to Manage Contract business process to negotiate contracts. • Supporting receipt and verification of program contractor’s Provider enrollment roster information (e.g., from Managed Care Organization (MCO) and Home and Community-Based Services (HCBS)). • Alert sent to Manage Provider Information business process to load initial and modified enrollment information, including Providers contracted with program contractors into the Provider data store. • Alert sent to Manage Provider Information business process to provide timely and accurate notification, or to make enrollment information required for operations available to all parties and affiliated business processes, including: - Alert sent to Prepare Provider Payment business process for capitation and premium payments. - To prepare Provider Electronic Funds Transfer (EFT) or check with the Manage Accounts Payable Disbursement business process. - The appropriate communications and outreach processes for follow-up with the affected parties, including informing parties of their procedural rights. • Periodic review is due or receipt of request to: - Negotiate payment rates. - Notify Provider of enrollment determination. Enroll Provider business process supports receipt and verification of program contractor’s Provider enrollment roster information (e.g., name, identification, contract information, type, specialty and services) from Managed Care Organization (MCO) and HCBS organizations.

The Inquire Provider Information business process receives requests for provider enrollment verification from authorized providers, programs or business associates; performs the inquiry, and prepares the response information for the Send Outbound Transaction.