EE
Enroll Member
Member Enrollment
Description
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.
Business Process Template
Trigger events
Environment-based
- Receive presumptive eligibility determination from provider.
Interaction-based
- Receive enrollment determination from Determine Member Eligibility business process.
Results
- Enroll eligible member in Medicaid health plans and health benefits.
- Alert sent to Manage Applicant and Member Communication to send welcome package, health plan, if applicable, health benefits, and identification cards.
- Alert sent to send enrollment information to contractor.
- If applicable, alert sent to Manage Member Financial Participation for premium payment arrangement.
- Tracking information as needed for measuring performance and business activity monitoring.
Business process steps
- 1. START: Receive eligibility determination to enroll member.
- 2. Agency associates member with elected health plan, if applicable, and health benefits.
- 3. Send alert to send enrollment information to contractor.
- 4. Send alert to send dual eligibility enrollment information to Medicare.
- 5. If applicable, send alert to Manage Member Financial Participation for premium payment arrangement.
- 6. END: Send notification to member with welcome package and identification cards via Manage Applicant and Member Communication business process.
Predecessor processes
- Receive Inbound Transaction
- Determine Member Eligibility
- Manage Applicant and Member Communication
Successor processes
- Send Outbound Transaction
- Manage Applicant and Member Communication
- Manage Member Information
- Manage Member Financial Participation
Shared data
- Plan data store including policy information
- Health Benefit data store including benefit package and benefit information
- Member data store including demographics and application information
- Provider data store including provider network information
- Contractor data store including provider network information
Constraints
State may have different programs and different enrollment criteria, or may use enrollment brokers for some or all of the business process steps. States may require non-HIPAA covered contractors to use the ANSI X12 834 Benefit Enrollment and Maintenance transaction or may rely on State specific formats for contractor notification.
Failures
- Alert fails to reach member or contractor.
- Duplicate enrollment requests,
- Required field missing or not correct
Performance measures
- Time to complete process: successful applicant is enrolled within __ days
- Accuracy of enrollment = ___%
- Consistency of enrollments and disposition = ___%
- Error rate is __% or less
- Disenroll Member
Source: CMS MITA 3.0 Business Process Template, Eligibility and Enrollment Management BPT.pdf, pages 16-18.
Business Capability Model (10 questions)
Each capability question defines five maturity levels, from Level 1 through Level 5.
Business Capability Descriptions
Is the process primarily manual or automated?
- LEVEL 1The process consists primarily of manual activity to accomplish tasks.
- LEVEL 2SMA uses a mix of manual and automated processes to accomplish tasks.
- LEVEL 3SMA provides electronic delivery system and plan selection opportunities for individuals that are eligible based on MAGI.
- LEVEL 4SMA provides electronic delivery system and plan selection opportunities for individuals that are eligible based on MAGI. SMA fully integrates with CHIP and Marketplace plan choice and enrollment process.
- LEVEL 5SMA provides electronic delivery system and plan selection opportunities for individuals that are eligible based on MAGI or non-MAGI. SMA fully integrates with CHIP and Marketplace plan choice and enrollment process.
Does the State Medicaid Agency use standards in the process?
- LEVEL 1SMA focuses on meeting compliance thresholds for state and federal regulations using state-specific standards.
- LEVEL 2SMA applies a mix of HIPAA and state-specific standards.
- LEVEL 3SMA adopts national standards (e.g. HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols) for exchange of enrollment information.
- LEVEL 4SMA adopts industry standards (e.g., HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols), and actively participates in the ongoing development of related standards.
- LEVEL 5SMA adopts industry standards e.g., HIPAA, Administrative Simplification, Health Information Technology Enrollment and Standards Protocols), actively participates in the ongoing development of standards, and works with other States and federal agencies to develop and adopt standards related to enrollment process, not limited to data exchange.
How does the State Medicaid Agency collaborate with other agencies or entities in performing the process?
- LEVEL 1Very little collaboration occurs with other agencies to standardize information exchange or business tasks.
- LEVEL 2SMA collaborates with other agencies and entities to adopt HIPAA standards and EDI transactions.
- LEVEL 3SMA collaborates with agencies administering other insurance affordability programs to develop and implement common enrollment standards.
- LEVEL 4SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage a shared enrollment process for all MAGI populations and to conduct joint planning and population management efforts. The SMA documents the arrangement in an agreement that is dynamic and updated as conditions change.
- LEVEL 5SMA participates in a joint governance effort with the Marketplace and CHIP agency to manage a shared enrollment process and to conduct joint planning and population management efforts. The SMA documents the arrangement in an agreement that is dynamic and updated as conditions change.
Business Capability Quality: Timeliness of Process
How timely is the end-to-end process?
- LEVEL 1SMA sometimes meets threshold or mandated requirements for timeliness (e.g., the process achieves results within the time specified by law, or regulation). SMA takes multiple weeks to complete paper handling, and does not have the capacity to process enrollments without human intervention.
- LEVEL 2SMA improves timeliness through increased use of automation. Timeliness always meets legal requirements. To the extent that SMA requires paper, SMA takes multiple weeks to complete paper handling.
- LEVEL 3SMA improves timeliness through increased use of automation. When an individual utilizes the electronic delivery system and plan selection process, SMA notifies delivery system or plan in overnight batch processing. SMA takes multiple days to complete paper handling.
- LEVEL 4SMA further improves timeliness through increased use of automation. When an individual utilizes the electronic delivery system and plan selection process, SMA notifies delivery system or plan in near real-time. SMA processes all paper requests within 72 hours of receipt.
- LEVEL 5SMA further improves timeliness through increased use of automation. When an individual utilizes the electronic delivery system and plan selection process, SMA notifies delivery system or plan in near real-time and provides temporary ID card. SMA processes all paper requests within 24 hours of receipt.
Business Capability Quality: Data Access and Accuracy
How accurate is the information in the process?
- LEVEL 1Use of direct data entry for information collection is manually intensive and susceptible to inconsistent or incorrect information. Stakeholders are unable to rely on information for decision-making.
- LEVEL 2HIPAA standard transactions improve accuracy of information but the decision-making process may be erroneous or misleading. Accuracy is higher than at Level 1.
- LEVEL 3Electronic delivery system and plan selection process means that information is collected in a shared enrollment service and therefore is significantly more accurate than in a paper process. SMA’s automation of MAGI eligibility determination results in more reliable information for use in enrollment process; automation of enrollment process eliminates the vast majority of human error from the process. Accuracy challenges still exist for paper enrollment requests, but SMA reduces errors as much as possible through standard operating procedures.
- LEVEL 4Electronic delivery system and plan selection process means that information is collected in a shared enrollment service and therefore is significantly more accurate than in a paper process. SMA’s automation of MAGI eligibility determination results in more reliable information for use in enrollment process; automation of enrollment process eliminates the vast majority of human error from the process. SMA uses shared eligibility service for MAGI determinations to eliminate inaccuracy in application of rules across insurance affordability programs, which has a corresponding effect on enrollment accuracy. Accuracy challenges still exist for paper enrollment requests, but SMA reduces errors as much as possible through standard operating procedures.
- LEVEL 5Electronic delivery system and plan selection process means that information is collected in a shared enrollment service and therefore is significantly more accurate than in a paper process. SMA’s automation of MAGI and non-MAGI eligibility determination results in more reliable information for use in enrollment process; automation of enrollment process eliminates the vast majority of human error from the process. SMA uses shared eligibility service for MAGI and non-MAGI determinations to eliminate inaccuracy in application of rules across insurance affordability programs, which has a corresponding effect on enrollment accuracy. Accuracy challenges still exist for paper enrollment requests, but SMA reduces errors as much as possible through standard operating procedures.
How accessible is the information in the process?
- LEVEL 1SMA stores information in disparate systems including paper storage. Systems experience extended scheduled and unscheduled downtime.
- LEVEL 2SMA stores information in disparate systems, but use of electronic information, automation, and HIPAA standards increase accessibility over Level 1. Systems experience extended scheduled and unscheduled downtime.
- LEVEL 3SMA easily exchanges information with delivery systems and plans based on MITA Framework and industry standards. SMA maintains individual information in an electronic account that is accessible to the individual for review and self-service. Self-service for non-MAGI populations is limited. Electronic account is accessible 24/7 through the portal except during state-approved maintenance timeframes.
- LEVEL 4SMA easily exchanges information with delivery systems and plans based on MITA Framework and industry standards. SMA maintains individual information in an electronic account that is accessible to the individual for review and self-service. Self-service for non-MAGI populations has a greater level of automation then level 3. Electronic account is accessible 24/7 through the portal except during state-approved maintenance timeframes.
- LEVEL 5SMA easily exchanges information with delivery systems and plans based on MITA Framework and industry standards. SMA maintains individual information in an electronic account that is accessible to the individual for review and self-service. Electronic account is accessible 24/7 through the portal except during state-approved maintenance timeframes.
Business Capability Quality: Cost Effectiveness
What is the cost of the process compared to the benefits of its results?
- LEVEL 1High relative cost due to low number of automated, standardized tasks.
- LEVEL 2Automation improves process and allows focus on exception resolution, increasing cost effectiveness ratio over Level 1.
- LEVEL 3SMA adopts Seven Standards and Conditions, MITA Framework, and intrastate standard messages and other nationally recognized standards further increasing cost effectiveness ratio over Level 2.
- LEVEL 4SMA adopts Seven Standards and Conditions, MITA Framework, regional standard messages and other nationally recognized standards for enrollment. SMA increases cost effectiveness ratio over Level 3.
- LEVEL 5SMA adopts Seven Standards and Conditions, MITA Framework, national standard messages and other nationally recognized standards for national enrollment. SMA increases cost effectiveness ratio over level 4.
Business Capability Quality: Effort to Perform; Efficiency
How efficient is the process?
- LEVEL 1Process is labor intensive. There is wasted effort or expense to accomplish tasks. Process meets minimum state process guidelines and agency performance standards. Efficiency is low.
- LEVEL 2Automation and state standards increase productivity. Efficiency is higher than Level 1.
- LEVEL 3SMA adopts automation of enrollment process improving efficiency to 90% or higher.
- LEVEL 4SMA adopts shared enrollment services for MAGI population, improving efficiency to 95% or higher.
- LEVEL 5SMA uses shared enrollment services for all populations, improving efficiency to 98% or higher.
Business Capability Quality: Accuracy of Process Results
How accurate are the results of the process?
- LEVEL 1SMA applies business rules manually and inconsistently, producing inconsistent and incorrect enrollments.
- LEVEL 2SMA applies some automated business rules, which increases accuracy of enrollments. Results remain inconsistent based on mix of automated and manual processes. Accuracy is higher than at Level 1.
- LEVEL 3SMA automates enrollment for MAGI populations eliminating the vast majority of human error from the process. Accuracy challenges still exist in the manual processing of enrollment requests. SMA reduces errors as much as possible through standard operating procedures.
- LEVEL 4SMA automates enrollment for MAGI populations eliminating the vast majority of human error from the process. SMA uses shared enrollment service increasing standardization across insurance affordability programs. Accuracy challenges still exist in the manual processing of enrollment requests, but SMA reduces errors as much as possible through standard operating procedures.
- LEVEL 5SMA automates enrollment for MAGI and non-MAGI populations, eliminating the vast majority of human error from the process. SMA uses shared enrollment service to eliminate inaccuracy in application of rules across insurance affordability programs. Accuracy challenges still exist in the manual processing of enrollment requests, but SMA reduces errors as much possible through standard operating procedures.
Business Capability Quality: Utility or Value to Stakeholders
How satisfied are the stakeholders?
- LEVEL 1Stakeholders lack confidence in information negatively affecting stakeholder satisfaction with the process.
- LEVEL 2Automation and standardization provides clear and useful information. Stakeholder satisfaction is greater than Level 1.
- LEVEL 3Automation of MAGI eligibility process and reliance on electronic delivery system and plan selection improve stakeholder satisfaction to 80% or higher.
- LEVEL 4Use of shared enrollment service for MAGI populations increases the efficiency, speed, and accuracy of information improving stakeholder satisfaction to 90% or higher.
- LEVEL 5Use of shared enrollment service that incorporates MAGI and non-MAGI populations increases the efficiency, speed, and accuracy of information improving stakeholder satisfaction to 98% or higher.
Source: CMS MITA 3.0 Business Capability Model, Eligibility and Enrollment Management BCM.pdf, pages 12-21.