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DRAFT
A service of Maryland Health Benefit Exchange
DRAFT
Broker & TPA JAD
May 23, 2013
DRAFT DRAFT
Broker Information
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DRAFT DRAFT A service of Maryland Health Benefit Exchange Broker - - PowerPoint PPT Presentation
DRAFT DRAFT A service of Maryland Health Benefit Exchange Broker - - PowerPoint PPT Presentation
Broker & TPA JAD May 23, 2013 DRAFT DRAFT A service of Maryland Health Benefit Exchange Broker Information DRAFT DRAFT 2 Broker Topics Transaction files Broker XSD Group file 834 Individual initial enrollment with broker
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DRAFT
Broker Topics
Transaction files
– Broker XSD – Group file – 834
Individual initial enrollment with broker information & Broker of Record changes SHOP initial enrollment with broker information & Broker of Record changes
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DRAFT
Broker XSD
Broker updates, additions, or terminations Daily batch Section 7.1.7 in the Carrier Integration Package Includes broker: Name, Address, PrimaryTelephoneNumber, EmailID, TaxPayerIdentificationNumber, etc
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DRAFT
Group file
Sent when any changes are made to the group Daily batch Section 7.1.6 in the Carrier Integration Package Includes broker: Name, TaxPayerIdentificationNumber, PrimaryTelephoneNumber, EmailID
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DRAFT
834
Loop ID 1000C – Broker Name
– Page 12 of the 834 MHBE Enrollment Companion Guide
Loop ID 1100C – Broker Account Information
– Page 13 of the 834 MHBE Enrollment Companion Guide
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DRAFT
Broker Topics
Transaction files
– Broker XSD – Group file – 834
Individual initial enrollment with broker information & Broker of Record changes SHOP initial enrollment with broker information & Broker of Record changes
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DRAFT
Individual Initial Enrollment
Select a broker Enroll in QHP Send 834 to carrier
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DRAFT
Individual Broker of Record Change
Select a new broker Send updated 834 to carrier Current manual process
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DRAFT
Broker Topics
Transaction files
– Broker XSD – Group file – 834
Individual initial enrollment with broker information & Broker of Record changes SHOP initial enrollment with broker information & Broker of Record changes
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DRAFT
SHOP Initial Enrollment
Select a broker Open enrollment 75% participation rate is met Send group file to carrier(s)
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DRAFT
SHOP Broker of Record Changes
Employer selects a new broker Send group file to carrier(s) Current manual process
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* Also applicable to BOR changes in TPA Program 2 & 3
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DRAFT DRAFT
TPA Information
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DRAFT
TPA Program Definitions
Program 1: Alternate Online Marketplace for SHOP QHPs Program 2: SHOP Back Office Administrative Systems Program 3: SHOP Online Administrative Services Provider
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DRAFT
Broker & TPA Relationship
How is this relationship captured today? How often does it change? Does this require an additional transaction scenario with the Maryland Health Connection?
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DRAFT
TPA of Record Change
How is this handled today?
How often does it occur?
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DRAFT
TPA of Record Changes
No TPA to Program 3 Maryland Health Connection
– All employer tasks remain on the Maryland Health Connection
Carrier
– No change in transactions
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DRAFT
TPA of Record Changes
No TPA to Program 2
– Employer’s bill payment moves to a TPA system – TPA is responsible for enrollment & payment transactions with the carrier(s)
Maryland Health Connection
– Employer’s enrollment and maintenance tasks remain on the Maryland Health Connection
Carrier
– Transactions move from Maryland Health Connection to TPA system
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DRAFT
TPA of Record Changes
No TPA to Program 1
– Employer moves to an alternate online marketplace from the Maryland Health Connection – TPA is responsible for enrollment & payment transactions with the carrier(s)
Carrier
– Transactions move from Maryland Health Connection to TPA system
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DRAFT
TPA of Record Changes
TPA Program 2 to Program 1
– Employer moves to an alternate online marketplace from the Maryland Health Connection – New TPA is responsible for enrollment & payment transactions with the carrier(s)
Carrier
– Transactions move from one TPA to another
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DRAFT
TPA of Record Changes
TPA Program 1 to Program 2
– Employer moves from an alternate online marketplace to the Maryland Health Connection – TPA is responsible for enrollment & payment transactions with the carrier(s)
Maryland Health Connection
– Onboard employer as if they are new to the system
Carrier
– Transactions move from one TPA to another
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DRAFT
TPA of Record Changes
TPA Program 1 to Program 3
– Employer moves from an alternate online marketplace to the Maryland Health Connection
Maryland Health Connection
– Onboard employer as if they are new to the system – Maryland Health Connection is esponsible for enrollment & payment transactions with the carrier(s)
Carrier
– Transactions move from a TPA to the Maryland Health Connection
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DRAFT
TPA of Record Changes
TPA Program 3 to Program 1
– Employer moves to an alternate online marketplace from the Maryland Health Connection – TPA is responsible for enrollment & payment transactions with the carrier(s)
Carrier
– Transactions move from the Maryland Health Connection to a TPA
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DRAFT
TPA of Record Changes
TPA Program 3 to Program 2
– Employer’s bill payment moves to a TPA system – TPA is responsible for enrollment & payment transactions with the carrier(s)
Maryland Health Connection
– Employer’s enrollment and maintenance tasks remain on the Maryland Health Connection
Carrier
– Transactions move from the Maryland Health Connection to a TPA
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DRAFT
TPA of Record Changes
TPA Program 2 to Program 3
– Employer’s bill payment moves from a TPA system to the Maryland Health Connection
Maryland Health Connection
– Employer’s enrollment and maintenance tasks remain
- n the Maryland Health Connection
– Maryland Health Connection is responsible for enrollment & payment transactions with the carrier(s)
Carrier
– Transactions move from a TPA to the Maryland Health Connection
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