State Based Exchange (SBE) Enrollment Reporting Office Hours Center - - PowerPoint PPT Presentation

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State Based Exchange (SBE) Enrollment Reporting Office Hours Center - - PowerPoint PPT Presentation

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State Based Exchange (SBE) Enrollment Reporting Office Hours Center for Consumer Information and Insurance Oversight (CCIIO) March 4, 2020 This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The

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State Based Exchange (SBE) Enrollment Reporting Office Hours

Center for Consumer Information and Insurance Oversight (CCIIO) March 4, 2020

This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is only intended to be a general informal summary of technical legal

  • standards. It is not intended to take the place of the regulations that it is based on. We encourage audience

members to refer to the applicable regulations for complete and current information about the requirements that apply to them.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Agenda

  • General Updates
  • Restatement Timeline
  • State-Based Marketplace Response (SBMR) File

Schema Update

  • Disputes Update
  • Production Payment Cycle Calendar
  • Reference Documents
  • Q&A
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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

General Updates

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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General Updates

  • CMS will schedule both the SBE and issuer meetings
  • n a quarterly basis instead of monthly.
  • Please send SBE contact updates via email to FMCC

fmcc@cms.hhs.gov.

  • If you have any ingestion or data issues, please email

the FEPS Help Desk at CMS_FEPS@cms.hhs.gov as soon as possible.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Restatement Timeline

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Restatement Timeline

Submission Schedule: Current Plan Year (submit monthly) Current Plan Year -1 (submit monthly through June, and then quarterly beginning September) Current Plan Year -2 (submit quarterly) Current Plan Year -3 (submit yearly) Current Plan Year -4 (submit yearly)

Note: This timeline is subject to change as CMS will continue to perform analysis and consult with the SBEs to determine if adjustments are needed.

Calendar Year Coverage Year 2020 2019 2018 2021 2020 2019 2018 2022 2021 2020 2019 2018 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec +2021 +2022 +2023 2020 2021

Submission Month

2022

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Restatement Timeline, continued – For 2018 plan year files:

  • Quarterly submissions will continue

through the end of 2020.

  • Yearly submissions will begin June 2021

and continue for up to five additional years.

  • CMS is willing to be flexible as to the timing
  • f submissions and will work with the SBE

to work through special circumstances.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Restatement Timeline, continued

– For 2019 plan year files:

  • Monthly submissions will continue through

the June submission (July payment cycle).

  • Quarterly submissions will begin September

2020 and continue through the end of 2021.

  • Yearly submissions will continue after the

quarterly submission period ends for up to five additional years.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Restatement Timeline, continued

  • The State-Based Marketplace Inbound (SBMI) submission

window is the 1st through the 10th of each month.

  • The freeze period each month is the 11th through the
  • 15th. CMS requires SBE files prior to the 11th. The SBE

may send files during the freeze period, but this timeframe should only be used in extenuating circumstances.

  • Because restated changes for prior years are not as

numerous, SBEs may send a prior-year file before the 1st

  • f each month. For example, a 2018 file may be sent

between the 16th and the last day of the month.

– If the SBE plans to send any file outside of the 1st through 10th please send email to CMS at sbmenrollment@cms.hhs.gov

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

SBMR Schema Update

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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SBMR Schema Changes for SBEs

  • To better represent the multiple file level errors and warnings

reported on the SBMR, a minor schema change is required which will remove the current File Error node limitation of allowing only one error or warning per SBMI File Info node.

  • SBEs consuming the SBMR for processing will need to update

the SBMR XML Schema Definition (XSD):

Old Schema: New Schema:

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Go-Live Date

  • 6/26/2020 Go-Live date – Update SBMR schema to

allow for multiple FileError nodes within a single SBMIFileInfo node

– No files processed in July should be delayed

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Disputes Updates

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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New Prior Year Advance Cost Sharing Reduction (CSR)* Rejections

  • Background
  • CMS collects data on and calculates advance CSR amounts for

verification purposes for all plan years.

  • CMS stops reporting advance CSR adjustments to issuers at the

end of each program year (for instance December 2020 for 2020 advance CSR adjustments, December 2019 for 2019 advance CSR adjustments).

  • Only current year Preliminary Payment Reports (PPRs) report the

policy-level advance CSR payments calculated by the Policy-Based Payment (PBP) system, along with a program-level manual adjustment that reverses those payments for the current year.

  • Advance CSR adjustments are not shown as a line item on the PPR

for prior years.

* REMINDER: CMS stopped making CSR payments in October 2017 due to lack of a valid appropriation. See Memo from Eric Hargan, Acting HHS Secretary, to Seema Verma, CMS Administrator, dated Oct.11, 2017 https://www.hhs.gov/sites/default/files/csr-payment-memo.pdf.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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New Prior Year CSR Rejections

  • Change Summary
  • Beginning in early 2020

– All prior-year (PY) CSR-only amount disputes will be rejected with a new disposition code. – When issuers submit prior year disputes for CSR along with other amounts in dispute (such as APTC amount) a new informational only detail code will be assigned for the CSR portion. Non-CSR values will be processed normally.

  • Current year CSR amount disputes will continue to process

as normal according to our established business rules.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Prior Year CSR-Only Processing

Description of Dispute

  • An issuer submits a payment dispute for prior year coverage period CSR
  • nly.
  • CSR is the only value in dispute.
  • The disputed coverage period is for a prior year of coverage.
  • The dispute is received on January 1 of the current year or later.

Issuer Guidance

  • New SR10 Disposition Code
  • Dispute Not Supported by PPR – Prior Year
  • New SPY1401 Detail Code
  • The issuer is disputing the CSR Amount only for a prior year. ER&R cannot

process CSR disputes for prior years. Please refer to https://www.cms.gov/CCIIO/Resources/Regulations-and- Guidance/index.html for guidance related to CSR.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Other Prior Year CSR Processing

Description of Dispute

  • An issuer submits a payment dispute for prior year coverage period in which the CSR amount

and one or more other values (advance premium tax credit (APTC) amount , for example) are in dispute.

  • CSR is one of the values in dispute.
  • The disputed coverage period is for a prior year of coverage.
  • The dispute is received on January 1 of the current year or later.

Issuer Guidance

  • New Informational Detail Code SPY1406
  • Informational – The issuer is disputing the CSR Amount for a prior year. ER&R cannot

process CSR disputes for prior years. Please refer to https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/index.html for guidance related to CSR. This informational code does not impact processing of other values in dispute.

  • No disposition code is associated with an informational detail code. These disputes are

assigned a detail and disposition code combination as determined by the other non-CSR values in the dispute.

  • This informational detail code is applied to the case to inform the issuer that prior year CSR

was part of the dispute.

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Updated Code List

SBE Disposition and Detail Code List

  • The new disposition and detail codes updated on the SBE Issuer

Information page on zONE:

– https://zone.cms.gov/wiki/sbm-issuer-information – https://zone.cms.gov/document/sbm-disputes-disposition-and-detail-code-list

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Production Payment Cycle Calendar

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Production Payment Cycle Calendar

Key:

Milestone Completed

PROD Cycle Milestones March Payment Cycle April Payment Cycle May Payment Cycle SBE Submission Window 2/1 - 2/10 3/1 - 3/10 4/1 - 4/10 CMS Freeze Period 2/11 - 2/15 3/11 - 3/15 4/11 - 4/15 1A Manual Workbook Submission 2/18 - 2/19 3/18 - 3/19 4/20 - 4/21 Transmit EPS Extracts to SBEs & Issuers 2/24 NLT 3/20 NLT 4/20 Generation and review of 1A/PLR vs SBM EPS Comparison Analysis Report* 2/24 3/24 4/24 SBE Dispute Disposition Report (DDR) sent to SBEs 3/3 4/3 5/5 Transmit 820 PPR to SBEs & Issuers NLT 3/15 NLT 4/15 NLT 5/15 Treasury Funds Transmittal 3/20 4/22 5/20 Transmit HIX 820 to Issuers 3/31 4/30 5/29

*If applicable

PROD Cycle Milestones March - May 2020

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

Reference Documents

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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SBE Reference Documents

  • SBE zONE page: https://zone.cms.gov/community/exchange-community
  • Examples of documentation available:

― ICD: https://zone.cms.gov/document/state-internal-control-document-icd ― SBE PBP Transition Guide: https://zone.cms.gov/document/sbe-issuer-transition- guide ― Payment Disputes Technical Reference Guide https://zone.cms.gov/document/sbe-payment-disputes-technical-reference-guide ― Enrollment and Payment Files Chart: https://zone.cms.gov/document/caltid- doc155988_sbm-policy-based-payment-pbp-files-chart ― PBP Transition FAQ: https://zone.cms.gov/document/sbe-faqs-pbp-transition ― CSR Operations FAQ: https://zone.cms.gov/document/csr-operations-faq ― Temporary Manual Adjustment Scenarios: https://zone.cms.gov/document/temporary-manual-adjustments-scenarios

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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SBE Issuer Reference Documents

  • SBE Issuer Information page: https://zone.cms.gov/wiki/sbm-

issuer-information

  • Examples of documentation available:

– SBE Issuer Interface Control Document (ICD) – SBE PBP Transition Guides – SBE Issuer PBP FAQs – SBE Payment Disputes Technical Reference Guide – Issuer Dispute Form – SBE Disputes Disposition and Detail Code List (UPDATED) – Previous Issuer Meeting Presentation Slides – CMS HIX820 Companion Guide

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INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW: This information has not been publicly disclosed and may be privileged and

  • confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the
  • information. Unauthorized disclosure may result in prosecution to the full extent of the law.

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Q&A