policy

While it was anticipated that health plans would see a reduction in Health Insurance Casework System (HICS) cases post open enrollment, this has turned out not to be the case. While some plans have seen slight reductions, health plans continue to see large volumes on HICS cases on a daily basis. Very few to little cases in HICS are related to complaints and instead related to areas of deferred functionality by the FFM. Below we provide an explanation of current category of cases and what can be done to eliminate them.

 Backlogged Cases: Health plans are still seeing backlogged cases being assigned to issuers from April/May. CMS should devote resources to quickly assign all pending cases assigned to issuers so they can be worked and resolved.

 Enrollment Verification: A new trend in HICS cases relates to requests for enrollment verification. We recommend CMS not submit HICS cases every time a consumer calls and asks to confirm their coverage. It is important for the call center to let consumers know that there may be a delay in processing the enrollment and that they should call the issuer directly for updates. This is more consumer-friendly and will result in faster response (as there is typically a long lag between when a case is entered into HICS by the call center and then assigned to the issuer by the caseworker).

 Change in Effective Dates: Most plans report about 50% of their HICS volume is related to changing effective dates (in most cases retroactive effective dates due to SEP), but these also include requests for plan change, adding/drop dependents, change in personal information which should be handled by the FFM and not entered into HICS. Effective date cases will continue until CMS can implement enrollment maintenance functionality via an 834 enrollment which has been deferred until after the 2015 open enrollment.

 Nonpayment: Plans are seeing an increase of cases for customers who’ve termed for nonpayment. Because CMS is not currently processing health plan terminations, CMS is showing these members active on their system and consumers can access their Account and make changes to their plan (e.g., add a newborn). Plans report receiving change in circumstances for members they’ve termed due to non-payment which they do not process as the member is no longer enrolled. Then a plan receives a HICS case. The call center should be aware that this is occurring and first confirm with callers that they haven’t been terminated for non-payment.

 Incorrect Invoices: Plans continue to report HICS cases related to what members believed they saw on HC.gov regarding their APTC and premium. All health plans can do is verify they are billing using the correct premium and the APTC provided on the 834. Most of these cases should not be HICS cases but should be researched by CMS for appropriate action.

 Incomplete Applications: Plans report receiving HICS tickets for consumers who have not yet completed an application. CMS should confirm consumers have completed an application prior to sending HICS cases to issuers.

 Orphans: Plans report receiving HICS tickets for consumers for whom there was no initial 834 sent, and no record of an enrollment as of the last pre-audit file (April 19th). CMS should confirm that an initial 834 transaction has been sent to an issuer, prior to sending a HICS ticket modifying the enrollment.

 Retroactive Effective Dates: Plans report receiving HICS tickets for retroactive effective dates, only to learn that the consumer does not want retroactive coverage, and will not pay for back premiums. Prior to sending a HICS ticket requiring retroactive coverage, CMS should clearly explain to consumers the consequences, including back premiums owed.

Finally, since the shift to enrollment policy calls only for 1 hour every other week, we note there isn’t a good forum for discussing trends in HICS cases, problems with the 834s, etc. and get to resolutions. The weekly enrollment calls are not enough and many times the queues are too long for plans to get their specific questions answered. We recommend CMS establish more regular forums for plans to get their enrollment and HICS questions addressed by CMS subject matter experts.

View full text