December 9, 2019 - FM Payment Processing 2019 Q4
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FM Payment Processing 2019 Q4 Policy-based Payments (PBP): Upper Bound Adjustments, 1095-A Reminder, and Payment Dispute Guidance Updates December 9, 2019 Division of Financial Transfers and Operations (DFTO) 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 regu lations that it is based on. We encourage audience members to refer to the applicable regulations for complete and current information about the requireme nts that apply to them. WWW.REGTAP.INFO
Session Guidelines • This is a 60-minute webinar session • For questions regarding content, submit inquiries to fmcc@cms.hhs.gov • For questions regarding logistics and registration, contact the Registrar at: (800) 257-9520 2 WWW.REGTAP.INFO
Agenda • Policy-based Payments (PBP): Upper Bound Adjustments • 1095-A Reminder • Payment Dispute Guidance 3 WWW.REGTAP.INFO
Temporary Manual Adjustments for FFE and SBE-FP Issuer January and February 2020 Policy-based Payments (PBP): • Historically, advance payments in the January and February monthly payment cycles experience a lag caused by premium collection and reporting of policy effectuations beyond the December 15th cutoff for payment reporting. • Centers for Medicare & Medicaid Services (CMS) will make a temporary manual adjustment (Upper Bound) to the January and February 2020 PBP for Federally-facilitated Exchange (FFE) Issuers and Issuers in State-based Exchanges using the Federal platform (SBE-FP) offering major medical plans. • This adjustment is intended to mitigate the cash flow impact of the transition to 2020 for FFE and SBE-FP Issuers on PBP. • The Upper Bound adjustments will be applicable to only APTC and UF payments and charges and will not apply to CSR which has been discontinued as of October 2017 payment cycle. • Adjustment(s) will show on the Issuers’ Preliminary Payment Report (PPR) and HIX-820s as two separate manual adjustments to APTC and User Fees. • Note: CMS will also be making payment adjustments to some State-based Exchange (SBE) issuers that have transitioned to policy-based payments as established through CMS discussions with each SBE. CMS will notify issuers in each state of planned adjustments for their state. 5 WWW.REGTAP.INFO
Temporary Manual Adjustments for FFE and SBE-FP Issuers (continued) January and February 2020 PBP Upper Bound Adjustment: • CMS will calculate this adjustment using a payment estimate equal to 80 percent of the estimated PBP on effectuated enrollment plus enrollment still in “initial” status (i.e., “Upper Bound”). • If the Issuer’s calculated YTD PBP are less than 80 percent of this amount, CMS will apply an adjustment to increase the Issuer’s advance payment, net of FFM user fees, up to the 80 percent threshold. • CMS will not make any downward payment adjustments to Issuers whose total calculated Policy- based Payments equal or are above the 80 percent threshold. • Note: It is currently planned that calendar year 2020 will be the last year that CMS will issue Upper Bound adjustments and therefore the adjustments will not be issued in January and February 2021 or any year thereafter. CMS defines the Payment Upper Bound as the payment that would be due for all non-cancelled enrollment (regardless of effectuation status) 6 WWW.REGTAP.INFO
Temporary Manual Adjustments for FFE and SBE-FP Issuer Transition (continued) Reversing Upper Bound Manual Adjustments: February 2020: • If there was an Upper Bound Adjustment for January 2020, CMS will reverse this temporary manual adjustments in February 2020 payment cycle and recalculate the Upper Bound to see if the year-to-date total Policy-based Payment reached the 80 percent threshold. • If the 80 percent threshold is reached, no other temporary adjustments will be made and Issuer will be paid on system calculated PBP amounts only from this point forward. • If the 80 percent threshold is not reached, one last temporary Upper Bound adjustment will be made for February 2020 payment cycle which will be reversed in March 2020 payment cycle. 7 WWW.REGTAP.INFO
Temporary Manual Adjustments for FFE and SBE-FP Issuer Transition (continued) Reversing Upper Bound Manual Adjustments March 2020: • If there was an Upper Bound Adjustment for February 2020 Payment cycle, CMS will reverse this temporary Upper Bound manual adjustments in March 2020 Payment cycle. This would be the last Upper Bound reversal. All future payments will be made on system calculated PBP amounts only. • All Issuers from this point will be paid based on system calculated PBP amounts. • Adjustment(s) will show on the Issuers’ Preliminary Payment Report (PPR) and HIX-820s as two separate manual adjustments to APTC and User Fees. 8 WWW.REGTAP.INFO
Upper Bound Payment Cycle: 80% Cap Examples: Year to Date APTC Payments: 80% of Upper PBP Capped Total bound PBP APTC Amount < 80 Temporary APTC APTC APTC Scenario APTC % of Capped APTC Upper Adjustment applied Amount Upper Amount Amount Bound Amount? to Payment (YTD) Bound Paid YTD (YTD) Amount 1 $90.00 $110.00 $88.00 No $0.00 $90.00 2 $70.00 $110.00 $88.00 Yes $18.00 $88.00 3 $40.00 $100.00 $80.00 Yes $40.00 $80.00 4 $65.00 $80.00 $64.00 No $0.00 $65.00 Note: The same calculation will apply to User Fees 9 WWW.REGTAP.INFO
Upper Bound Example Upper Bound Example 10 WWW.REGTAP.INFO
Exchange Payment Type Codes for FFE/SBE-FP Policy-based Payments Year Exchange Coverage Period Coverage Period Issuer Type Process Transaction Type Payment Type Start Date End Date Retroactive FFE and SBE-FP APTCADJ, CSRADJ, 2019 PBP Adjustments – APTC, 2019MMDD 2019MMDD Issuers UFADJ CSR, UF UFRMADJ, FFE/SBE-FP UFR MA, Manual APTCMADJ, 2019 APTC, CSR, UF, UFR 2019MMDD 2019MMDD adjustments workbooks CSRMADJ, UFMADJ Prospective and APTC, CSR, UF FFE and SBE-FP Retroactive 2020 PBP 2020MMDD 2020MMDD Issuers Adjustments – APTC, APTCADJ, CSR, UF CSRADJ, UFADJ UFRMADJ, FFE/SBE-FP UFR and MA, Manual APTCMADJ, 2020 January temporary APTC, CSR, UF, UFR 2020MMDD 2020MMDD workbooks CSRMADJ, Manual adjustments UFMADJ 11 WWW.REGTAP.INFO
References • 2019 Manual Adjustments Guidance: https://www.regtap.info/reg_librarye.php?i=2731 • Enrollment, Payment Processing, and Invoicing New Issuer Training (FFEs): https://www.regtap.info/reg_librarye.php?i=3084 • Early Year Payment Adjustment Issuer Slides: https://zone.cms.gov/document/november-9th-2018-issuer-meeting- slides • Financial Management Overview for 2020 SBE Issuers: https://www.regtap.info/reg_librarye.php?i=3083 12 WWW.REGTAP.INFO
1095- A Reminder 13 WWW.REGTAP.INFO
1095-A Reminder • This is a friendly reminder to make sure your 2019 enrollment information is accurate and up-to- date for the upcoming release of 1095-As to your members – Check all remaining “initial” enrollments on your RCNI file • Submit effectuation or cancellations to CMS through enrollment reconciliation or the dispute process. • Check all remaining “I” and “F” flags on your RCNO file • Make updates to your enrollment system or submit disputes or reconcile with CMS to make corrections as necessary – Submit timely grace period expiration terminations to CMS through inbound 834s or enrollment recon – Submit disputes to CMS to correct any remaining enrollment reconciliation issues by 12/23/19 – Submit Enrollment Reconciliation updates in the December RCNI Errors in 2019 enrollment that remain in January will lead to 1095-A errors, consumer disputes, research costs for CMS and issuers, and a poor customer experience for your members 14 WWW.REGTAP.INFO
Payment Dispute Guidance 15 WWW.REGTAP.INFO
Payment Dispute Guidance I. Payment Dispute Reminders II. Enrollment Dispute Form v12 Deployment III. New Detail Codes: 1. PD942 IV. Modified Detail Codes: 1. PD533 2. PD645 & PY645 V. Reminder: AM Approval of Prior Year Disputes VI. Common Errors: Avoiding FV9 VII. zONE Publications 16 WWW.REGTAP.INFO
Payment Dispute Reminders • Please submit your Payment Disputes! – Submit a Payment Dispute for any record perceived to be incorrect. – Issuers may submit large volumes of Payment Disputes without impeding processing time. • Payment Dispute Support – As a reminder, the FMCC team is the primary point of contact for resolving rejected Payment Disputes. Please reach out to the FMCC team at FMCC@cms.hhs.gov with any questions regarding rejected Payment Disputes. 17 WWW.REGTAP.INFO
Reminder: AM Approval for Prior Year Disputes • Issuers must get approval from their Account Manager (AM) before submitting prior year disputes. • AM approval is not required for HICS Direct Disputes or prior year disputes that contain supporting HICS cases. • Issuers must email a completed Issuer Prior Year Approval Request Form to their AM to request prior year dispute approval. The form is available on zONE: – https://zone.cms.gov/system/files/documents/issuerprioryearapprovalrequest.xlsx • Upon receiving a confirmation email from ER&R, issuers should submit the approved prior year disputes before the due date. • ER&R will return prior year disputes submitted after the AM-approved deadline with detail code FV110. • ER&R will return prior year disputes that did not receive AM approval and do not contain a supporting HICS case with detail code FV111. 18 WWW.REGTAP.INFO
Enrollment Dispute Form v12 Deployment • ER&R began accepting Enrollment Dispute Form v12 on Tuesday, November 12th. • CMS published the final v12 production file (enrollmentdisputeformv12.xlsx) to zONE. – https://zone.cms.gov/document/enrollment-resolution-and-reconciliation • ER&R will return any Enrollment Disputes submitted using v11 with instructions to resubmit using v12. • Issuers who wish to use add-ins when submitting disputes must download and install the new Enrollment Dispute v12 Add-ins from zONE. – The instructions for installing and using the add-ins are on the PSV Format tab of the Enrollment Dispute Form; however, issuers should contact their IT department before installing the add-ins. – Prior to installing the new version, issuers should uninstall any previous version. 19 WWW.REGTAP.INFO
Detail Code for Disputes Where an FFM Payment Was Made • New Detail Code: PD942 • PD942 applies to a dispute for a missing payment that initially received an In Process disposition code and subsequent manual analysis found a payment was made by the FFM. NOTE: PD942 is similar to PD511, which also indicates that a payment was found in the PPR for the “missing payment” disputed policy. The two are different in that PD511 is resolved through automated business rules, whereas PD942 required additional analysis, likely because multiple payments were made on multiple segments within the policy. – PD942 Issuer Action: Review the PPR or HIX 820 reports for payments on the disputed policy. If the payments are incorrect, submit a dispute with the FFM values and appropriate HICS Case ID for APTC or Total Premium disputes. • PD942 results in disposition code C6: Timing Issue – PPR Record Found. 20 WWW.REGTAP.INFO
Modified Detail Code for Policies to Be Cancelled by the FFM • PD533 applies to disputes where the issuer is reporting an unexpected payment on a policy that will be cancelled by the FFM in the upcoming cycle. • PD533 modifications are as follows: – Previously, PD533 only applied to disputes involving uneven or unexpected RCNO records with record-level flags of F, G, W, or L. – Going forward, PD533 will also be used for disputes involving uneven RCNO records with record-level flags of V as well as instances where the issuer reported an Issuer Premium Paid Indicator of C for the disputed record. • PD533 results in disposition code I1: In Process. 21 WWW.REGTAP.INFO
Modified Detail Codes for Unexpected Payments on Effectuated Policies • PD645 and PY645 apply when the dispute is for an unexpected payment and the issuer did not report the record as cancelled. • PD645 and PY645 modifications are as follows: – Previously, PD645 and PY645 applied to disputes where the issuer had not sent in an RCNI record for the policy. – Going forward, PD645 and PY645 will apply to all disputes of unexpected payments where the RCNI did not contain a record or where the record is present but does not have an Issuer Initial Premium Paid Indicator of C. • PD645 results in disposition code R6: Dispute Not Supported By RCNI. • PY645 results in disposition code R10: Dispute Not Supported By RCNI – Prior Year. • As a result of these changes, ER&R deactivated detail codes PD542, PY542, PD621, and PY621. 22 WWW.REGTAP.INFO
Common Errors: Avoiding FV9 • ER&R has noticed an increase in the number of Payment Disputes receiving the FV9 detail code, which results in the disposition code R3: FFM Fields on Form do not Match PPR/HIX 820. • Disputes are assigned the FV9 detail code when an issuer disputes an unexpected or incorrect payment but the PPR/HIX 820 report does not contain a record of a payment that matches the disputed data. • Most disputes that receive the FV9 detail code have the wrong Payment Cycle Month on the dispute. • In order to avoid the FV9 detail code, issuers must ensure that the Payment Cycle Month on the dispute matches the month in the Policy- Based Transition Payment Month field of the PPR file and not the month the coverage took place. 23 WWW.REGTAP.INFO
Common Errors: Avoiding FV9 (Cont.) • Here is an example of a dispute that will receive an FV9 detail code: • Other fields that can result in FV9 detail codes include: – HIOS ID – Exchange Assigned Policy ID – Coverage Period Start Date (FFM) – Coverage Period End Date (FFM) 24 WWW.REGTAP.INFO
zONE Publications • Disposition and Detail Code List v24 is available on zONE. This version includes the new detail codes that were presented in the previous slides. • The Combined Enrollment and Payment TRG v8.0 contains updates for AM approvals on prior year disputes. • UIR TRG v7.0 and UIR Master Guidance contain details regarding the UIRY function code. • Issuers can review the updated documentation on CMS zONE: – https://zone.cms.gov/document/enrollment-resolution-and-reconciliation 25 WWW.REGTAP.INFO
Questions? To submit or withdraw questions by phone: • Dial *# (star-pound) on your phone’s keypad to ask a question. • Dial *# (star-pound) on your phone’s keypad to withdraw your question. To submit questions by webinar: • Type your question in the text box under the ‘Q&A’ tab. 26 WWW.REGTAP.INFO
APPENDIX WWW.REGTAP.INFO
ACCESS TO CMSzONE Step 1: CMS Secure Portal Registration Process: (Pre-requisite to CMSzONE Access) 1. Register for access at CMS Secure Portal Here: https://portal.cms.gov/ 2. Click on “New User Registration” under CMS Secure Portal 3. Complete information and create User ID and Password Step 2: CMS zONE Access Request: 1. Log in at https://portal.cms.gov/ with your CMS Secure Portal credentials 2. Click on “Request Access Now” 3. Scroll down the page to find “zONE” and click on “Request Access” 4. Complete information and wait for confirmation email 5. Once confirmation email is received, user may log -in to CMSzONE Step 3: CMSzONE Private issuer Community Access: (After being granted CMS zONE access) 1. Log into zONE; click on the Communities tab 2. Click Browse Private Communities 3. Click Issuer Community – Private 4. Click Join Community 5. Provide explanation of why you need access to this community; Include: · name and contact information · issuer POC contacts · specific work for issuer (i.e. fill out QHP templates, processing 834’s, etc.) User Access Quick Guide A copy of the comprehensive User Access Quick Guide is posted on zONE @: https://zone.cms.gov/document/zone-end-user-access-quick-guide (pre-log in required to access zONE links) 28 WWW.REGTAP.INFO
Reference Documents • SBE Issuer Information page (all of the following documents are available on this page): https://zone.cms.gov/wiki/sbm-Issuer-information • SBE Issuer ICD: https://zone.cms.gov/document/sbe-Issuer-icd • SBE PBP Transition Guide: https://zone.cms.gov/document/sbe-Issuer- transition-guide • SBE Issuer PBP FAQ: https://zone.cms.gov/document/policy-based- payments-transition-faq • CSR Operations FAQ: https://zone.cms.gov/document/csr-operations-faq • Monthly Batch Cycle Calendars: https://zone.cms.gov/wiki/sbm-Issuer- information 29 WWW.REGTAP.INFO
Reference Documents Continued • Issuer Dispute Form: https://zone.cms.gov/document/Issuer-dispute-form • Enrollment and Payment Files Chart: https://zone.cms.gov/document/sbm- pbp-files-chart • Managed File Transfers (MFT) Thin Client Help Guide: https://www.regtap.info/reg_librarye.php?i=1778 • CMS Individual Market HIX 820 X12 Scenarios: https://zone.cms.gov/document/cms-individual-market-hix-820-x12- scenarios • Payee Information Report (Function code: PNR) for Payee: https://zone.cms.gov/document/payee-information-report • Temporary Manual Adjustment Scenarios: https://zone.cms.gov/document/temporary-manual-adjustments-scenarios 30 WWW.REGTAP.INFO
Sample Intent to Refer Letter Initial Invoice FINAL REQUEST Re: Program : Advance Payments of the Premium Tax Credit Entity ID : A123456 Invoice Number : A1111A011001001 Invoice Date : 13-JUL-2018 Invoice Amount : $101.99 Interest Charge : $10.01 Administrative Fee : $15.00 Total Amount Due : $127.00 • The Program, Entity ID, Invoice Number, Invoice Date, and Invoice Amount are the same fields transmitted in the Initial Invoice. • Interest Charge – The interest charge is the interest owed and is calculated based on the original invoice amount, number of months outstanding, and the current interest rate • Interest is assessed on a monthly basis • Administrative Fee – The administrative fee is a fixed fee of $15 that is applied only once when an invoice is over 30 days old • Total Amount Due – The total amount due is the sum of the invoice amount, interest charge, and administrative fee 31 WWW.REGTAP.INFO
Contacting FMCC When contacting the FMCC, issuers should include their five (5)-digit Health Insurance Oversight System (HIOS) ID and their seven (7)-character Payee ID, along with their request. 32 WWW.REGTAP.INFO
Acronyms Acronym Definition DSH/HUB Data Services Hub EFT Electronic File Transfer/Electronic FundsTransfer EPS Enrollment and Payment System FFE Federally-facilitated Exchange FMCC Financial Management Coordination Center HIOS Health Insurance Oversight System HIX Health Insurance Exchange PBP Policy-based Payments PNR Payee Information Report PPR Preliminary Payment Report PSV Pipe-separated value SBE State-based Exchange SHOP Small Business Health Options Program 33 WWW.REGTAP.INFO
Resources WWW.REGTAP.INFO
Resources Inbound 834 Process (CMS zOne Dedicated Page): • Production Overview, Technical Specifications, Reporting • For further assistance, please contact: Inbound834@bah.com Enrollment Reconciliation: • For further assistance, please contact:recon_Issuer_support@bah.com Dispute submission: • Resources • Payment dispute form: https://zone.cms.gov/system/files/documents/ft_ppr_820_dispute_form_002.xls x • Combined Enrollment and Payment Dispute Technical Reference Guide: https://www.regtap.info/reg_librarye.php?i=2664. • For further assistance, please contact the ER&R Support Center at errsupportcenter@cognosante.com or (855) 591-7113 35 WWW.REGTAP.INFO
Combined Enrollment and Payment Dispute Technical Reference Guide • The Combined Enrollment and Payment Dispute Technical Reference Guide (TRG) provides guidelines for issuers regarding how to submit payment disputes. • Issuers can access the TRG at the following links: • https://www.regtap.info/reg_librarye.php?i=2664 • https://zone.cms.gov/system/files/documents/combined _enrollment_and_payment_disputes_trg_v3.2.docx 36 WWW.REGTAP.INFO
Resources Resource Resource Link Centers for Medicare & Medicaid Services http://www.cms.gov/ (CMS) U.S. Department of Health & Human Services http://www.hhs.gov/ (HHS) The Center for Consumer Information & http://www.cms.gov/cciio Insurance Oversight (CCIIO) web page Consumer website on Health Reform http://www.healthcare.gov/ ASC X12Store http://store.x12.org/store/health- insurance-exchanges Registration for Technical Assistance Portal https://www.REGTAP.info (REGTAP) - presentations, FAQs CMS zONE – reference material https://zone.cms.gov 37 WWW.REGTAP.INFO
Inquiry Tracking and Management System (ITMS) Stakeholders can submit inquiries to ITMS at https://www.REGTAP.info Select “Submit an Inquiry” or to view submitted inquiries select ‘My Inquiries’ from My Dashboard. 38 WWW.REGTAP.INFO
FAQ Database on REGTAP The FAQ Database allows users to search FAQs by FAQ ID, Keyword/Phrase, Program Area, Primary and Secondary Categories, Benefit Year, Retired and Current FAQs, and Publish Date. FAQ Database is available at https://www.regtap.info/ 39 WWW.REGTAP.INFO
Closing Remarks WWW.REGTAP.INFO
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