DRAFT ONLY - Tribal Sponsorship Program Policies and Procedures Checklist

Transcription

1 American Indian Health Commission for Washington State Improving Indian Health through Tribal-State Collaboration DRAFT ONLY - Tribal Sponsorship Program Policies and Procedures Checklist Under the Patient Protection and Affordable Care Act (ACA) of 2010, Indian tribes, tribal organizations, and urban Indian organizations have the ability to pay Qualified Health Plan premiums on behalf of their tribal members who are enrolled in health plans in the commercial market. RCW (3) directs the Washington Health Benefit Exchange Board to establish policies that permit Indian tribes, tribal organization, and urban Indian organizations to pay premiums on behalf of qualified enrollees. In 2014 to 2015, the American Indian Health Commission (AIHC) conducted a number of focus groups and site visits. Several tribal organizations indicated that development of policies and procedures are essential to implementing and operating an effective tribal sponsorship program. The AIHC developed this checklist based on interviews with several Washington tribes who are currently participating in the Washington Healthplanfinder Sponsorship Program as well as the Washington Health Benefit Exchange (WHBE) sponsorship requirements. This checklist is intended as a guide only. Since all Indian health care providers and tribal governments are unique in structure, tribal sponsorship program policies and procedures will vary greatly from program to program. Sponsorship programs should also stay up-todate with frequent changes in Washington Health Benefit Exchange policies. 1. ELIGIBILITY FOR SPONSORSHIP PROGRAM 1.1 Must be eligible to purchase insurance through the Washington Healthplanfinder 1.2 Must be uninsured with no offer of employer sponsored health care 1.3 Must be eligible for Contract Health Services (including proof of residence) 1.4 Must choose a bronze plan in the Exchange 1.5 Must file federal taxes or be willing to file during the next tax filing season. When married, clients are required to file IRS taxes jointly so as to maximize the amount of federal tax subsidy available to the enrollees in the household. 1.6 Have a certain percentage of their sponsored insurance premium paid for by Advanced Premium Tax Credits 1.7 Exception to 1.6 for high cost/chronic care individuals where it would be cost effective 2. ENROLLEE TERMS OF PARTICIPATION 2.1 Must provide current information about income 2.2 Offered on a first-come, first-served basis 2.3 Update income information

2 2.4 Allow Washington Healthplanfinder to share all enrollee communications with TSP representative or Tribal Assister 2.5 Sponsorship program will not approve discretionary changes to health plans without cause 2.6 Agree to apply full tax credit to premium 2.7 Agree to provide current insurance card upon receipt 2.8 Follow CHS policies including using the X Tribal Health Clinic for primary care and referrals 2.9 Enrollees must report problems/issues with provider access, coverage of services, and/or QHP payments 2.10 Payment of premiums is dependent on authorized tribal funding and compliance with sponsorship terms and conditions 2.11 Timely response to requests for information from tribal staff, state, or federal agencies 2.12 Agree to apply for financial assistance 2.13 Agree to work with sponsorship representative 2.14 Health Assessment (Chronic Health Conditions) 3. EXAMPLE SPONSORSHIP ENROLLMENT PROCESS 3.1 Tribal Assister completes Washington Healthplanfinder Application 3.2 Patient meets eligibility requirements for tribal sponsorship program 3.3 Tribal Assister partners patient with sponsorship representative Commented [HE1]: Forms Commented [HE2]: Lou to incorporate integration of all related departments and information is flowing in both directions. 3.4 Tribal Assister informs patient that he/she is eligible for tribal sponsorship, and he/she will be contacted by sponsorship representative who will explain the tribal sponsorship program 3.5 Tribal Assister prints eligibility screen and handwrites application ID number 3.6 Tribal Assister forwards printout to sponsorship representative 3.7 Sponsorship representative selects a bronze plan and pays the premium 3.8 Washington Healthplanfinder automatically determines the advanced premium tax credit and remaining monthly premium based on the information the patient has entered 3.9 The tribal sponsorship program pays premiums for the new enrollee for the remainder of the policy year. The policy year ends December 31 of each calendar year 3.10 Sponsorship representative prints payment confirmation 3.11 Sponsorship representative contacts patient to inform them of coverage 3.12 Sponsorship representative sends a printed monthly list of sponsored patients and premium information to a tribal accounting department for account reconciliation 3.13 Sponsor representatives may inform individuals which plans are sponsored, but when selecting a plan, the individual must be shown all available plan choices. If an individual choses a plan, tier or carrier that is not included in the sponsor s list of supported plans, the sponsor is not required to sponsor that enrollee s premium payment. DRAFT AIHC Tribal Sponsorship Policies and Procedures Checklist Page 2 of 6

3 4. EXAMPLE SPONSORSHIP ACCOUNTING AND RECORDKEEPING PROCESS 4.1 Sponsorship representative maintains a paper file for each sponsored client with a printout of payment confirmation (or electronic file and stored) 4.2 Sponsorship representative checks paper file and enters payment information for all new sponsored clients in Excel spreadsheet (or data is pulled from electronic records) 4.3 Sponsorship representative contacts Tribal Human Resources to check if clients sponsored in the previous month were hired and obtained employer coverage 4.4 Sponsorship representative pays premium for clients sponsored in the previous month if not hired by the tribe. 4.5 Sponsorship representative prints payment confirmation for clients continued on sponsorship program 4.6 Sponsorship representative forwards requisition form to accounting department 4.7 Sponsorship representative attaches copies of payment confirmations for all clients sponsored in the current month to requisition form 4.8 Sponsorship representative completes accounting requisition forms 5. SPONSORSHIP PROGRAM STAFF ADMINISTRATIVE RESPONSIBILITIES 5.1 Supervision/Administration of sponsorship funds account (identify location, amount, and type of fund). 5.2 Development and implementation of policies and procedures 5.3 Coordination with appropriate departments (social services, etc.) 5.4 On-going financial assessment of sponsorship program 5.5 On-going assessment of program effectiveness in meeting the health needs of community 5.6 Creation of long term improvement plans and objectives for the sponsorship program 5.7 Staff training on sponsorship policies and procedures 5.8 Preparation of operational sponsorship program budget 5.9 Implementation of appropriate financial controls consistent with tribal government/organizational requirements 5.10 Establishment and monitoring of a fair and equitable TSP Appeals process 5.11 Maintenance of records for program planning, evaluation and financial controls 6. CONFLICT OF INTEREST 6.1 As required by the Washington Health Benefit Exchange, if a sponsor organization receives any compensation, directly, or indirectly, from a health insurance issuer for enrolling individuals or employees in insurance coverage, than the Sponsor Organization must disclose that fact to the Exchange and the sponsored individuals at the time of enrollment DRAFT AIHC Tribal Sponsorship Policies and Procedures Checklist Page 3 of 6

4 7. WASHINGTON HEALTHPLANFINDER REGISTRATION PROCESS AND PAYMENT REQUIREMENTS 7.1 Sponsorship Information Requirement. Tribal Sponsorship Program will provide the following information to the Washington Health Benefit Exchange: a) Sponsor contact information b) Condition of program participation c) Name(s) and contact information for authorized sponsor representatives i. Sponsor representatives will be able to authorize payment information on behalf of the sponsors in Healthplanfinder ii. Sponsor representatives will be required to attend a training on managing sponsorship payments in Healthplanfinder, complete security training and complete a background check iii. Tribal assisters may perform sponsor representative functions upon request of the sponsor 7.2 Sponsorship Duration Requirement. Tribal Sponsorship program must commit to sponsoring an enrollee for no less than 6 months. Exceptions to this durational requirement based on unexpected events will be considered on a case-by-case basis (e.g., a Sponsor experiences a sudden financial shortfall). In addition, this duration requirement does not apply if the sponsored individual fails to comply with a Sponsor s rules of participation. 7.3 Entity Accepting Payment Premium payments will be made directly to Healthplanfinder on behalf of the sponsored enrollees. For the initial payment, the Exchange will accept credit cards, debit cards, or e-checks. QHP enrollees may also pay their premium contribution directly to their QHP issuer. Starting in January 2015, sponsorship programs will pay QHP issuers only. 7.4 Payment Period. The initial open enrollment period begins October 1, 2015 and extends through March 31, Enrollment Completed Coverage Effective Date On or before December 23, 2014 January 1, 2015 January 1-23, 2014 February 1, 2015 February 1-23, 2014 March 1, 2015 March 1-23, 2014 April 1, 2015 January 24-31, 2014 February 14-28, 2014 March 24-31, 2014 March 1, 2015 April 1, 2015 May 1, 2015 Initial payment is entered in the Healthplanfinder by the Sponsor Representative. This payment amount will be in the amount of the first month's premium payment. For the initial payment, the Sponsorship Representative will choose a date between 12/1/14 and 12/23/14 when the initial premium payment will be withdrawn. 7.5 Payment Amount. Sponsors must cover the entire premium after any eligible health insurance premium tax credit has been applied. No partial payments are allowed. 7.6 Payment of Household Members. Sponsors must pay the full invoice amount (for all household members seeking coverage through a single application). For example, if three members in a family enroll together in a qualified health plan, the sponsor would need to coverall all enrollees in that household. If a sponsor wants to sponsor one member of a household, this household member will need to complete a separate application seeking coverage only for him/herself. 7.7 Payment Information Required. Sponsor payment information must be entered for each QHP enrollment household or individual that is being sponsored. DRAFT AIHC Tribal Sponsorship Policies and Procedures Checklist Page 4 of 6

5 7.8 Automatic/Recurring Payments A Sponsorship Representative can set up a monthly recurring electronic payment for each sponsored enrollee, so the Sponsor account information only needs to be entered once. Recurring payments are processed each month on the date designated by the Sponsorship Representative. Recurring Payments can only be made using the echeck option (savings or checking account), after the initial payment has been posted. If the recurring payment is set up before 5pm it will take effect the following business day. 7.9 Invoicing and Payment Processing After coverage begins, invoices will be sent to enrollees on the 1st of the month based on their selected communication preference (electronic or postal mail). For example, an invoice will be sent on March 1st for the April 1st-30th coverage period. The individual payment is due by the 23rd of each month (March 23 in this example). The Exchange will generate a receipt when a premium payment is made through the Healthplanfinder. Key Bank will be responsible for processing payments and sending electronic payments to carriers on behalf of covered individuals Late Payment. A sponsored enrollee is responsible to ensure their premium payment was successfully made. If a premium payment is not made on behalf of the sponsored enrollee, delinquency, grace period and termination could occur. In these cases the enrollee must submit premium payment to the Exchange to be removed from delinquency status. o If payment is not received or is invalid due to insufficient funds, the Exchange will send a delinquency notice to the enrollee on the 1st of the month in which a payment for that month was not received. o Households that are eligible to receive Premium Health Insurance Tax Credit are eligible for a 3-month grace period to make payments, beginning on the 1st of the month following a missed payment. 1 If a payment is not made during the 90 day grace period, coverage will terminate effective the last day of the month in the 1 st month s grace period. For example, enrollee fails to make payment by March 23 rd for the coverage period of April 1- April 30. If no payment is made during their April 1 June 30 grace period, coverage will terminate effective April 30. The QHP will be expected to pay claims during the first month of a grace period, but may suspend claims in the second and third months Termination. A Sponsor is always able to remove their sponsorship, by deleting payment information or no longer providing it. The Sponsor is responsible for notifying individuals who are being removed at least 15 business days before the next payment is due Exchange Services/Aggregate Payment For the individual market, the Exchange will aggregate the premium contributions of QHP enrollees, and transmit those aggregated premium payments to the appropriate carrier. The federal government will coordinate payments of the HIPTCs (and cost-sharing reductions) directly with the carriers. The Exchange will by provide staff to manage the sponsorship process, provide training for Sponsor Representatives, and grant access so Representatives can initiate payment on behalf of the sponsored individuals As needed, the Exchange will also generate periodic reports to assist Sponsors with budgeting and future planning. Sponsorship Timeline Calendar Year 2014 Mid-June WAHBE hosts a Premium Sponsorship webinar with potential Sponsors End of June-WAHBE receives notice of intent from interested Sponsors July- Sponsors identifies authorized Sponsorship Representatives; WAHBE hosts a Premium Sponsorship webinar with interested Sponsors Mid-August WAHBE hosts a Premium Sponsorship webinar with interested Sponsors September-Sponsorship Representatives receive training DRAFT AIHC Tribal Sponsorship Policies and Procedures Checklist Page 5 of 6

6 Fall-Sponsors conduct outreach to sponsored individuals October 1-Dec 23 Enroll sponsored individuals for coverage effective January 1, 2014 March 31 Open enrollment ends 8. APPENDIX OF FORMS 8.1 Release of Information 8.2 Tribal Sponsorship Application 8.3 Tribal Sponsorship Termination Letter 8.4 Tribal Sponsorship Requisition Form 8.5 Copy of Council Resolution(s) addressing Tribal Sponsorship 8.6 Description of Washington Healthplanfinder and Advanced Premium Tax Credits 8.7 WAHBE Premium Sponsorship Program Requirements 8.8 HIPTC Agreement of Understanding DRAFT AIHC Tribal Sponsorship Policies and Procedures Checklist Page 6 of 6