a service of the Maryland Health Benefit Exchange Third-Party Administrator Reference Manual

Transcription

1 a service of the Maryland Health Benefit Exchange Third-Party Administrator Reference Manual Release 1.0 July 2013

2 Table of Contents Section 1: General Information 1 Manual Purpose Maryland Health Connection...5 Section 2: Small Business Health Options Program (SHOP) 3 Small Business Health Options Program (SHOP)...8 Section 3: Third-Party Administrator (TPA) Certification Program 4 TPA Certification Program Background SHOP TPA Certification: Program Options TPA Technical Integration TPA Certification Eligibility Criteria The 4-Step Certification Process Maryland Health Benefit Exchange (MHBE) Review Criteria...30 Appendices Appendix A List of MHBE Authorized Carriers...33 Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

3 SECTION 1 GENERAL INFORMATION Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

4 Chapter 2: Maryland s State-Based Exchange: Maryland Health Connection CHAPTER 1 Manual Purpose The Maryland Health Benefit Exchange (MHBE) will establish a Small Business Health Options Program (SHOP). The operational and technological framework for the SHOP allows Third Party Benefit Administrators (TPAs) to partner with the MHBE for several important business functions, including: supporting employers and employees as they compare and select Qualified Health Plans (QHPs); administering enrollment and eligibility changes; premium aggregation; billing; and collections. Licensed TPAs can apply to become certified by the MHBE to perform these functions using either the MHBE-hosted system or the TPAs own systems. This manual contains information on the policies and interim procedures that have been adopted by the MHBE Board of Trustees to guide TPAs in applying for and maintaining certification with the MHBE. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

5 CHAPTER 2 Maryland Health Connection: State-Based Health Insurance Marketplace On March 23, 2010, the Patient Protection and Affordable Care Act (ACA) was signed into law by President Obama. A key provision of the law requires all states to participate in health insurance exchanges beginning January 1, A health insurance exchange is a marketplace to help individuals, families and small businesses shop for coverage through easy comparison of available plan options based on price, benefits and services, and quality. MARYLAND S MODEL: A STATE- BASED MARKETPLACE Each state has the flexibility to determine the design and operating model that will work best for its citizens. An exchange may be operated by the state government, the federal government, or through services coordinated in a state-federal government partnership. In a letter dated October 9, 2012, to U.S. Secretary of Health Sebelius, Governor Martin O Malley formally declared the State of Maryland s intention to establish a state-based health insurance marketplace as a requirement for certification in January In December 2012, the State of Maryland received conditional approval to operate Maryland Health Connection. As a state-based marketplace, Maryland is responsible for the development and operation of all core functions including: Consumer support for coverage decisions Eligibility determinations for individuals Enrollment in QHPs Approval of participating carriers Certification of plans Operation of a SHOP In 2011, as the MHBE Board of Trustees worked to develop policies for operating the core functions, a set of seven principles was adopted to ensure the health care needs of Maryland individuals, families, employers and employees would be met. These principles continue to guide the policy development and implementation decisions for Maryland Health Connection: 1. ACCESSIBILITY Maryland Health Connection should reduce the number of Marylanders without health insurance and improve access for all Marylanders. 2. AFFORDABILITY The affordability of coverage, within the exchange and within the state, is essential to improving Maryland s health care system and economy. 3. SUSTAINABILITY Maryland Health Connection will need to be sustainable in order to succeed in the long run. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

6 Chapter 2: Maryland s State-Based Exchange: Maryland Health Connection 4. STABILITY Maryland Health Connection should promote solutions that respect existing strengths of our state s health care system and promote stability within the Exchange. 5. HEALTH EQUITY Maryland Health Connection should work to address longstanding, unjust disparities in health access and health outcomes in Maryland. 6. FLEXIBILITY Maryland Health Connection should be nimble and flexible in responding to the quickly changing insurance market, health care delivery system, and general economic conditions in Maryland, while being sensitive and responsive to consumer demands. 7. TRANSPARENCY Maryland Health Connection is accountable to the public, and its activities should be transparent, its services easily available, and its information easily understandable by the populations it assists. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

7 SECTION 2 SMALL BUSINESS HEALTH OPTIONS PROGRAM (SHOP) Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

8 CHAPTER 3 The Small Business Health Options Program (SHOP) The SHOP is a program of Maryland Health Connection, a new online marketplace that enables small businesses and their employees to compare and shop for QHPs. The benefits of the SHOP for employers and employees are summarized below. Employers Can: Offer employees choices of insurance companies and QHPs Continue to use their insurance producers Use online tools with their insurance producers to help predict costs Qualify for tax credits Use simple, online administration tools for adding or dropping coverage, and handling billing and payments Access support by phone and online Employees Can: Choose health plans that suit their individual needs Make meaningful comparisons between QHPs using online tools Enroll online Manage their accounts online Through legislation ratified in April 2011, the Maryland General Assembly created the Maryland Health Benefit Exchange and gave it the mission to implement key parts of the ACA including a no wrong door eligibility and enrollment platform and the establishment of the individual exchange, which allows consumers to qualify for federal cost-share assistance and to enroll into qualified health plans (QHPs) that provide essential health benefits, among other requirements. The Center for Consumer Information and Insurance Oversight (CCIIO) requires that certified state exchanges establish SHOPs that allow small businesses to purchase qualified health plans (QHPs) and to receive certain tax incentives depending on the size of the group and the average income of its workers. SHOPs must also allow employees to select from all the QHPs within levels of plans. QHPs must adhere to a specified cost-sharing requirement or actuarial value to be considered a bronze, silver, gold, or platinum plan. In the 2012 legislative session, the Maryland General Assembly enacted the SHOP eligibility requirement that allows small businesses with a maximum of 50 employees to purchase from the SHOP in the initial years. In 2016, the maximum employer size for SHOP eligibility will be 100 employees as required by the ACA. Since 2012, the MHBE Board of Trustees has adopted several additional policies pertaining to the SHOP that give guidance on a range of topics. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

9 Chapter 3: The Small Business Health Options Program (SHOP) COUNTING EMPLOYEES In the State of Maryland, a small business with 2 to 50 employees is qualified to purchase health insurance for its employees through the SHOP. In December 2012, the MHBE Board of Trustees adopted the Internal Revenue Service (IRS) counting methodology, also called the full-time equivalent (FTE) aggregation, for determining the number of employees in a small business. When this method is applied, the average weekly hours of part-time workers are used to determine the aggregate number of full-time employees. However, it is up to the employer to determine whether or not health insurance benefits are extended to parttime employees as well as full-time employees. Examples: Employer Profile # of Employees Disposition An accounting company with 120 full-time employees (30+ hours per week) A paving company with 20 full-time employees and 20 part-time employees that average 15 hours per week A restaurant with 10 full-time employees and 60 parttime employees that average 15 hours a week A retailer with 20 full-time employees, 50 part-time employees and 50 seasonal employees (Nov.-Jan.) 120 Large group/not SHOP eligible 30 Small group/shop eligible 40 Small group/shop eligible 45 Small group/shop eligible COVERAGE MODEL Small businesses that purchase coverage through the SHOP will have the option of choosing between two coverage models for their employees: Employer Choice Small employers may select one holding company and allow employees to choose from among the plans offered by that company across all metal levels. Employee Choice The Maryland Health Benefit Exchange Act of 2012 establishes the employee choice model for the SHOP. Employee choice means that a small employer selects a metal level and then employees may choose any plan within that level. RATING METHODOLOGY Individual rating for every member, with only variation being age and tobacco use. EMPLOYER CONTRIBUTION An employer may choose to contribute toward employees premium payments by using one of two methods: Percent contribution In this method, the employer pays a set percentage of employees health insurance premiums based on a reference plan. Employers can set separate percentages for employees and dependents. Employees pay the same amount In this method, the employer uses a reference plan to determine a set amount that employees will pay toward their total monthly premium based on designated employee tiers. Each employee within a tier pays the same monthly dollar amount. The employer pays the balance of the premiums. In order to determine the employee percentage contribution, a composite rate is derived for each tier. Employers are not required to contribute toward their employees premiums, but they will not be eligible for tax credits unless they contribute at least 50 percent of the total premium cost. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

10 Chapter 3: The Small Business Health Options Program (SHOP) MINIMUM PARTICIPATION RATE Employers must have a minimum participation rate of 75 percent of employees in order to purchase insurance in the SHOP. This policy, adopted in December 2012, is meant to maintain current minimum participation rates in the small group market in Maryland. Employees covered under other group health plans or enrolled in public programs, will not be included in the minimum participation calculation. For employers opting for the employee choice benefit model, the group must have 75 percent of its employees participating when aggregated across all carriers. SHOP OPEN ENROLLMENT SHOP enrollment will begin on January 1, The first effective date for groups purchasing in the SHOP exchange will be March 1, There is no open enrollment for small businesses. Therefore, once the SHOP opens, it will remain open throughout the year. Both the employer choice and employee choice models will be available on January 1, MARYLAND BUSINESSES WITH OUT-OF-STATE EMPLOYEES When some employees live or work outof-state, an eligble employer may: Choose a carrier with a national network so that employees in any state can select their plans through Maryland Health Connection and still be covered where they live or work. Become qualified to purchase on the SHOP in both the state where they are headquartered as well as the state where their employees work. This is possible if the business meets requirements in both states and both states allow for dual certification. This allows out-ofstate employees to select a plan through that state s SHOP, so that they will have a network of providers where they live and work. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

11 SECTION 3 THIRD-PARTY ADMINISTRATOR (TPA) CERTIFICATION PROGRAM Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

12 CHAPTER 4 TPA Program Background The MHBE recognizes the key role TPAs play in the sale, enrollment, and financial administration of small group health plans. The electronic dataprocessing capabilities of TPAs in Maryland are sophisticated, and health insurance carriers, producers and employers in the state rely on TPAs to perform many administrative functions. Additionally, while Maryland Health Connection offers a robust selection of medical and dental plans, TPAs in Maryland typically provide benefit administration beyond the scope of the medical and dental coverage, such as life insurance, disability coverage, and even payroll management. After considerable analysis and engagement with stakeholders including a request for information (RFI) issued to market stakeholders in March 2012, the MHBE concluded that the best approach for building Maryland s SHOP is a hybrid where the MHBE develops its own SHOP technical capabilities and allows a certification program for TPAs to provide similar services for the SHOP. The MHBE will partner with TPAs to provide value-added services to the MHBE, insurance companies, and employers in connecting to the SHOP exchange. The advantages to this hybrid approach are numerous. With SHOP, Maryland achieves the following advantages: Allows straightforward testing and review by the federal government Enables a consistent plan selection and enrollment experience for individuals shopping for coverage through SHOP or Maryland Health Connection Allows multiple benefit administrators to perform employer services on the same Maryland Health Connection software Additionally, the TPA certification program to supplement SHOP has the following advantages: Leverages the existing employer/insurance agent relationships and experiences of multiple full-service TPAs Creates marketplace choices for employers to shop for health coverage Allows TPAs to continue to provide onestop shop services to employers for all their benefit administration needs (e.g. payroll services, life and disability insurance, etc.) Reduces the number of staff that the MHBE will need to manage billing, collections, payments, and financial reconciliations By leveraging the experience and technology of Maryland s TPAs together with the power of Maryland Health Connection, the MHBE expects to achieve the following objectives: Meet the requirements of the ACA as it pertains to SHOP set-up and management (45 CFR 155 Subpart H) Encourage small businesses to purchase coverage through SHOP while giving them a choice of administrative processes to meet their needs Provide minimum disruption to current small group health insurance market while promoting innovation Leverage the knowledge and expertise of current market players for key technical and business functions Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

13 Chapter 4: TPA Program Background Minimize duplicative development effort among Maryland stakeholders through the development of common service components that can be leveraged equitably by the broadest number of market players Allow producers to continue using familiar TPA systems as they advise small businesses on diverse insurance options and other benefits Provide a SHOP solution that satisfies the needs of employers, employees, and health plans in an efficient and consumer-friendly manner Ensure that operations are transparent and managed with effective oversight whereby the MHBE and the State of Maryland meet all their management oversight and fiduciary responsibilities to the state s small employer community Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

14 CHAPTER 5 SHOP TPA Certification: Program Options When an employer creates an account in the SHOP, he or she will be able to designate a producer of record if desired. The producer of record will have the option of selecting from a list of certified SHOP TPAs to perform administrative functions associated with the employer s eligibility, enrollment and premium billing. The producer is not required to select a TPA. To become certified, TPAs may choose to apply for one of three programs that allow the use of Maryland Health Connection, the TPA s own systems or a combination of these systems to perform administrative functions for employers. TPAs will offer services based on their certification in one of three programs: Program 1: Alternate Online Marketplace and Back-Office Services Certifies TPAs to establish their own online shopping websites where employees can compare and enroll in medical and dental plans per the parameters specified by the employers. Additionally, Program 1 participants will perform all the back-office administrative services included in Program 2 below. Program 2: SHOP Back-Office Administrative Services Certifies TPAs to use their systems for billing, and collections, employer enrollment changes, and payments to carriers. Program 3: SHOP Online Administrative Services Provider Certifies TPAs to use Maryland Health Connection systems to support employers and employees in both plan set-up and selection as well as backoffice administrative services such as billing and collections support and managing eligibility and group roster changes. Program 1: Alternate Online Marketplace for SHOP QHPs Program Description TPAs will be certified by the MHBE to provide alternate online marketplaces for employers, producers, and employees to compare, select, and purchase SHOP QHPs. Organizations interested in obtaining Program 1 certification must be able to demonstrate the capability to build and maintain an online retail shopping experience that meets the applicable standards and conditions established by the ACA and the MHBE. Specifically, Program 1 organizations must have the ability to support both the employer choice and employee choice plan set-up and selection models. Additionally, companies interested in providing an alternate online marketplace should indicate how their approach will further the goals and objectives of the SHOP through innovative processes and techniques and ability to drive enrollment into QHPs. The alternate online marketplace concept is not currently envisioned as a stand-alone program and will include all the functional and technical requirements included in Program 2: SHOP Back-Office Administrative Services. Accordingly, Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

15 Chapter 5: SHOP TPA Certification: Program Options Program 1 participants will adhere to all terms and conditions including performance metrics, service levels, and required technology and functions for Program 2 (described separately). Program 1 is a separate entity that requires endto-end system functionality. By contrast, Program 2 is a subset of Program 1 for back-office billing and enrollment system functionality only. Eligibility Requirements Due to ACA requirements and concerns about conflicts of interest, health insurance carriers, their parent companies, and subsidiaries are prohibited from being certified to perform Program 1 services. Aside from this prohibition, all organizations that can demonstrate the required functional and technical capabilities, and that are approved by the Maryland Insurance Administration (MIA) as registered Third-Party Administrators, may apply for certification. Due to limitations on how many organizations with which the MHBE can simultaneously build interfaces and perform joint testing, the MHBE may need to work with organizations to determine a reasonable timeline for the certification process. Program Application Companies seeking certification to provide an alternate online marketplace must have an authorized company representative submit an application to the MHBE committing their organization to meeting all business and technical requirements of Program 1 as well as to the terms and conditions of the Program 1 business agreement if their company should receive certification. There is no application fee for the program. The MHBE will determine whether to accept the company s application based on the strength of the company s capabilities, experience and expected innovations and contributions to the enhancing and increasing participation in the Maryland SHOP Exchange. The estimated time from application submission through to decision from the MHBE as to whether an organization can move to the certification process will be 30 business days. The MHBE reserves the right to accept an organization s application for certification while deferring the applicant s certification process by up to a year depending on the number of qualified applicants going through the certification process. Business Agreement Companies seeking certification to participate in Program 1 must have an authorized company official sign a business agreement that commits them to meeting all business and technical requirements of the program as well as all applicable terms and conditions. This will include committing the resources required for development of capabilities, certification testing, and ongoing operations. At minimum, companies seeking Program 1 certification must designate a project manager during the development and certification testing phase who will be the liaison with the MHBE for the overall implementation of key data exchanges and interfaces. Functional Requirements Certified organizations for Program 1 will have the flexibility to design and implement web systems that connect employers and employees to SHOP QHPs in a manner that promotes innovation, ease of use, transparency, and overall SHOP enrollment. There will be, however, minimum functional requirements derived from federal guidelines that participant organizations must meet. These functional requirements include the following. A formal business requirements document for certification will be provided to Program 1 applicants: SHOP QHP Plan Presentment Certified Program 1 organizations will be required to intake certified SHOP QHPs from the MHBE and be able to display them in the manner prescribed by federal regulations on their websites. The list of QHP attributes that must be displayed by the alternate online marketplace website includes but is not limited to the following: Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

16 Chapter 5: SHOP TPA Certification: Program Options Issuer administrative information (e.g. company name, location, etc.) QHP name Coverage type (e.g. medical, dental, vision) Plan type (e.g. HMO, PPO, etc.) Benefit information Cost-share information (deductible, copay, and coinsurance) Plan rates Actuarial value/metal level (platinum, gold, silver, bronze) Summary of benefits and coverage Plan quality information Provider network information The alternate online marketplace website must allow employers and employees to browse applicable plan options using multiple userdefined search criteria and data filters. Only plans that conform to the employers plan setup selections should be displayed. Further, the website must allow employers and employees to compare options side-by-side. The MHBE will provide data elements listed above to certified organizations through a standard data file. Qualified Employer Information Management All SHOP employers must be qualified to purchase SHOP QHPs on the MHBE web portal. Once an employer is deemed qualified to purchase SHOP QHPs (based on demographic information such as size and principal office location) and designates the Program 1 participant as the shopping experience of choice, the MHBE will send this employer information to the Program 1 organization electronically. The Program 1 participant must have the ability to intake qualified employer information and allow employers or their agents (e.g. brokers) to review this information and provide additional details as required. The list of qualified employer attributes that must be displayed for review and update on the alternate online marketplace website includes but is not limited to the following: Employer administrative information (e.g. company name, location, etc.) Producer of record Employer group size Open enrollment period start and finish Employer plan year effective date Employer census Employee name Employee income Employee age Employee dependents Employee dependents ages Plan set-up information Employer or employee choice model Metal level (if employee choice) Carrier (if employer choice) Defined contribution amount Inclusion of dental and vision plans Employer Price Quotes Based on the employer plan set-up options and census, the alternate online marketplace website must be able to present price quotes to employers or their designated agents. Employers should be able to make changes to their plan set-up, contributions, employee rosters, and plan selections to determine the impact to their overall monthly contribution and the premium costs to their employees. Employee Plan Comparison and Premium Calculator The alternate online marketplace website must allow employees to use the system to review their plan options (as constrained by employer set-up choices) so that they can determine which options work best for them. Employees must be able to perform side by side comparisons for plan choices and drill down to detailed QHP information as provided by the MHBE. The premium displayed to employees should include the portion that is contributed by their employers as well as what they will be responsible for paying on their own (via payroll deduction). Cost information also should take into consideration dependent coverage. Employee Plan Selection and Enrollment The alternate online website must allow employees to select the QHP of their choice within the allowable options as determined by their employer. Additionally, employees must be allowed to select other coverage options, including dental. The alternate online marketplace website Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

17 Chapter 5: SHOP TPA Certification: Program Options should clearly display the open enrollment period dates for employees and send out notifications as open enrollment comes to an end. Employer Enrollment Tracking and Reporting The alternate online marketplace website must allow employers and their designated agents to review the status of employee QHP elections. Once the open enrollment period closes, employers must be allowed to review their employee enrollments as well as their final monthly cost. Maryland Health Connection will inform the employer if one of their employees takes coverage through that option. Reports to the MHBE Program 1 participants must submit monthly reports to the MHBE detailing their activity and the volume of transactions handled by their websites. Specifically, the MHBE will require monthly reports on the following, for example: Number of groups that are using the services of their website to purchase SHOP QHPs Number of employees that are using the services of the Program 1 participant to enroll in SHOP QHPs Percentage of groups that complete the process for purchasing QHPs Percentage of employees that complete the process for enrolling into SHOP QHPs Technical Requirements Technical requirements for alternate online marketplace systems fall into the following categories. These requirements are derived from federal architectural and security guidelines for SHOP technology and must be met for alternate online marketplace certification. General System Requirements They include but are not limited to the same as those the MHBE has established for its information technology (IT) vendor, based on federal and state IT requirements. The requirements are contained in the Centers for Medicare and Medicaid Services (CMS) Reference Architecture Supplement. To obtain a copy, see: Data-and-Systems/CMS-Information- Technology/Technical-Reference- Architecture-Standards/index.html. Data Exchange Requirements Alternate online marketplace providers must be able to exchange QHP, employer, and enrollment data with the MHBE according to the technical standards established by the MHBE. The MHBE will specify the data file formats, allowable transmission methods, and timing of the required data exchanges. Examples of data exchanges will include: QHP data from the MHBE to the Program 1 participant Employer plan set-up and cost data from the Program 1 participant to the MHBE Employee enrollment data from the Program 1 participant to the MHBE Additionally, the Program 1 participant will send group files and enrollment files to carriers in a timely and accurate manner. The MHBE may consider serving as a clearinghouse for group and enrollment files between Program 1 participants and carriers for the first year if warranted by circumstances. Security and Privacy Requirements: Program 1 participants must be able to demonstrate compliance with all relevant state and federal security and privacy requirements. They include but are not limited to the same as those the MHBE has established for its IT vendor based on federal and state IT requirements. These include those contained in HIPAA, FISMA, FIMS, NIST, IRS circular 70, etc. The requirements are contained in the (CMS) Reference Architecture Supplement. Operational Requirements Certified alternate online marketplace providers must establish the appropriate operational policies and functions for customer service and reporting to the MHBE. Additionally, Program 1 participants must meet minimum service levels in order to maintain their certifications. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

18 Chapter 5: SHOP TPA Certification: Program Options Employer Data Management Program 1 participants must ensure that employer and employee information is captured accurately and submitted to the MHBE in a timely manner. Employers will use the alternate online marketplace system to complete plan set-up information including the entry of employee census information and plan selections. Customer Service Program 1 participants must establish a toll-free customer service line for employers, producers, and employees to talk to customer service representatives when they need assistance with the online website. Additionally, the Program 1 participant must be able to transfer calls to the MHBE or carriers as required. The MHBE will provide the TPA with policies and procedures for call handling and transfers. Further, Program 1 participants must ensure that customer service representatives receive MHBE training on SHOP. Performance Reporting Requirements Program 1 participants must track key performance statistics, which shall be reported to the MHBE on a monthly basis. These reports shall include but are not limited to the following: Web statistics reports including number of registrations, and unique visits Technical performance reports including website uptime, number of data exchanges with the MHBE, number of data exchanges with errors, and number of data exchanges that required manual intervention to resolve Call center statistic reports including number of calls, average speed to answer, first call resolution Service Level Agreements Program 1 participants are expected to provide a high level of service and online capabilities to employers, employees, and their agents. As such they must agree to meet service levels identified in the business agreement. If Program 1 participants do not meet these service levels, the MHBE may withhold fees, suspend or de-certify the participant. Testing and Certification Processes Prospective Program 1 participants must be able to demonstrate compliance with MHBE functional and business requirements in order to become certified as an alternate online marketplace provider. A requirements checklist will be developed as part of the certification process. For each functional and technical requirement on the checklist, the prospective Program 1 participant will provide the following to the MHBE for inspection: Attestation that the inspection item is complete, has been tested, and is ready for production operations The design specification used to develop the functional/technical requirement The test case used to validate the functional/technical requirement The test results for the validated functional/technical requirement Additionally, the MHBE will conduct independent testing of the Program 1 participant s online system to determine compliance with all requirements. Upon confirmation that the alternate online marketplace system has met all requirements, the MHBE will issue a two-year certification to the Program 1 participant. De-certification In the event that a certified Program 1 participant cannot meet the contractual terms of their business agreement, the MHBE may decide to suspend or revoke the Program 1 participant s certification. In cases where the Program 1 participant is in violation with federal and state requirements, the MHBE may require the participant to shut down their website until issues are resolved. In the event that the Program 1 participant cannot meet the required service levels specified in the business agreement, the MHBE may put the Program 1 participant on notice that certification will be revoked unless the appropriate remediation steps are taken. Upon notice that service levels are not being met, the Program 1 participant will have 60 days to develop and implement a corrective action Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

19 Chapter 5: SHOP TPA Certification: Program Options plan. The results of that plan will be reviewed by the MHBE to determine if performance measures show the desired improvement. At this time, if the service levels are still not being met, the MHBE may choose to de-certify the Program 1 participant, and the organization will not be permitted to continue operations on behalf of the MHBE. In the case where only the Program 1 participant s online marketplace is deficient, the MHBE may discuss opportunities for the Program 1 participant to convert to a Program 2 participant. Program 2: SHOP Back-Office Administrative Systems Program Description Qualified companies will be certified by the MHBE to provide back-office financial management services for SHOP QHP administration. Organizations interested in obtaining a Program 2 certification must be able to demonstrate the capability to build and maintain a mature premium billing and collections system that meets the applicable standards and conditions established by the ACA and the MHBE. Specifically, Program 2 participants must have the ability to support both the employer choice and employee choice plan billing and collections models. Additionally, companies interested in providing back-office administrative systems and services should indicate how their approach will provide outstanding service to employers and carriers in managing complete financial and reconciliation transactions. Eligibility Requirements Due to ACA requirements and concerns about conflicts of interest, health insurance carriers and their parent companies or subsidiaries are prohibited from being certified as Program 2 participants for SHOP QHPs. Aside from this prohibition, all organizations that can demonstrate the required functional and technical capabilities, and that are approved by the Maryland Insurance Administration (MIA) as registered TPAs, may apply for certification. All Program 2 participants must be appointed by all SHOP carriers as designated TPAs prior to receiving Program 2 certification. Due to limitations on how many organizations with which the MHBE can simultaneously build interfaces and perform joint testing, the MHBE may need to work with organizations to determine a reasonable timeline for the certification process. Program Application Companies seeking certification to provide back-office administrative services must have an authorized company representative submit an application to the MHBE committing the organization to meeting all business and technical requirements of Program 2, as well as the applicable terms and conditions of the business agreement if their company should receive Program 2 certification. There is no application fee for the program. The MHBE will determine whether to accept the company s application based on the strength of the company s capabilities, experience and expected innovations and contributions to the enhancing the experience of SHOP market participants. The estimated time from application submission through to decision from the MHBE as to whether an organization can move to the certification process will be 30 days. The MHBE reserves the right to accept an organization s application for Program 2 certification while deferring the applicant s certification process by up to one year depending on the number of qualified applicants going through the certification process. Business Agreement Companies seeking certification to provide back-office administrative systems must have an authorized company official sign a business agreement that commits to meeting all business and technical requirements of Program 2 as well as all applicable terms and conditions of the program. This will include committing the resources required for development of capabilities, certification testing, and ongoing operations. At a minimum, companies seeking Program 2 certification must designate Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

20 Chapter 5: SHOP TPA Certification: Program Options a project manager during the development and certification testing phases who will be the liaison with the MHBE for the overall implementation of key data exchanges and interfaces. Functional Requirements Program 2 participants will have the flexibility to design and implement integrated connection to the SHOP, Maryland Health Connection where employers and employees will be able to shop for QHPs in a manner that promotes efficient operations, ease of use, transparency, and overall high quality operations. However, there will be minimum functional requirements derived from federal guidelines that Program 2 participants must meet. These functional requirements include the following. A formal business requirements document for certification will be provided to Program 2 applicants: Employer/Employee Information Intake Program 2 participants can be designated by employers as primary benefit administrators. Employer information along with employee rosters and benefit elections are entered in the Maryland Health Connection. The MHBE will send group 834 and 820 files that Program 2 participants must be able to intake, manage, track and monitor changes. The list of employer attributes that must be managed by the Program 2 participants includes but is not limited to the following: Employer administrative information (e.g. company name, location, etc.) Producer of record Employer group size Employer plan year effective dates Plan set-up information Employer or employee choice model Metal level (if employee choice) Carrier (if employer choice) Defined contribution amount Inclusion of dental and vision plans Employer payment type Additionally, the Program 2 participant will need to take in the following employee roster information: Employee information Employee name Employee income Employee age Employee birth date Employee dependents Employee dependent ages and birth dates Employee health, dental, and vision plan elections QHP name Coverage type (e.g. medical, dental, vision) Plan type (e.g. HMO, PPO, etc.) Plan premium Employee contribution amount If the Program 2 participant also provides an alternate online marketplace (Program 1), they will have the information required for initial account installation with carriers. In the event that a Program 2 participant does not perform Program 1 services, this data will be provided to Program 2 participants electronically from the MHBE. Program 1 is a separate entity that requires end-to-end system functionality, versus Program 2 that is a separate entity and a subset of Program 1 for only back-office billing and enrollment system functionality. Carrier Account Installation Program 2 participants will have the responsibility to work with all carriers in supporting group account installation and set-up. Minimally, this will involve being able to take employer/employee benefit elections information from the MHBE and format the information according to the templates that will be provided by the MHBE for group installation. Program 2 participants must be appointed by all carriers offering SHOP QHPs and must have developed the mechanisms for electronic data exchanges with all carriers. Additionally, Program 2 participants will be responsible for ensuring the quality of the account installation process and have trained resources ready to respond to any issues or discrepancies that arise in the account set-up process. Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

21 Chapter 5: SHOP TPA Certification: Program Options Employer/Employee Information Management The MHBE will notify the Program 2 participant of additions, changes, and deletions from employer rosters, and the participant must update the systems accordingly. Alternatively, employers or producers may notify the Program 2 participant directly of additions, changes, and deletions from employer rosters in the Maryland Health Connection. In either case, Maryland Health Connection is the source system of record for the employer groups and will track and monitor employer group changes. In the case of new enrollments, terminations, and allowable changes in circumstances, the Program 2 participant must ensure that information is sent to carriers as near to real time as possible. If the employee requires a new benefit election, the Program 2 participant must direct the employee back to the MHBE SHOP system or to the appropriate alternate online marketplace for the election to be made. Additionally, the Program 2 participant must meet the following requirements: Change of circumstances Per 45 CFR , SHOP exchanges must follow the same rules as individual exchanges for special enrollment periods, which are codified in 45 CFR Program 2 participants must allow coverage changes to be effective on the first day of the next coverage month after the event occurs if notification is received between the 1st and 15th of the previous month. If notification is received the 16th day of the month or after, coverage must begin on the 1st day of the following month. The exception is for newborn babies, where coverage must begin immediately. Terminations The Program 2 participant should allow employers to stop coverage for terminated employees either on the first day of the next plan month or immediately at the employers discretion. Premium Aggregation, Billing, and Collections Program 2 participants must be able to aggregate employee plan selections and employee premium amounts along with employer contributions into a single list bill. Employers must be able to review billing information online or receive a monthly paper bill that includes the following information: Total amount due to the employer Debits and credits from previous months Employee list Employee name Employee tier (individual, individual plus one, family, etc.) Employee medical and dental, QHPs Employer contribution Employee premium responsibility Payment due date Other special notices determined by the MHBE As employers make changes to their rosters in the Maryland Health Connection, the Program 2 participant must be able to adjust the bill appropriately. Additionally, the Program 2 participant must notify the MHBE and the carriers affected by the changes. Program 2 participants must be able to implement the billing and collections cycle specified by the MHBE. Program 2 participants must provide appropriate late notices and termination notices when payments are not received. Key features of this billing cycle include the following: The Program 2 participant must issue the employer bill (or make available online) on the 15th day of the month proceeding the next coverage month. The exception is if the 15th falls on a weekend or a holiday, then the bill must be produced for the employer on the next business day following the 15th. The Program 2 participant must be able to collect and recognize the receipt of employer payment, recording the payment date and amount. Acceptable forms of payments will be determined by the MHBE and will include paper check, cashier s check, money orders, and ACH (auto debit and a customer monthly authorization online pay). Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

22 Chapter 5: SHOP TPA Certification: Program Options Partial payments will trigger non-payment notices and tracking. In the case of a partial payment, the Program 2 participant holds money versus distributing to carriers (when there are multiple carriers involved e.g. employee choice model). The Program 2 participant refunds the money to the employer upon termination. The Program 2 participant must issue the first late notice to the employer via or written notice on the 20th day of the coverage month (e.g. for October 1st coverage, the first late notice is issued on October 20th). The Program 2 participant must issue the final late notice on the last day of the coverage month (e.g. for October 1st coverage, the first late notice is issued on October 31st). The Program 2 participant must issue the termination notice on the 15th day of the subsequent month (e.g. for October 1st coverage, the termination date is November 15th). Carrier Payment Program 2 participants must transfer payments received from employers to carriers on a scheduled basis determined by the MHBE, which will typically be four times a month. Additionally, Program 2 participants must transmit updated employee rosters that carriers can use to reconcile their accounts receivable against those rosters. The format of the employee rosters will be specified by the MHBE (most likely 834s). In order for a Program 2 participant to operate successfully in the employee choice model, the Program 2 participant must have appointments and the capability to perform electronic data exchanges with all SHOP QHP carriers. Reports to the MHBE Program 2 participants must submit monthly reports to the MHBE detailing their activity and the volume of transactions handled by their websites and/ or operations units. Specifically, the MHBE will require monthly reports on the following: Number of groups that are using the services of the Program 2 participant to administer SHOP QHPs Premiums billed by the Program 2 participant to qualified SHOP employers including the following information for each employer group: Total bill amount Bill issue date Payment received date Outstanding balances Number of qualified changes (additions, changes, deletions) processed List of employers with late payments and record of notices from the Program 2 participant to employers List of employers who have exceeded the threshold for termination Technical Requirements Technical requirements for back-office administrative systems fall into the following categories. These requirements are derived from federal architectural and security guidelines for SHOP technology and must be met for Program 2 participant certification. General System Requirements The requirements are the same as those the MHBE has established for its IT vendor-based on federal and state IT requirements, as outlined in CMS Reference Architecture Supplement. Data Exchange Requirements Program 2 participants must be able to exchange enrollment and financial data with the MHBE and carriers according to the technical standards established by the MHBE. The MHBE will specify the data file formats, allowable transmission methods, and timing of the required data exchanges. Examples of data exchanges will include: Employer data from the MHBE to the Program 2 participant Employee enrollment data from the MHBE to the Program 2 participant Enrollment updates and changes from the Program 2 participant to the carriers Payment transfers from employers to the Program 2 participant Payment transfers from the Program 2 participant to carriers Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July

23 Chapter 5: SHOP TPA Certification: Program Options Payment and collections data from the Program 2 participant to the MHBE Late payment and terminations data from the Program 2 participant to the MHBE Security and Privacy Requirements Program 2 participants must be able to demonstrate compliance with all relevant state and federal security and privacy requirements. These include but are not limited to the following: The requirements are the same those the MHBE has established for its IT vendor based on federal and state IT requirements. These include those contained in HIPAA, FISMA, FIMS, NIST, IRS circular 70, etc. Requirements can be found in the CMS Reference Architecture Supplement. Operational Requirements Certified Program 2 participants must establish the appropriate operational capabilities for transaction processing, billing, customer service, and reporting to the MHBE. Additionally, the Program 2 participants must meet minimum service levels in order to maintain certifications and to collect their full fee amounts. Employer/Employee Data Management Program 2 participants must ensure that employer and employee information is captured accurately and submitted to carriers and the MHBE in a timely manner. Program 2 participants must develop relationships with employers and their agents in order to ensure that changes to employer and employee status are communicated to the Program 2 participant. Billing and Collection Services Program 2 participants must ensure that they can produce accurate and timely bills to employers according to the functional requirements described above. Further, Program 2 participants must be able to track and manage overpayments, underpayments, arrears, late notices, and terminations as required, communicating employer payment status to employers, carriers, and the MHBE. Customer Service Program 2 participants must establish a toll-free customer service line for employers, producers, and employees to talk to a customer service representative when they need assistance with enrollment change and billing and collections issues. Additionally, the Program 2 participant must be able to transfer calls to the MHBE or carriers as required. The MHBE will provide the Program 2 participant with policies and procedures for call handling and transfers. Further, the Program 2 participant must ensure that customer service representatives receive MHBE training on the SHOP. Performance Reporting Requirements Program 2 participants must track key performance statistics, which shall be reported to the MHBE on a monthly basis. These reports shall include but are not limited to the following: Number of groups that are using the services of the Program 2 participant to administer SHOP QHPs Premiums billed and collected by the Program 2 participant to qualified SHOP employers including the following information for each employer group: Total bill amount Bill issue date Number of late notices Payment received date Outstanding balances Premium payments to carriers including: Carrier name Employer group ID Payment owed Payment made Outstanding balance Number of qualified changes (additions, changes, deletions) processed by the Program 2 participant Service Level Agreements Program 2 participants are expected to provide a high level of service and online capabilities to employers, employees, and their agents. As such, Program 2 participant must agree to meet service levels identified in the business Maryland Health Benefit Exchange Third-Party Administator Reference Manual Release 1.0 July