Enrollment Date Change
What are the types of enrollment changes a Tier 2 agent can assist with?
Retro-Enrollment, Retro-Termination, Forward-Enrollment, Coverage Void, Complex Retro-Enrollment
If a reinstatement case gets routed to Tier 2 it is important to look at the various details about each status prior to taking an action. Which two items should the agent review?
The status on the plan card and the notes from T1 to determine the member’s request
What are the ways a member can submit a payment?
Online Member Portal, Online Guest Portal, IVR (Payment by Phone if applicable), Mail
List 3 of the 11 carriers.
•Mass General Brigham Health
•Altus Dental
•Blue Cross Blue Shield of Massachusetts
•WellSense
•Delta Dental
•Fallon Health
•Harvard Pilgrim Health Care
•Health New England
•Tufts Health – Direct
•Tufts Health - Premier
•UnitedHealthcare
Where can you find a member’s latest eligibility?
“Latest Eligibility” under Account Dashboard in HIX
What are the allowable reasons for an enrollment date change?
•Hospitalization that prevented a member’s enrollment or payment.
•Death or Adding of a dependent (newborn, adoption, or spouse)
•Natural Disaster
•Technical Error or Health Connector Error
•Loss of ESI after the Health Conner payment/enrollment deadline
•Exceptional Circumstances
Why should a Tier 2 Agent look at a member’s termination notice?
To determine if they are within the 35-day window of their termination notice.
What three key pieces of information must a Tier 2 Agent review in the Tier 1 case notes and the Member Application?
•Confirms Eligibility
•Payment Assistance
•Confirms EDI file submission
What are the four Carrier Exception request types described in this SOP?
Carrier Forward Enrollment Request, Reinstatement Exception Request, Retro-Enrollment Exception Request, Retro-Termination Exception Request
What are two reasons that can lead to loss of subsidies?
• Change in income- outside income range
• Expired income RFI
• Change in immigration status
• MassHealth pending status
• Access to ES or GSI (MEC)
• Tax filing status attestation
• Tax discrepancies
• APTCs not reconciled for previous years
What happens if an enrollment date change request is requested past the 90-day timeframe?
In some exceptional circumstances, enrollment date changes with allowable reasons may be reviewed beyond the 90-day window. These requests should be reviewed by a Tier 2 supervisor for approval to proceed.
"If a member is reinstatement eligible, what tool can the Agent use to determine the amount owed to reinstate their account?"
They would use the Reinstatement Calculator, located in the “Dental Plans” menu under “Reinstate Plan” in Member Portal
If the Enrollment Status on a Plan Card says “Terminated, Reinstatement Eligible” what SOP should Agent proceed to?
Reinstatement SOP
Which SOP would you need to refer to (on top of this one) for a Reinstatement Exception Request?
Reinstatement SOP
What are four types of Admin Closure that can be removed by an Escalations agent?
12- Member no longer in the household
33- Already receiving MH
38 – Voluntary Withdrawal
46-Incancerated 48 – Not a Resident of Massachusetts
49 – Death of a member reported by someone other than SSA
50-Whereabouts Unknown
A5- Duplicate Application
S3- Entered Penal institution
S6- Entered penal institution based on a data match
S7 – Death by a member reported by SSA
Where on HIX would an agent go to change the effective date of a member’s plan (once determined eligible, within appropriate timeframe, etc.)?
Under Retroactive Enrollment (from menu)
If a member is over the 35-day window, what are the allowable reasons to proceed with a reinstatement?
-Hospitalization that prevented a member’s enrollment or payment
-Death or Adding of a dependent (newborn, adoption, or spouse)
-Natural Disaster
-Technical error or Health Connector error
-Loss of ESI after the Health Connector payment/enrollment deadline
- Exceptional Circumstance
What system do you use to confirm an enrollment and EDI?
Softheon Web
Where do you go in Salesforce CRM as the first steps to routing a case to the carrier?
Navigate to the Details tab, go to carrier information. Locate the fields listed below and make the appropriate selection from the picklist, then click Save button.
Carrier:<Carrier Name> picklist
Carrier Request Type: <Carrier Request Type>picklist
“Members that receive _____ must reconcile every year.”
APTCs
How long should an agent set a Task Reminder on Salesforce for once they’ve changed a member’s effective plan date? Why should they be waiting?
1 business day to confirm HIX has updated the requested retro-enrollment date.
If a member’s status is Terminated, how are they able to make a payment for reinstatement?
Member needs to pay by Mail or Online on the Member Portal
What type of request/ticket would an agent submit if the EDI file is not present and what SOP /Job Aid would they refer to ensure they follow the correct process?
Softheon Service Request and Softheon Service Request Job Aid
What are the Carrier TATs?
Carrier’s Turnaround Time to respond to a carrier request is 1 to 5 business days:
-Urgent: 1 business day
-All others: up to 5 business days
What are the triggers for the eligibility SOP?
Applicant was not found to be eligible for MA Connector Plan or Tier 1 agent unable to determine member’s eligibility status due to Admin Closure or other reasons.