Hra Simple
What does ICHRA stand for and what it is?
Individual Coverage Health Reimbursement Arrangement; It is an arrangement where an employer provides funding to its employees to purchase their own individual/family plans instead of having a traditional group plan.
A member is calling in because her claim was denied for non-covered services. She said she had to have a physical for school to play soccer. What do you advise?
Services for administrative purposes are not covered per the plan COC (Certificate of Coverage).
Routine Physical Examinations – Routine physical examinations, screening procedures, and immunizations necessitated by employment, foreign travel or participation in school athletic programs, recreational camps or retreats, which are not called for by known symptoms, illness or Injury except those which may be specifically listed as covered in this Certificate.
Where can terminations for Off-Exchange SoloCare policies be requested?
Admin Portal (Dave), on the member's policy profile and requesting termination.
A policy changing from On-Exchange to Off-Exchange, would the new policy have to be effectuated or will the member have a Grace Period since there will be no gap in coverage?
The new policy will have to be effectuated since it will be a new policy ID.
A member is calling in asking why their plan changed from 40017-06 to 40017-05 for next year. What do you advise?
What is an eligible expense that can be reimbursed by HRASimple?
Medication, glasses, contacts, paying out of pocket for medical visits (copays).
If a check is showing ACH reversal in Zelis what are the next steps?
Send a wf up to Finance> ACH reversal
Explain the 3 month grace period to a member and how they can come out of grace should they fall behind.
3 months grace period is for members with APTC, it gives the member additional time to make their premium payments. Month 1 benefits are active, months 2 and 3 benefits are not active. Payments are due on the 1st but as long as the full premium payment is made within the month they will not fall in a Grace Period. If payment is not made, the first of the following month will start the grace period and they have to pay the full account balance (current and previous month) to come out of grace. Failure to come out of grace period will result in a termination back to the end of the first month of grace.
What documents are accepted for a newborn to be added to a policy?
Birth confirmation letter from hospital, (birth certificate or social security card can take weeks to be ready).
Member did not make their plan selection during Open Enrollment because they were out of the country for the holidays. It is now Jan 31st and they want to change their plan to something cheaper. What do you advise?
An HRASimple member is calling in because their address is incorrect in the HRASimple Portal. Can they just enroll without changing their information? Who do they contact to update?
No, they should not enroll. They will need to contact their HR representative to have their information updated in the portal. Once updated, then they can enroll since a wrong address can lead to incorrect premium/funding, claim denials, policy cancellation, etc.
A member received an EOB for a denied claim needing an Accident Injury Report/Police Report. She is calling in and asking what she needs to do, what do you advise?
The accident injury report can be taken over the phone, preferably, or it can be submitted on the Accident Injury Report Form.
What are the requirements to qualify for a reinstatement request?
No APTC
Never been termed before or reinstated previously in policy history
Must sign up for AutoPay
Must pay full balance due same day of request
All items must be completed otherwise request will be not processed and policy will not be reinstated.
When must a qualifying member request reinstatement by?
The 15th of the month following their termination.
Example: Termed as of 11/30/2025, reinstatement request must be made by 12/15/2025.
A member lives in Cartersville and wants to purchase a Vitruvian Health Plan, what do you advise?
This plan would not be available in their area as they are limited to residents in Gordon, Murray, Catoosa and Whitfield county.
Can a Vitruvian Health employee's spouse or dependent be covered under their plan if they are offered health insurance elsewhere?
No, they can not due to the VH carveout.
Are land ambulances covered under the No Surprise Act/SBCPA?
No, they are not. Only air/water ambulances are covered.
A current member is on ACH, their banking information has not changed but they are on a new policy ID next year. Will ACH renew into the new year?
No, the member will have to submit a new ACH Form because the policy ID number has changed.
What is a SEP and how can someone qualify?
Examples: Losing group coverage, aging out of parent's policy, moving to a new state, marriage/divorce, acquiring legal status.
Can we cancel passive enrollments for Market Place (TN) members?
Yes.
A HRASimple member is calling in because there is a credit on their account and they would like a refund, however they are Simple Pay. What do you advise?
This policy is paid through Simple Pay meaning the employer is making the payments. Any refunds will be returned to the employer and not the employee.
What is the 4th Quarter Carry Over?
Deductible accumulations from services in Oct 1st - Dec 31st, does not apply to HDHP plans. Only deductible carries over, and does not apply to the out of pocket.
A member with APTC has a monthly premium of $20. The last payment made was $20.00 on 08/10/2025 and PTD is 08/30/2025. On 11/30 the member paid $50. It is now December 23rd and they want to pay the remainder due, what do you advise?
The full balance of $60 (September, October, November) was due by end of November to avoid cancellation; a partial payment would not bring them out of grace and has caused the policy to terminate back to 09/30/2025 9end of GP1).
A SimpleCare member is calling because they have moved and need to update their address. What are next steps?
Advise we can update their billing and mailing address, but their physical must be reported to their HR and they will then send us the correct physical address to update our systems.
Can we cancel passive enrollments (auto renewals) for GAA (GA) members?
No, the member will have to contact GAA or go into their Consumer Portal and cancel 2026 coverage.