Enrollment Date Changes
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 before 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 Plan
•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 Circumstance
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 to review in the Tier 1 case notes and the Member Application?
Eligibility
Payment Assistance
Confirms EDI file submission
What are the four Carrier Exception request types ?
Carrier Forward Enrollment Request, Reinstatement Exception Request, Retro-Enrollment Exception Request, Retro-Termination Exception Request
What are two reasons that can lead to the 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 remoted past the 90-day timefr
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, how would the Agent 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 for a Reinstatement Exception Request?
Reinstatement SOP
What are the two types of Admin Closure that can be removed by a Tier 2 Agent?
38 – Voluntary Withdrawal
49 – Death of a member reported by someone other than SSA
S7 – Death by a member reported by SSA
48 – Not a Resident of Massachusetts
Where on HIX would an agent go to change the effective date of a member’s plan (once determined eligible, within the appropriate timeframe etc.)?
Under Retroactive Enrollment (from menu)
If 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
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 the Carrier Information section. 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 member’s status is Terminated, how are they able to make a payment for reinstatement?
They need to pay by Mail or Online
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 to ensure they follow the correct process?
What are the Carrier TATs?
Softheon Service Request and Outbound 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 this 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.