Health Exchanges – Enrollment & Eligibility

Health Exchanges – Enrollment & Eligibility

Our 2-in1 Software and Services combo is ready for Health Exchanges as well as Qualified Health Plans (QHPs). We can help our clients to be ready for Oct 1 dead-line via following services:

  1. Enrollment
  2. Eligibility
  3. Credentialing
  4. Premium Billing
  5. Claims
  6. Call Center Support  – Member & Provider Services + Language Support
  7. Advanced Analytics
  8. Actuarial Support
  9. Portal
  10. Consulting & Project Management

Eligibility Solutions (including, but not limited to)

  • Age
  • American Indian/Native American status
  • Citizenship or immigration status
  • Disability or blindness
  • Emergency medical condition
  • Family/household composition
  • Incarceration status
  • Income
  • Parental status
  • Pregnancy
  • Residency/geography

Eligibility Functions (including, but not limited to)

  • Determine eligibility for Exchange participation
  • Determine eligibility for exemption from individual responsibility requirement
  • Determine eligibility for Medicaid, CHIP, other State health care programs, and tax credits and cost-sharing reductions
  • Determine eligibility for specific health benefit plans
  • Accept and process appeals of eligibility and exemption determinations
  • Accept and process information for eligibility and exemption changes (e.g. new employment, change in income, change in family composition, etc.) during the coverage year
  • Accept information regarding eligibility and exemptions from individuals and associated family/household
  • Allow for the possible future determination of eligibility and/or transfer of eligibility information to other systems for public programs including, but not limited to food support, cash assistance, child care assistance, and child support
  • Communicate eligibility and exemption information to individual/family/household and Navigator/broker if appropriate
  • Facilitate referrals and transfers of information to the Medicaid agency for individuals who require more detailed eligibility analysis from other data sources in accordance with privacy and security standards
  • Locate, match, and verify eligibility and exemption information for individuals and family/household
  • Verify relevant information with Federal data source and individual/family/household

Individual Enrollment

Enrollment Functions (including, but not limited to)

  • Allow enrollment and changes in enrollment only during open enrollment and special enrollment periods (e.g. changes in eligibility due to new employment, change in income, change in family composition, etc.)
  • Allow Medicaid enrollees to change enrollment in Medicaid health benefit plans outside of open and special enrollment periods
  • Assess current health benefit plan and specific health care provider (if applicable) enrollment status
  • Communicate enrollment, disenrollment, and termination information with individual/family/household and Navigator/broker if appropriate
  • Notify Federal government of confirmed enrollment, disenrollment, and termination to facilitate appropriate payment of any tax credits and cost-sharing reductions
  • Notify insurer and/or Medicaid/CHIP agency of individual changes in enrollment including renewal, disenrollment, and termination
  • Notify insurer and/or Medicaid/CHIP agency of individual changes in information including contact
  • Only allow enrollment in a health benefit plan for which an individual is eligible
  • Process individual renewals, disenrollment, and terminations
  • Process insurer and/or Medicaid/CHIP agency responses and verifications to enrollment transactions and notifications, including verification that individual is enrolled and that enrollment packages and identification cards have been provided to individual
  • Receive notifications from insurers and/or Medicaid/CHIP agency regarding disenrollment, termination, and other changes in enrollment provided by individual to insurer and/or Medicaid/CHIP agency
  • Send and receive HIPAA-compliant 834 transactions and acknowledgements related to enrollment and disenrollment information

Small Employer Eligibility and Enrollment

Eligibility Criteria (including, but not limited to)

  • Average employee wage
  • Contribution level
  • Employer size
  • Geography/location

Eligibility Functions (including, but not limited to)

  • Accept and process appeals of employer and employee eligibility
  • Accept, update, and verify information regarding employer eligibility
  • Allow for renewal of employer and employee eligibility in next coverage year
  • Collect, update, and verify employee eligibility information from employer and/or employees
  • Communicate eligibility information to employers, employees, and Navigators/brokers as appropriate
  • Determine eligibility for employer Exchange participation
  • Determine employer eligibility for premium tax credits
  • Facilitate employer choice of group health benefit plan or defined contribution
  • Locate, match, and verify eligibility information from other data sources

Enrollment Functions (including, but not limited to)

  • Communicate enrollment, disenrollment, and termination information with employees, employers, and Navigators/brokers as appropriate
  • If employer chooses defined contribution, facilitate establishment of defined contribution levels towards a benchmark individual health benefit plan, communicate contribution information to employees, and connect employees to individual enrollment module
  • Notify Federal government of confirmed enrollment, disenrollment, and termination to facilitate appropriate payment of any tax credits
  • Notify insurer of changes in employer and employee enrollment including renewal, disenrollment, and termination
  • Process employer and employee renewals, disenrollment, and terminations
  • Process insurer responses and verifications to group health benefit plan enrollment transactions and notifications, including verification that employee is enrolled and that enrollment packages and identification cards have been provided to employees
  • Receive notifications from insurers regarding disenrollment, termination, and other changes in enrollment provided to insurer
  • Send and receive HIPAA-compliant 834 transactions and acknowledgements related to enrollment and disenrollment information

Contact Manish Jaiswal @ 646.644.3049 for Health Exchange Software Demo and Services

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425 Washington Blvd., Jersey City,
New Jersey 07302, USA

Phone: +1 201.258.4704 / 201.258.4704
Fax: +1 201.604.3480