Issuers of public exchange plans should use enrollment records and formal appeal processes to clear up any consumer concerns about tax credit subsidy amounts. Issuers of "qualified health plans" (QHPs) should not simply assume a consumer knows what the right subsidy amount is.
Officials at the Center for Consumer Information & Insurance Oversight (CCIIO) -- the U.S. Department of Health and Human Services (HHS) agency in charge of overseeing Patient Protection and Affordable Care Act (PPACA) commercial health insurance programs -- give that answer and others in a new batch of exchange plan casework advice.
CCIIO officials also answer questions about matters such as "plan enrollees" who appear out of nowhere, the definition of "defective enrollment," and the meaning of "ARC referral."
In answers to questions about QHP "advance premium tax credit" problems, officials note that QHP issuers may have access to two sets of enrollment data: 834 transaction files from the exchange, and "pre-audit files." An issuer can use either the 834 file data or the pre-audit file data to solve tax credit questions, officials say. If neither source works, the consumer will have to file a formal appeal through the exchange program appeal system, according to officials.
Similarly, if consumers say they have enrolled in a QHP, and the QHP has no ready information about the consumers, the first step should be for the issuer to look at the 834 files and the pre-audit files. If consumers can show that they have formal confirmation that they enrolled in the QHP, the issuer should talk to the help desk CCIIO runs for the QHP issuers, the CCIIO says.
Officials note that they are using the term "defective enrollment" to refer to a situation in which a consumer has completed a QHP enrollment through an exchange, but the QHP issuer has no record of the enrollment in either an 834 file or a pre-audit file.
In the answer to a question about "ARC referrals," CCIIO officials say they use the term to describe urgent QHP problems that are referred to an "advance resolution center." The call center routes those urgent cases to regional offices.
For insurers, the standard resolution time for ARC referral cases is 72 hours. But "we request that issuers give these infrequent cases their prompt attention," officials say.