What happens when a plan enrollee seemingly appears out of thin air? Or what can an insurer do if a consumer is concerned with his or her tax credit subsidy? The Center for Consumer Information & Insurance Oversight (CCIIO) answers these questions and many others in its latest batch of exchange plan casework advice.
So what happens if a consumer claims he or she is enrolled with the insurer, but there is no record of information for the consumer? Review any pre-audit files or supplemental files to make sure the 834 file was neither rejected nor received.
If there appears to be no file on hand, the insurer can attempt to contact the consumer. If the insurer can't reach the consumer by phone, the CCIIO recommends reaching out by mail. If for some reason, the insurer cannot find the enrollment via the 834 file, but the consumer did receive confirmation of the enrollment, the insurer will need to contact the XOSC Help Desk.
Minnesota's exchange failure shows just how important it is for the 834 files to reach insurers. Not only did the 834 files never reach insurers, they also contained duplicate transmissions and various errors, FierceHealthPayer previously reported.
The CCIIO also explains what an insurer should do if it appears a consumer should receive a higher tax subsidy than previously stated on their 834 file. Once again, the insurer should review the consumer's pre-audit file to confirm the advanced premium tax credits (APTC) aligns with the amount provided by the Centers for Medicare & Medicaid Services.
If the pre-audit file confirms the premium tax credit on the 834, it's possible the consumer didn't choose the amount of APTC he or she would like to use. A technical issue with the file also could have led to issues with the APTC--the insurer should then open an XOSC Help Desk ticket.
- check out the FAQs (.pdf)