In March of 2020, I got an opportunity with Centene to work on the next generation member enrollment platform that they were building in house from scratch. The vision was to build a platform that can enroll members of all line of businesses that Centene was involved, which included Health Insurance Exchanges (HIX/ACA), Medicare and Medicaid. HIX was selected to be the first line of business that was to be onboarded into the new platform. I was hired as the lead business analyst for the project and was entrusted with the responsibility to work with the Product Owners to come up with the necessary processes, flow diagrams and user stories for the development team to start with the development of the platform as soon as possible.
This opportunity was a great experience for me to learn about the rules for processing enrollment of ACA members. Centene was involved primarily in the individual health insurance market and this platform was to support only that portion of the exchange and not the small business health insurance. This page details about my experience in building the platform and what I have learnt about the different rules that governs in enrolling individuals in the health plan.
The marketplace is an exchange that is established by the state or the federal government that allows individuals and their family to shop and enroll themselves in a health plan that suits their needs and budget.
The ACA went live on January 1, 2014. The vision of the act was to have each of the individual states to operate their own individual exchanges which will be overseen by the HHS. Many of the states were not ready to operate an health insurance exchange on their own by January 1, 2014. The federal government stood up health insurance exchange called as “Federally Facilitated Marketplace” (FFM) for citizens of states to enroll in health insurance through the exchange until the state developed and became ready to operate their own exchange.
The exchanges that are owned and operated by individual states from which the citizens of the state will be getting insurance are called “State Based Exchanges” (SBE). There may be a period during which FFM and SBE marketplace types are active in a state.
The exchanges that are outside of both FFM and SBE are called as “OFF Exchanges” (OFFX).
Largely, processing enrollment from various marketplace types are same, but they also have some changes in rules to complete processing of the transaction. One example of such rule is to have one or more documentation received and reviewed for an enrollment that is received from OFF Exchange than if the enrollment is received from SBE or FFM.
The enrollment platform was initially built around the rules that are governed by FFM. As of 2020 when the development effort for the platform was started, FFM was still the way most of the states had provided health insurance to their citizens based ACA. Hence the rules and processing steps where laid out for enrolling members from FFM and were tweaked for the changes for each of the state based exchanges and off exchange marketplaces. This section provides some of the key differences between the marketplaces.
The Washington state operated health exchange can send
ADD/CHANGE/REINSTATEMENT transactions where the primary subscriber is not being covered and only the dependents in the transactions are being enrolled.
The ADD/CHANGE/REINSTATEMENT transactions can contain multiple financial amounts that are effective for different dates
The Kentucky state operated health exchange can send
A CHANGE transaction that contains only the dependent who is undergoing the change. These transactions will only contain non-financial changes for the dependent.
The CANCEL transactions will be received with end date that is one day less than the effective date of the enrollment span that is being requested for cancellation. For example if the start of the enrollment span that is being requested for cancellation is 1/1/2023, the date that is received in the transaction as end date is 12/31/2022.
The California state operated health exchange can send
A CHANGE transactions that updates the end date of an enrollment span using CHANGE transaction. This transaction typically only happens for an enrollment span that is already termed and the update is to set the end date prior to the current end date. For example if an enrollment span is already termed as of 7/31/2023, a CHANGE transaction can be received that updates the end date of the enrollment span to a date that is less than 7/31/2023. They should not be sending to a date that is greater than 7/31/2023.
The enrollment transactions are received from FFM and SBE marketplaces in the 834 EDI format. OFF Exchanges do send transactions in proprietary formats. The transactions received in these proprietary formats were converted into 834 EDI before they were processed through the enrollment system.
Once the transaction was received in the system, it was processed through various business rules to identify any issues in the transaction data. The transaction were processed through business rules based on the type of transaction or the state or marketplace type from which the transaction was received. If the transaction passes through all the business rule validations, it will be processed through a workflow that is defined for the transaction type and the account information will be updated based on the transaction data.