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    Exchange Enrollment Flow Chart

    Uploaded by

    Tim Cavanaugh
    This document outlines the end-to-end enrollment flow for an individual enrolling in a qualified health plan through an Exchange. The flow includes key activities such as the individual submitting an application, determining eligibility, plan selection and payment, processing enrollment information between the Exchange, issuer and CMS, and the individual receiving plan documents and subsidies. It shows the sequence of steps and data being exchanged between the different entities in the enrollment process.

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    Download as PDF, TXT or read online from Scribd

    Exchange Enrollment Flow Chart

    Uploaded by

    Tim Cavanaugh
    4K views1 page
    This document outlines the end-to-end enrollment flow for an individual enrolling in a qualified health plan through an Exchange. The flow includes key activities such as the individual submitting an application, determining eligibility, plan selection and payment, processing enrollment information between the Exchange, issuer and CMS, and the individual receiving plan documents and subsidies. It shows the sequence of steps and data being exchanged between the different entities in the enrollment process.

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    This document outlines the end-to-end enrollment flow for an individual enrolling in a qualified health plan through an Exchange. The flow includes key activities such as the individual submitting an application, determining eligibility, plan selection and payment, processing enrollment information between the Exchange, issuer and CMS, and the individual receiving plan documents and subsidies. It shows the sequence of steps and data being exchanged between the different entities in the enrollment process.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    4K views1 page

    Exchange Enrollment Flow Chart

    Uploaded by

    Tim Cavanaugh
    This document outlines the end-to-end enrollment flow for an individual enrolling in a qualified health plan through an Exchange. The flow includes key activities such as the individual submitting an application, determining eligibility, plan selection and payment, processing enrollment information between the Exchange, issuer and CMS, and the individual receiving plan documents and subsidies. It shows the sequence of steps and data being exchanged between the different entities in the enrollment process.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    Enrollment End-to-End Flow

    End-to-end flow of the key activities related to initial enrollment for an Individual (and household) enrolling in a qualified health plan through the Exchange. The scope of this flow does not include changes in eligibility or terminations after initial enrollment.

    Acronyms: APTC Advanced Premium Tax Credit CSR Cost-Sharing Reduction

    Sequence Flow Showing Data Data [flow condition]

    Annotation
    Average time elapsed=

    Start Event End Event Timed Event Link Event Data Store Parallel Complex

    Supporting Business Service

    Individual Accesses State Exchange

    End Event Individual Makes Payment?

    [Yes, still eligible for enrollment period]

    [No, not eligible for enrollment period]

    SBS-TBD:00 SupportingBusinessServiceName

    Generic Insurance Exchange Blueprint End-to-End Process Flow

    Synopsis

    Notes

    Legend:

    Exclusive

    Inclusive

    Individual

    End Event
    [No] [Yes]

    Still Eligible for Enrollment Period?

    End Event End Event

    01.05 Individual Submits Application

    01.12 Individual Receives Notice (not eligible for Enrollment Period)

    01.20 Individual Compares and Selects Plan and Chooses Amount of APTC and CSR Plan Variation, if Eligible

    01.34 Individual Receives Welcome Packet

    Individual is Enrolled

    01.39 Individual Receives Premium Refund As Necessary

    01.40 Individual Receives Notice of Cancellation

    01.56 Individual Receives CSRs at Point of Service and APTC When Paying Premium

    Issuer Transactional 834 DS 834 Enrollment Transaction

    834 Enrollment Transaction

    01.31 Issuer Processes Payment and Compares Against Enrollment Information 01.35 Issuer Processes 834 Cancellation 01.38 Issuer Refunds Premium Payment As Necessary

    Payment in Full and Timely?


    [Yes]

    [No]

    Issuer

    01.51 Issuer Processes 834 and Sends 999 Acknowledgement


    End Event
    999 Acknowledgement

    01.32 Issuer Sends 834 Confirmation File to Exchange 01.37 Issuer Processes 999 Acknowledgement
    Issuer coordinates the following in parallel sends welcome package to individual and sends an 834 confirmation to the Exchange

    01.55 Issuer Receives APTC and Advance CSR Payments

    01.10 Exchange Receives Application and Determines Eligibility for Coverage Program and APTC/CSR, if Applicable

    01.11 Exchange Sends Notice that Individual is Not Eligible for Enrollment Period

    01.25 Exchange Processes Individual Selection

    01.30 Exchange Redirects Individual to Issuer for Payment

    999 Acknowledgement

    End Event

    Exchange

    Eligible for Enrollment Period?

    [No] [Yes]

    Exchange coordinates the following in parallel redirects the individual to the Issuer and creates the 834

    01.50 Exchange Sends 834 Enrollment Information


    834 Enrollment Transaction

    Exchange coordinates the following in parallel sends the 834 to the Issuer and CMS End Event

    01.33 Exchange Receives 834 and Sends 999 Acknowledgement

    01.36 Exchange Receives and Processes 834 Cancellation and Sends 999 Acknowledgement

    Exchange coordinates in parallel sends 999 to Issuer and sends cancellation of enrollment notice to individual

    01.15 Exchange Provides Tools for Plan Comparison and Selection

    834 Enrollment Transaction

    Exchange Transactional 834 DS

    Exchange Transactional 834 DS

    999 Acknowledgement

    834 Enrollment Transaction

    01.52 CMS Processes 834 and Sends 999 Acknowledgement

    CMS

    834 Enrollment Transaction

    CMS Transactional 834 DS

    APTC / CSR Data

    01.53 Extract/Calculate/Record APTC and Advance CSR Amounts


    APTC and Advance CSR Amounts Federal APTC/ CSR DS

    01.54 Process and Make APTC and Advance CSR Payments

    Enrollment Mega Meeting Flows v15 2012-05-04_Clearance_Enrollment Only

    Enrollment Flow - Restricted Distribution - Draft

    Thursday, May 17, 2012 - Page 1

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