HCR provides a plan management integration contract allowing individuals to shop for and enroll in Medicaid, CHIP and Qualified Health Plans as part of the application process through integration with a plan management vendor of the customer's choice.
The starting point for the integration is in the calculation of the maximum tax credit available to a citizen/family that is necessary in determination for Insurance Assistance. The tax credit calculation requires the appropriate cost to use for the benchmark plan for this coverage family to be known. In order to do that, the system passes high-level information about the people in the coverage family, their ages and where they live into a web service to be provided by the plan management vendor. In case the enrollment is being assisted by a Navigator, the assister information is also passed on to the plan management system. This returns a monthly premium for the benchmark plan (the second-lowest cost silver plan available in the exchange) along with the cost of essential health benefit as an amount as well as a percentage of the benchmark plan premium. If there is no plan management system in place, default values of $150 per adult and $75 per child are used in the calculation of the benchmark plan.
Once eligibility and entitlement have been determined, citizens have the option to enroll in different types of plans depending on their eligibility. Enrollment options such as the enrollment group household members and the primary member of the insurance plan are captured before passing the information to the plan management system.
An iFrame is used to display the plan management pages. In order to load the plan management pages, an enrollmentID is passed via the plan management URL, which the plan management system then uses to call a Cúram web service which returns information on each of the people involved in the enrollment and the assistance they are eligible for, for example, to return the maximum tax credit available the household.
The plan selection process differs depending on the programs that the individual and their household has been found eligible for. Medicaid generally has no monthly costs associated with it and as a result there is no need to capture payment details. There may also be no need to select from a large number of plans if the State limits the plans available through Medicaid; in this way the enrollment process is simplified. CHIP plans do have a monthly cost associated with them. An individual seeking CHIP coverage must consider the monthly premium for coverage and the annual co-payment limit when choosing a plan. As such, CHIP enrollment requires additional information including payment details to be captured. Insurance Assistance plans also have premiums that must be paid so that household members can be covered and cost-sharing reductions that affect the annual costs an individual may be expected to pay. The QHP premium for plans selected is also adjusted for essential health benefits/additional benefits. Payment details are captured during Insurance Assistance plan enrollment, and this is further complicated by the premium credits - as they are issued in advance, applicants can decide to forego the entire amount of tax credit and use only a portion of this in helping pay plan premiums. Upon completing enrollment, IBM Cúram maintains the household contribution thereby ensuring the QHP premium is covered (by a combination of tax credits and household contribution). Any subsequent household enrollments can use an adjusted APTC amount; ensuring they can never use more than they have been determined eligible for. If a household has multiple enrollments, and does not use all of their maximum APTC; they have the ability to revisit an enrollment and update the amount they have apportioned to ensure they use all of their APTC; alternatively they can continue without using all of their credit. This is a likely scenario when the individual knows that the financial situation is likely to change. An increase in household income will result in a lower actual tax credit being issued, and if they have used an amount higher than this then they are obliged to pay back the excess as part of reconciliation.
Following completion of enrollment in a plan, the plan management system re-directs the iFrame to a URL provided by Cúram which returns the individual to the results page, which is updated based on the enrollment details. In order to get these enrollment details, a web service provided by the plan management system is called via the enrollmentID. Plan enrollment details are then returned, for example, the plan name, premium, tax credit used, or deductible associated with the plan.