1. Conditional Eligibility Verification
February 2018

2. Topics Conditional Eligibility Conditional Eligibility Categories
What
Why
How
When
Conditional Eligibility Categories
How to upload documentation
Navigator/Assister tips
Conditional Eligibility Verification Team
Customer Scenarios
Questions
November 7, 2018

3. Conditional Eligibility
What?
Federal regulations require all state-based exchanges and the federal marketplace to verify eligibility for all customers
“Conditional Eligibility” is a status a Qualified health plan/Qualified dental plan customer may receive if they have submitted an application and the federal hub was unable to verify a part of their application
Conditional means a customer can still get enrolled, but has a deadline (or designated time frame) to provide documentation that resolves the inconsistencies that don’t match with the Federal Hub
Why?
The conditional status could be with customer income, incarceration status, social security number, citizenship/lawful presence, or other insurance eligibility (Medicare/VA/Tricare/etc.)
Conditional eligibility can happen to any individual customer who is enrolling through Washington Healthplanfinder, applying for a Qualified health/dental plan, or simply making a change to an existing Qualified health/dental plan application
November 7, 2018

4. Conditional Eligibility
When?
Customers must upload verification documents within 95 days of being found “conditionally eligible”
Customers receive 2 Washington Healthplanfinder correspondences:
Eligibility Decision or Updated Eligibility Decision
Important Deadline to Submit Information – this correspondence tells the customer everything they need to know related to their Conditional Eligibility status
Customers account will display a warning message on their Account Home which directs them to the Document Center to view what additional documentation is requested and for who
November 7, 2018

5. Conditional Eligibility
How?
Customers can upload verification documents several ways
Upload a 5MB or smaller file to their Document Center from their Washington Healthplanfinder account
Upload a document via WAPlanfinder to their Document Center
Submit document via fax (360)
Submit document via US Mail –
Washington Healthplanfinder
PO Box 946
Olympia, WA 98501
If customers submit documents via fax or US Mail include customer name and application ID# on the document
Do not mail original copies – they will not be returned to customers
If the deadline is less than 2 weeks away do not mail documents. Using an online method will guarantee the documents arrive on time
Customer instructions on How to Submit Documents
November 7, 2018

6. Conditional Eligibility Categories
Proof of Income or Deductions
Proof of Lawful Presence
Proof of Citizenship
Proof of No Other Coverage
Proof of Non-Incarceration
Proof of Social Security Number
Proof of Tribal Membership
Customer instructions on How to Submit Documents
November 7, 2018

7. Conditional Eligibility – Income or Deductions
What proves Income/Deductions?
Customers will need to provide proof of income for each household member on their application
Some example documents that prove income include:
Payroll statements for the last 60 days
The first 2 pages of most recent tax return
Self-employment Profit and Loss document for the past 3 months
Receipts showing recent payment of reported deductions
Washington Healthplanfinder verifies income with the federal hub. If the customer’s attested income in Washington Healthplanfinder differs from the federal hub by 25% or more, the customer will be conditional for income and have to submit documents.
CEV team will not update customer income without customer consent – this means they will call the customer when reviewing income documentation if it needs to be updated.
With this category a customer may lose or see a change in tax credits if they do not provide proof of income that reconciles the inconsistency. We won't/may not cancel their converge. Other categories could result in a loss of coverage.
Customer instructions on How to Submit Documents
November 7, 2018

8. Conditional Eligibility – Lawful Presence & Citizenship
What proves US Citizenship?:
Some example documents that prove your citizenship include:
U.S. Passport or U.S. Passport card
Enhanced Driver’s license or Enhanced State ID (must say “enhanced”)
Certificate of Naturalization
Official U.S. county birth certificate
What proves Lawful Presence?:
Some example documents that prove lawful presence include:
Permanent Resident Card (Form I-551)
Refugee Travel Document (Form I-571)
Valid foreign passport with I-94 stamp of admission
Visa with I-94 stamp of admission
Customer instructions on How to Submit Documents
November 7, 2018

9. Conditional Eligibility – Proof of No Other Coverage
Some example documents that prove you don’t have other coverage include:
Copy of insurance policy showing enrollment end date
Termination letter from insurance company
Declaration of Ineligibility for Other Health Insurance Coverage form (below)
Customers can also use a form to attest that they or their household member(s) are not eligible for other coverage (The form is available in 9 languages and can be found here)
Customer instructions on How to Submit Documents
November 7, 2018

10. Conditional Eligibility – Proof of Non-Incarceration
Customers can use a form to attest that they or their household member(s) are not incarcerated in a city, county, state, or federal jail or prison. (The form is available in 9 languages and can be found here)
Customer instructions on How to Submit Documents
November 7, 2018

11. Conditional Eligibility – Proof of Social Security Number
Some example documents that prove your Social Security number include:
Social Security card
IRS, military, or payroll documents showing complete SSN
Proof of a pending Social Security Application
Customer instructions on How to Submit Documents
November 7, 2018

12. Conditional Eligibility – Proof of Tribal Membership
Some example documents that prove your tribal membership include:
Any official document issued by a federally recognized tribe that shows that you’re a member of that tribe, such as:
Tribal Membership or Enrollment Card
Certificate of Indian Blood (must state that you’re a member or enrolled in the tribe)
Customer instructions on How to Submit Documents
November 7, 2018

13. Medicare & Washington Healthplanfinder
If you are:
Can you keep your Washington Healthplanfinder Qualified health plan after enrolling in Medicare?
Are you eligible to continue receiving tax credits and reduced cost-sharing?
Currently enrolled in a Qualified health plan and become entitled to free Part A
Yes
No. Any tax credits the individual is receiving in the Qualified health plan will be discontinued once Part A coverage begins
Currently enrolled in a Qualified health plan and become eligible to buy Premium Part A and Part B
Yes, if you enroll in Part B only. Part B doesn’t qualify as Minimum Essential Coverage.
No, if you enroll in Premium Part A
The Exchange cannot sell a Qualified health plan to someone already enrolled in Medicare. It is illegal to knowingly sell or issue a Qualified health plan to a Medicare beneficiary
Customer should be referred to SHIBA Resources who are trained state volunteers with expertise in Medicare and advising customers on the law and actions to take -
November 7, 2018

14. Conditional Eligibility – Application Review Page
If a customer has information that doesn’t match the Federal Hub, it will appear on the Application Review Page
This page displays prior to eSigning customers application
Anything that has mismatched will display in Red
Use this as an opportunity to verify all application information entered is accurate to the best of the customers knowledge
If a mistake was made or information was miss-typed, Edit the incorrect information, before clicking Next to eSign and submit customers application
November 7, 2018

15. Conditional Eligibility – Eligibility Status Page
On the Eligibility Status page customers will see their Conditional eligibility status for Qualified health plan & Qualified dental plan
There will be a Yellow box that calls out that additional documents required
Click Next to complete plan selection and enrollment
Customers are required to upload documentation within 95 days
November 7, 2018

16. Conditional Eligibility – Account Home
On the customers Account Home a warning and yellow box with messaging that additional documents are needed to verify their eligibility
Click Upload Documents to upload documents or click on Document Center tab
Customers are required to upload documentation within 95 days
November 7, 2018

17. Conditional Eligibility – Document Center
A tab displays for each household member in the Document Center
Documents Needed with warning symbol will display for household members who need to upload additional documentation
Click Upload Documents to view Documents Needed page
Self-Attestation forms may be available for certain conditional categories
November 7, 2018

18. Submitting Documents
Upload documents to their Washington Healthplanfinder account:
Sign in to your account
Click the tab Document Center
The documents you need to submit will be under the “Documents Needed” section
Click Upload Documents button
Upload via WAPlanfinder, available on the Google Play or App Store
Fax or mail a copy of their documents (we can’t return original copies to you)
Fax: 
Mail:
Washington Healthplanfinder P.O. Box 946, Olympia, WA 98507
IMPORTANT! Customers should not mail documents if their deadline is less than 2 weeks away
November 7, 2018

19. Navigator Responsibility
If a customer, broker, navigator or account worker is submitting an application and sees the red messaging on their Application Review page then additional documentation is required
Review the application page for typos or any wrong information displayed click Edit to view that page and update information
If still red on the Application Review, submit the documentation requested
Customers are notified in the following places of their Conditional Eligibility:
Application Review page (Red Messaging)
On the Eligibility Status page
Eligibility Decision or Updated Eligibility Decision letter
Important Deadline to Submit Information letter
November 7, 2018

20. Navigator Responsibility
Customer past 95 day window – no documents uploaded
Customer within 95 day window – no documents uploaded
Customer within 95 day window – documents uploaded
Explain Conditional Eligibility to the customer
Explain the timeline and deadline for conditional documentation
Tell them their deadline and to upload documentation
Answer questions they may have to the best of your knowledge; OR
Refer them to “How to Submit Documents” page on corporate site
Advise customer that documents need to be uploaded for review within 95 day deadline
Tell them their deadline and view documentation already uploaded
Advise customer that documents will be reviewed without any additional contact to Customer Support needed.
Review may or may not happen before the 95-day deadline, but a delay in reviewing their documents does not impact their current enrollment
If customer insists on escalating, once documentation is uploaded, submit a ticket
If customer insists on escalating, submit a ticket, otherwise only submit tickets after they’ve missed their 95-day deadline
If customer has uploaded documentation, submit a ticket
Navigators contact your Lead Organization to submit a ticket. CACs contact the Customer Support Center to submit a ticket:
November 7, 2018

21. What if a customer uploads documentation after the 95 day verification period?
Federal regulations allow the Exchange to review documents after the customers verification period
If a customer uploads documentation after the verification period has ended a Zendesk ticket can be submitted by an Enhanced User to L2 Documentation Review
If the document uploaded resolves the inconsistency that made them conditional, the customer is now eligible for a Special Enrollment Period and may chose a new plan. The customers deductibles and cost-sharing start over since they select a new plan. The customer is not eligible for retro-active enrollment of the same plan
Customers will be notified of their updated eligibility for a Special Enrollment Period by USPS or (depending on their notification preference in Washington Healthplanfinder)
Customers must select their plan within 60 days of the date the inconsistency is resolved
November 7, 2018

22. Who reviews customer’s conditional eligibility?
Exchange staff completes conditional eligibility verification (they are referred to as “Conditional Eligibility Verification team” or “CEV Team”)
CEV Team is responsible for
Reviewing uploaded documents; and
Contacting customers whose documents are insufficient to resolve the inconsistency; and
Resolving the inconsistency or failing the customer’s eligibility
CEV Team sometimes contacts customers via Important Deadline to Submit Information (EE001) & General Notice (EE13) letter (with free form text this letter will show on customer Message Center), to customer and by calling the customer
If the CEV outreaches to the customer via or direct call, the customer is instructed to connect directly with that CEV worker
November 7, 2018

23. Failing CEV
The Exchange has a batch process that runs “on demand”. The batch is used outside Open Enrollment
The batch fails eligibility for applications that meet all the below conditions:
Person isn’t enrolled in a Qualified health or Qualified dental plan
Application isn’t in a special enrollment period
Customer has no open and unresolved Zendesk tickets
Application has had no new activity on the account for at least 2 weeks
Customers who are enrolled are never failed through a batch process
Enrolled customers are contacted prior to the CEV team failing eligibility (this is subject to change)
When a customers eligibility is failed for one of the following, the failure will result in the termination of their enrollment:
Incarceration
Citizenship
Lawful Presence
Medicare
SSN
Trainer talking points:
Last bullet – While those listed failures of status may terminate a customers enrollment, failure to prove income will result in potential loss of APTC/program eligibility
November 7, 2018

24. Customer Tips about Conditional Eligibility
Customer who missed the verification deadline to upload documents may lose their coverage, and/or lose tax credit or see a change in their tax credit – resulting in a higher or lower monthly premium amount
Customers should upload documents as soon as they receive conditional eligibility results. The sooner the better!
Customers can and should select a health plan and enroll in coverage even if they are in “conditional” status
Customers have 95 days from the date on the eligibility notice to resolve the eligibility status on their account
When a customer is conditional for SSN, they are usually conditional for multiple other CEV categories – they should upload all documentation that is being requested of them and their household members (check for typos!)
November 7, 2018

25. Navigator User Tips
You can help your customer avoid loss of coverage or termination by:
Entering information into Washington Healthplanfinder carefully, avoid typos and be sure your customer understands they are answering all questions under the penalty of perjury 
Input customer name as it appears on their document (for example Certificate of Naturalization or Lawful Permanent Resident Card)
Be sure customer inputs their legal name and not what they choose to go by (for example customer is married, but legal documents are still in their maiden name)
Notifying your customers immediately when they are conditional 
Explaining to your customer what “conditional eligibility” means
Explaining to customers that they can and should choose a plan
Telling the customer what their deadline is and how best to send documents (online methods are the fastest!)
WAPlanfinder allows customers to upload documentation from their phone to their Washington Healthplanfinder account!
Faxing or mailing documents delays the upload into their account by 1-3 weeks
Explain that failure to provide documentation could result in the loss of their coverage or tax credits
November 7, 2018

26. Customer Appeals
Customers have the right to appeal if they think their eligibility decision is wrong. An appeal is a hearing before a Presiding Officer where customers can present case for their eligibility determination
Eligibility decisions customers can appeal include:
The amount of their tax credit
The amount of their cost-sharing reduction
Employers, can appeal whether the insurance they provide their employees meets the coverage requirements and whether that insurance coverage is affordable for their employees
Failure to provide timely notice of an eligibility decision
Being found not eligible to enroll in a Qualified health plan
Customer Appeals website - customers/appeals/ - only for QHP/QDP enrollments
HCA Customer Appeals website - appeal-apple-health-medicaid - WAH only
November 7, 2018

27. Customer Scenario 1
Jennie just had a baby (Jean) and has added her to her Qualified health plan application & enrollment. Jean has no SSN yet, so Jennie has not provided the SSN. Jean is shown as “conditionally eligible” and required to provide proof of the SSN. How can you help Jennie understand this status?
Jennie your baby Jean is conditionally eligible. This means that the computer system couldn’t verify some of the information on your application. We’ll be asking you to send us more information
Be sure to check your dashboard’s Message Center tomorrow morning. You’ll see a letter that is called Additional Verification Required and that will have all the information you need 
You have only 95 days from today to provide the documents
You will need to upload a copy of your babies Social Security Card in your Washington Healthplanfinder account in the Document Center tab
November 7, 2018

28. Customer Scenario 2
You just finished helping Shelly & Matt apply for a Qualified health plan with tax credits. On the eligibility results screen you see that they are “conditional” for Qualified health plan with tax credits. What does this mean? Where can you find what this means in the system? Where can they upload documents to prove their conditional status?
What does this mean? A part of the customers application mismatched with the Federal Hub. This means they need to provide documentation
Where can you find what this means in the system? You can view the customers conditional eligibility on their Eligibility Status page, in their Document Center and on their Application Review page. They will also receive a notice in their message center titled Additional Verification Required
Where can they upload documents to prove what they are conditional for? They can upload through their Document Center or WAPlanfinder and identify each individual that is conditionally eligible and what is needed
November 7, 2018

29. Customer Scenario 3
Customer who has been enrolled, just retired and made an update to their income. After helping them make that change you submit the application. You see that the customer is conditional for income and Medicare. How do you help the customer understand what happened? What do they need to do?
How do you help them understand? Say something like: “You just reported your new monthly income because you recently retired. This new income doesn’t match what the federal hub has and we couldn’t verify your eligibility for Medicare.”
What do they need to do? A Self-Attestation form is available from the Document Center immediately after eligibility determination. Customer needs to provide documents that verify their new income and provide documents that let Washington Healthplanfinder know if they’re eligible for Medicare.
The Affordable Care Act doesn’t allow you to be eligible for Medicare AND receive tax credits. If you’re now eligible for Medicare you’re no longer eligible for tax credits. Clients can check their Message Center the next day for more information
Customer should be referred to SHIBA Resources who are trained state volunteers with expertise in Medicare and advising customers on the law and actions to take -
Training Talking Points:
Note – Customers can be eligible and purchase a plan if they are not enrolled in Medicare. A person that reports that they have Medicare (Other insurance question) will not be eligible at all. If they are not enrolled in coverage but submit documents (Medicare card) that proves they do have Medicare, they will be not able to enroll in coverage
Please be aware there are additional complexities to customers eligible/enrolled in Medicare and the Washington Healthplanfinder. Please refer to those training decks for more details
November 7, 2018

30. Customer Scenario 4
Customer is conditionally eligible and uploads documents for the proper conditional categories before the deadline 
Enhanced Users do not need to create a ticket to ask the CEV Eligibility Specialists to review the documents
CEV team will process the customers documents with their normal workload
November 7, 2018

31. Customer Scenario 5
Customer is conditionally eligible and uploads documents for the wrong categories prior to the deadline
Enhanced Users do not submit a ticket. Tell the customer what documents they need to upload
You can identify this by reviewing what they are conditional for in their Document Center
You can find information here at How to Submit Documents
Review the customer’s Additional Verification Requested letter that shows on their dashboard with them to help them understand what is needed
If income is being requested it should be uploaded for all household members who have income
If the customer insists on escalated support then an Enhanced User can submit/request a Zendesk ticket
The ticket should be assigned to L2 Document Review
The CEV team will contact the customer to provide information on what documentation is acceptable
November 7, 2018

32. Customer Scenario 6
Customer uploads documents after the deadline, but is still conditionally eligible, in other words CEV Team hasn’t yet reviewed their documents and customer is still in conditional status
Enhanced User does not need to create a ticket for this 
If the customer insists on a follow-up then an Enhanced User can submit a ticket for follow-up
The ticket should be assigned to L2 Document Review
The CEV team will contact the customer for follow-up
November 7, 2018

33. Customer Scenario 7
Customer's eligibility has been failed and they lost their tax credits or their coverage has been terminated. Customer calls after the 95 day deadline and has uploaded documentation
Enhanced Users should submit/request a ticket for this customer
The ticket should be assigned to L2 Document Review
The CEV team will contact the customer for follow-up
This does NOT guarantee that the customer’s enrollment or tax credits will be reinstated
November 7, 2018

34. Customer Scenario 8
You are working with a customer who has been enrolled since They are marked “conditionally eligible” for income every year at their renewal time. What do they need to do? How can you help them?
What do they need to do? Upload current household income documentation for review for all members in the household with income
How can you help them? Navigator should help the customer understand what documents were requested and needs to be uploaded
You can identify this by reviewing what they are conditional for in their Document Center or on the Additional Verification Required notice
Explain to them the reason for their “conditional status” and that documents need to be uploaded within 95 days
November 7, 2018