1. Washington Healthplanfinder Overview
CEV and Appeals Refresher
February 8, 2018

2. Inconsistencies
Customer’s attested information doesn’t match federal hub. Must ask customer to supply documents that resolve the inconsistency.
Customers have 95 days to resolve the inconsistency.
Failure to resolve the inconsistency has serious impacts:
Customer’s insurance will be cancelled.
Customer’s tax credits are removed.
Customer’s tax credits are changed.

3. Conditional Eligibility Verification Refresher
Income (attested income >25% variance from fed hub)
Social Security Number
Citizenship
Lawful Presence
Eligibility for other Minimum Essential Coverage
Medicare
TriCare, PeaceCorps, Veterans,
Employer Sponsored Insurance
Alaska Native (member of a corporation)
American Indian (enrolled in a federally recognized tribe)
Incarceration
% Indian Blood – doesn’t prove enrollment in a federally recognized tribe.
HPF is working on updating the tribal list to match fed recognized list.

4. CEV Resources on HPF
Dashboard Message Center Document Center Application Review Screen Eligibility Status Screen

5. Dashboard

6. Message Center

7. Application Review Screen

8. Document Center

9. Eligibility Status Screen

10. Best Practice – DoubleCheck √√
Social Security Number Unverified?
Customer will be conditional for everything: SSN, Income, Citizenship/LP, Medicare, VA, PeaceCorp, TriCare.
Did the customer use their legal name or a nickname?
Is there a typo on SSN, birthdate, name?
Fix the name or typo and re-submit the application.
U.S. Citizen or Lawful Presence Unverified?
If the customer attests to being a U.S. citizen but uploads a lawful presence verification document: Correct their application to reflect that they are lawfully present and resubmit the application.
Customers who were lawfully present but are now Naturalized Citizens: Update their application and resubmit.
This Photo by Unknown Author is licensed under CC BY-SA
Joe instead of Joseph

11. Verification Deadline
Termination of Coverage
Social Security Number
U.S. Citizenship
Lawful Presence
Medicare without continuous enrollment in a QHP
Incarceration
Other MEC: VA, PeaceCorps, TriCare
Change in or Loss of Tax Credit
Medicare with continuous enrollment in a QHP (loss)
Income (loss or change)

12. Where we are today
On February 4, 2018 (96 days after November 1, 2017)
12,345 applications in conditional status
10,064 of those had no documents uploaded
4901 applications were past due with no documents uploaded
204 applications were past due with documents uploaded
Of the 204, 29 had not been previously reviewed by CEV team
The sooner a customer uploads their documents, the sooner we will review it. If the document doesn’t resolve the inconsistency, they may still have time to send another document before the deadline.
Exception is Medicare, VA, TriCare, PeaceCorp eligibility.

13. What if my client misses the deadline?
Check for typos;
Upload document(s) immediately;
Submit a Zendesk ticket (call your Lead Organization or Customer Support to create a Zendesk ticket). Request to have the late document reviewed. Include the following info:
What category(ies) were they conditional for?
What was the due date or deadline?
When were the documents uploaded?
When late document resolves the inconsistency:
If customer’s enrollment was terminated, customer will be given an SEP to enroll again. We do not reinstate coverage when a customer fails to respond.
Tax Credits will be reinstated using attested income. We do not retroactively apply advanced premium tax credits. Follows 15th rule.

14. CEV Team Priority Workload
Fail applications past due with no documents uploaded.
Review applications with documents uploaded, not yet past due.
Work Zendesk tickets for documents uploaded after the verification deadline.
Work Zendesk tickets for documents uploaded before the deadline.
There is no need to submit a Zendesk ticket to ask us to review documents uploaded before the deadline.

15. Trainer Talking Points:
What questions do you have regarding the course?
Questions that cannot be answered immediately will be written in the “Parking Lot”

16. Customer Disputes How WAHBE Applied the Regulations
Appeals
Customer Disputes How WAHBE Applied the Regulations

17. What can be appealed? Eligibility to enroll using WA Healthplanfinder
Eligibility for and/or amount of advanced premium tax credits
Eligibility for a Special Enrollment Period
Employers may appeal an employee’s tax credit eligibility when the employer offered employer sponsored insurance (ESI) that meets the requirements of the ACA.
IRS is threatening to and has authority to penalize employers when employee didn’t answer ESI questions on WA Healthplanfinder correctly!

18. Presiding Officers May Not Rule
Enrollment Start Date or End Date
aka Zendesk ticket requests for retroactive enrollment or termination
1095 Correction
Usually grace period issue
WA Apple Health Termination
Carrier Decision
Denial of Special Enrollment Period
Billing or Payment Issue
Enrollment Start Dates unrelated to SEP

19. Legal Stuff about Appeals
Burden of proof is upon the appellant to show that WA Health Benefit Exchange (WAHBE) did not apply the federal regulations appropriately
Appeals filed by 3rd party: Appellant must designate legal representative in writing and submit it with the appeal. A legal representative is not the same as the authorized representative.
Invalid Appeals
Filed for a matter for which the Presiding Officers have not authority to rule;
Filed for eligibility decisions more than 90 days old
Filed with WAHBE for a dispute regarding a Carrier or HCA decision
This Photo by Unknown Author is licensed under CC BY-SA

20. Informal Resolution is Best
Appeals and are an expensive way to resolve a customer’s complaint or get an explanation.
Use the appeals process when appropriate.
Appeals are time-consuming for all parties.
After a customer files an appeal, WAHBE must complete each step outlined in the federal regulations. No shortcuts allowed – even if the appellant changes their mind about wanting a hearing.
Use resources you have to find the answers and explanations your client needs. When you believe WAHBE has violated a federal regulation, encourage your client to file an appeal.
Appeal Request Forms:

21. Trainer Talking Points:
What questions do you have regarding the course?
Questions that cannot be answered immediately will be written in the “Parking Lot”

22. Got a Tough Question about CEV or Appeals?
Use available resources: “in-house” experts, co-workers, newsletters, and training materials.
Clients can always contact Customer Support have lots of answers – and if they don’t know the answer they will create a Zendesk ticket.
Still confused? Feel free to contact us at:
WA Health Benefit Exchange (WAHBE)
Appeals & Conditional Eligibility Verifications
Legal Services Division
Legal Services only has 1 person to answer all phone calls and s and upload documents sent to us. Be nice to LuAnn.