1. Conditional Eligibility Verification
September 2018 – Enrollment Knowledge Transfer

2. Topics: Overview The electronic verification process
The post eligibility manual verification process
How information can be submitted
What happens when documentation is not submitted
Questions?

3. Overview:
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 information entered in their application, such as:
Social Security Number
Citizenship/Lawful Presence (if indicated as a lawfully present immigrant/nonimmigrant
Incarceration
Eligibility/Enrollment in Non-Employer Sponsored Insurance (Medicare, Tricare*, Veteran’s Health*, and Peace Corp*)
Income*
Tribal Membership
Conditional eligibility allows a customer to receive tax credits/cost sharing reductions and enroll in coverage, while they have a 95 day time frame to provide documents that resolve the inconsistencies.
*APTC only

4. Electronic Verifications: When does this happen?
There are several points during the data collection process where Healthplanfinder calls the Federal Hub for validations. This is being done behind the scenes in real time. There is no message on-screen that would indicate that this is taking place.
After the Contact Information screen
HPF verifies Identity, SSN, Incarceration, and Citizenship on all applications
After e-signing
All applications for free or low cost coverage when;
Client has provided consent to obtain FTI records
Client’s SSN and Identity were verified
All applications where at least one individual has indicated lawful presence status as a Non-citizen

5. Electronic Verifications: Federal Hub Response
When a request is sent to the Federal Hub, there are 3 possible outcomes:
Federal Hub information matches the self-attested information
Federal Hub information does NOT match the self-attested information
Federal Hub sends back a technical exception error

6. Electronic Verifications: What does HPF do with the information received by the Federal Hub?
HPF/ES runs a secondary validation, comparing the self-attested information with the information received from the federal hub, and determines if the values are “verified” or “unverified”; this is referred to as the “Verification Status”
HPF would consider information “Verified” if all the self-attested and Federal Hub data matches
HPF would consider information “Unverified” if there is at least one value that could not be verified with the Federal Hub OR the Federal Hub returned a technical error
HPF then packages all the self-attested and federal hub information, to include the verification status, and sends through the designated rules engine.
Free or low cost applications (APTC) are sent to the Eligibility Service
QHP only applications are determined in HPF through OPA rules engine

7. Electronic Verifications: How does this impact eligibility?
The Verification Status determines eligibility. Depending on the Verification Status, an individual could expect 1 of the 3 results below:
Approved:
All values are verified through federal or state data sources. All values are marked with a verification status of “Verified”
Conditionally Approved:
At least one value was unable to be verified with the federal hub or state data sources. At least one value is marked with a verification status of “Unverified”
Denied:
At least one value was unable to be verified with the federal hub or state data sources AND the individual has failed manual verification process. At least one value is marked with a verification status of “Failed” This occurs AFTER the 95- day conditional eligibility period for most cases.

8. Electronic Verifications: Next Steps?
Depending on the eligibility determination, an individual may be required to complete additional steps to ensure continued eligibility through HPF.
Individuals who receive a determination of “Approved” are not required to take any additional action to prove eligibility.
Individuals who receive a determination of “Conditionally Eligible” will require additional follow up to remain eligible. These individuals are given 95 days to submit documentation (QHP/APTC clients). They will be allowed to purchase and enroll in a Qualified Health Plan immediately following the determination. The individual will be required to submit documents to HPF which will then be reviewed by the CEV Team.
Individuals who receive a determination of “Denied” will be closed either APTC or QHP at the end of the current month or according to the 15th rule in which the final determination was made. This assumes that the individual was found “Conditionally Eligible” and failed to supply sufficient proof within the 95-day timeframe.

9. How individual’s are notified of their Conditional status
An individual found Conditionally Eligible will have 95 days from the date the application/change is submitted, to provide documentation.
Customers receive 2 Washington Healthplanfinder correspondences:
Eligibility Decision or Updated Eligibility Decision (EE04/EE15)
Important Deadline to Submit Information (EE01) – 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 application which directs them to the Document Center to view what documents are needed per person

10. 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

11. Email Reminder – 30/60 days prior to due date
If a customer has an address in their account, they are sent an reminder to submit documents, 30 to 60 days prior to their due date.
is not sent through Healthplanfinder and will not appear on their Message Dashboard.

12. Individual’s Responsibilities
The individual may submit documentation:
By mail
By Fax
By uploading into Healthplanfinder
By uploading through the mobile application

13. Manual Verifications: Overview
When an individual is found “Conditionally Eligible” for enrollment into a QHP/APTC, and submits documentation for review, it is the responsibility of the CEV to conduct manual verifications.
The CEV Team is responsible for the following:
Reviewing documentation
Determining if documentation is sufficient to prove continued eligibility
Determining if sufficient notice was given
Updating Document and Verification Status based on determination
Conducting outreach, if needed

14. Electronic Verifications: Outcome if client FAILS to verify their inconsistency
The failed value will determine what coverage type the individual will lost (APTC and/or QHP)
Loss of QHP coverage (no longer enrolled)
SSN
Citizenship/Lawful Presence
Incarceration Status
MEC – Medicare
Loss of APTC (will still remain enrolled with/without tax credits; exceptions apply**)
MEC – Veteran’s Health
MEC – Tricare
MEC – Peace Corp
MEC – Medicare (only if continuously enrolled)
Income**
If income verification status if “Failed”, the system will determine eligibility based on the Federal Tax or State Wage Data
If Federal Tax or State Wage Data is <100% FPL OR >400% FPL the individual will likely be denied for being under or over income thresholds

15. How to determine if a client has been failed
Check HPF Message Center –
Important Information (EE013) – Each member that has been failed through the CEV process will receive an EE13 that details what verification they were failed for and why.
Important Deadline to Submit Info (EE001) – Each household that has a member that is conditional will receive an EE01. The EE01 has specific details on who is unverified, what verification is unverified, and the due date to submit documents.
HPF Application Review Screen – ) Verification will display in HPF App Review as “Failed” ) Application notes - CEV Team notes in HPF regarding the failure. The notes indicate which member by Person ID (PID) that has been failed and why they were failed.

16. Common reasons that cause elements to return unverified
SSN, Citizenship/Lawful Presence -
Name change
Typos
Wrong attestation – Change in citizenship/lawful presence status (now a citizen, no longer an immigrant)
Failure to provide SSN number
Not providing citizenship or lawful presence document numbers, or wrong number inputted
Some immigration statuses cannot be instantly verified.
Income -
Changes in employment (new job, different hours, loss of job)
Retirement (loss of job income and gaining retirement or Social Security benefits
No tax data available because household did not file taxes in prior years
Incarceration and Minimum Essential Coverage -
Failure to provide SSN
Electronic match with agencies that show applicant is enrolled in or eligible for other MEC
*Outages of the Federal Hub will also result in elements returning unverified

17. Client options after a Failure
Client submits document and the document is valid –
If they were failed for SSN, Citizenship/Lawful, Incarceration, or Medicare
Verification in HPF is updated to manually verified
Special enrollment period (SEP) is opened
Client can re-enroll in a health plan (prospective)
If they were failed for Income, MEC (VA, Tricare, PC)
APTC eligibility change (prospective)
Special enrollment period (SEP) is not opened
Client submits documents and the document is not valid –
1) No change until customer submits a document that can be used to verify what the triggered the application to become conditionally eligible

18. General Tips to Prevent and Resolve Conditional Eligibility
Double check that name, birth date, SSN and immigrant or citizenship document numbers have been inputted correctly.
Legal names i.e. William Doe instead of Bill Doe
Note: If name entered in application does match what is on SSN card or immigrant/citizenship document, member will likely not return verified
Provide SSN’s for everyone in the household who has one, especially for members that are applying for coverage
Check information on the application for accuracy
Advise customers to review notices sent from Washington Healthplanfinder
Uploading documents directly to Washington Healthplanfinder or through the mobile application is faster than mail.