December 9, 2019 - FM Payment Processing 2019 Q4
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FM Payment Processing 2019 Q4
Policy-based Payments (PBP): Upper Bound
Adjustments, 1095-A Reminder, and Payment
Dispute Guidance Updates
December 9, 2019
Division of Financial Transfers and Operations
(DFTO)
This communication was printed, published, or produced and disseminated at U.S. taxpayer expense. The information provided in this presentation is
only intended to be a general informal summary of technical legal standards. It is not intended to take the place of the regu lations that it is based on.
We encourage audience members to refer to the applicable regulations for complete and current information about the requireme nts that apply to
them.
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Session Guidelines
• This is a 60-minute webinar session
• For questions regarding content, submit
inquiries to fmcc@cms.hhs.gov
• For questions regarding logistics and
registration, contact the Registrar at:
(800) 257-9520
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Agenda
• Policy-based Payments (PBP): Upper Bound
Adjustments
• 1095-A Reminder
• Payment Dispute Guidance
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Policy-based Payments (PBP):
Upper Bound Adjustments
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Temporary Manual Adjustments for FFE and
SBE-FP Issuer
January and February 2020 Policy-based Payments (PBP):
• Historically, advance payments in the January and February monthly payment cycles experience a lag
caused by premium collection and reporting of policy effectuations beyond the December 15th cutoff
for payment reporting.
• Centers for Medicare & Medicaid Services (CMS) will make a temporary manual adjustment (Upper
Bound) to the January and February 2020 PBP for Federally-facilitated Exchange (FFE) Issuers and
Issuers in State-based Exchanges using the Federal platform (SBE-FP) offering major medical plans.
• This adjustment is intended to mitigate the cash flow impact of the transition to 2020 for FFE and
SBE-FP Issuers on PBP.
• The Upper Bound adjustments will be applicable to only APTC and UF payments and charges and will not
apply to CSR which has been discontinued as of October 2017 payment cycle.
• Adjustment(s) will show on the Issuers’ Preliminary Payment Report (PPR) and HIX-820s as two
separate manual adjustments to APTC and User Fees.
• Note: CMS will also be making payment adjustments to some State-based Exchange (SBE)
issuers that have transitioned to policy-based payments as established through CMS discussions
with each SBE. CMS will notify issuers in each state of planned adjustments for their state.
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Temporary Manual Adjustments for FFE and
SBE-FP Issuers (continued)
January and February 2020 PBP Upper Bound Adjustment:
• CMS will calculate this adjustment using a payment estimate equal to 80 percent of the estimated
PBP on effectuated enrollment plus enrollment still in “initial” status (i.e., “Upper Bound”).
• If the Issuer’s calculated YTD PBP are less than 80 percent of this amount, CMS will apply an
adjustment to increase the Issuer’s advance payment, net of FFM user fees, up to the 80 percent
threshold.
• CMS will not make any downward payment adjustments to Issuers whose total calculated Policy-
based Payments equal or are above the 80 percent threshold.
• Note: It is currently planned that calendar year 2020 will be the last year that CMS will issue Upper
Bound adjustments and therefore the adjustments will not be issued in January and February 2021
or any year thereafter.
CMS defines the Payment Upper Bound as the payment that would be
due for all non-cancelled enrollment (regardless of effectuation status)
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Temporary Manual Adjustments for FFE and
SBE-FP Issuer Transition (continued)
Reversing Upper Bound Manual Adjustments:
February 2020:
• If there was an Upper Bound Adjustment for January 2020, CMS will
reverse this temporary manual adjustments in February 2020 payment
cycle and recalculate the Upper Bound to see if the year-to-date total
Policy-based Payment reached the 80 percent threshold.
• If the 80 percent threshold is reached, no other temporary
adjustments will be made and Issuer will be paid on system
calculated PBP amounts only from this point forward.
• If the 80 percent threshold is not reached, one last temporary
Upper Bound adjustment will be made for February 2020 payment
cycle which will be reversed in March 2020 payment cycle.
7
WWW.REGTAP.INFOTemporary Manual Adjustments for FFE and
SBE-FP Issuer Transition (continued)
Reversing Upper Bound Manual Adjustments
March 2020:
• If there was an Upper Bound Adjustment for February 2020
Payment cycle, CMS will reverse this temporary Upper Bound
manual adjustments in March 2020 Payment cycle. This would
be the last Upper Bound reversal. All future payments will be
made on system calculated PBP amounts only.
• All Issuers from this point will be paid based on system
calculated PBP amounts.
• Adjustment(s) will show on the Issuers’ Preliminary Payment
Report (PPR) and HIX-820s as two separate manual
adjustments to APTC and User Fees.
8
WWW.REGTAP.INFOUpper Bound Payment Cycle: 80% Cap
Examples: Year to Date APTC Payments:
80% of
Upper
PBP Capped Total
bound PBP APTC Amount < 80 Temporary
APTC APTC APTC
Scenario APTC % of Capped APTC Upper Adjustment applied
Amount Upper Amount
Amount Bound Amount? to Payment
(YTD) Bound Paid YTD
(YTD)
Amount
1 $90.00 $110.00 $88.00 No $0.00 $90.00
2 $70.00 $110.00 $88.00 Yes $18.00 $88.00
3 $40.00 $100.00 $80.00 Yes $40.00 $80.00
4 $65.00 $80.00 $64.00 No $0.00 $65.00
Note: The same calculation will apply to User Fees
9 WWW.REGTAP.INFOUpper Bound Example
Upper Bound
Example
10 WWW.REGTAP.INFOExchange Payment Type Codes for FFE/SBE-FP
Policy-based Payments
Year Exchange Coverage Period Coverage Period
Issuer Type Process Transaction Type
Payment Type Start Date End Date
Retroactive
FFE and SBE-FP APTCADJ, CSRADJ,
2019 PBP Adjustments – APTC, 2019MMDD 2019MMDD
Issuers UFADJ
CSR, UF
UFRMADJ,
FFE/SBE-FP UFR MA, Manual APTCMADJ,
2019 APTC, CSR, UF, UFR 2019MMDD 2019MMDD
adjustments workbooks CSRMADJ,
UFMADJ
Prospective and APTC, CSR, UF
FFE and SBE-FP Retroactive
2020 PBP 2020MMDD 2020MMDD
Issuers Adjustments – APTC, APTCADJ,
CSR, UF CSRADJ, UFADJ
UFRMADJ,
FFE/SBE-FP UFR and
MA, Manual APTCMADJ,
2020 January temporary APTC, CSR, UF, UFR 2020MMDD 2020MMDD
workbooks CSRMADJ,
Manual adjustments
UFMADJ
11 WWW.REGTAP.INFOReferences
• 2019 Manual Adjustments Guidance:
https://www.regtap.info/reg_librarye.php?i=2731
• Enrollment, Payment Processing, and Invoicing New Issuer Training
(FFEs): https://www.regtap.info/reg_librarye.php?i=3084
• Early Year Payment Adjustment Issuer Slides:
https://zone.cms.gov/document/november-9th-2018-issuer-meeting-
slides
• Financial Management Overview for 2020 SBE Issuers:
https://www.regtap.info/reg_librarye.php?i=3083
12 WWW.REGTAP.INFO1095- A Reminder
13 WWW.REGTAP.INFO1095-A Reminder
• This is a friendly reminder to make sure your 2019 enrollment information is accurate and up-to-
date for the upcoming release of 1095-As to your members
– Check all remaining “initial” enrollments on your RCNI file
• Submit effectuation or cancellations to CMS through enrollment reconciliation or the
dispute process.
• Check all remaining “I” and “F” flags on your RCNO file
• Make updates to your enrollment system or submit disputes or reconcile with CMS to
make corrections as necessary
– Submit timely grace period expiration terminations to CMS through inbound 834s or
enrollment recon
– Submit disputes to CMS to correct any remaining enrollment reconciliation issues by
12/23/19
– Submit Enrollment Reconciliation updates in the December RCNI
Errors in 2019 enrollment that remain in January will lead to 1095-A errors,
consumer disputes, research costs for CMS and issuers, and a poor customer
experience for your members
14 WWW.REGTAP.INFOPayment Dispute Guidance
15 WWW.REGTAP.INFOPayment Dispute Guidance
I. Payment Dispute Reminders
II. Enrollment Dispute Form v12 Deployment
III. New Detail Codes:
1. PD942
IV. Modified Detail Codes:
1. PD533
2. PD645 & PY645
V. Reminder: AM Approval of Prior Year Disputes
VI. Common Errors: Avoiding FV9
VII. zONE Publications
16 WWW.REGTAP.INFOPayment Dispute Reminders
• Please submit your Payment Disputes!
– Submit a Payment Dispute for any record perceived to be incorrect.
– Issuers may submit large volumes of Payment Disputes without impeding
processing time.
• Payment Dispute Support
– As a reminder, the FMCC team is the primary point of contact for resolving
rejected Payment Disputes. Please reach out to the FMCC team at
FMCC@cms.hhs.gov with any questions regarding rejected Payment
Disputes.
17 WWW.REGTAP.INFOReminder: AM Approval for Prior Year
Disputes
• Issuers must get approval from their Account Manager (AM) before
submitting prior year disputes.
• AM approval is not required for HICS Direct Disputes or prior year disputes that
contain supporting HICS cases.
• Issuers must email a completed Issuer Prior Year Approval Request Form to
their AM to request prior year dispute approval. The form is available on zONE:
– https://zone.cms.gov/system/files/documents/issuerprioryearapprovalrequest.xlsx
• Upon receiving a confirmation email from ER&R, issuers should submit the
approved prior year disputes before the due date.
• ER&R will return prior year disputes submitted after the AM-approved deadline
with detail code FV110.
• ER&R will return prior year disputes that did not receive AM approval and do not
contain a supporting HICS case with detail code FV111.
18 WWW.REGTAP.INFOEnrollment Dispute Form v12 Deployment
• ER&R began accepting Enrollment Dispute Form v12 on Tuesday,
November 12th.
• CMS published the final v12 production file (enrollmentdisputeformv12.xlsx) to
zONE.
– https://zone.cms.gov/document/enrollment-resolution-and-reconciliation
• ER&R will return any Enrollment Disputes submitted using v11 with instructions
to resubmit using v12.
• Issuers who wish to use add-ins when submitting disputes must download and
install the new Enrollment Dispute v12 Add-ins from zONE.
– The instructions for installing and using the add-ins are on the PSV Format tab of the
Enrollment Dispute Form; however, issuers should contact their IT department before
installing the add-ins.
– Prior to installing the new version, issuers should uninstall any previous version.
19 WWW.REGTAP.INFODetail Code for Disputes Where an FFM
Payment Was Made
• New Detail Code: PD942
• PD942 applies to a dispute for a missing payment that initially received an In
Process disposition code and subsequent manual analysis found a payment was
made by the FFM.
NOTE: PD942 is similar to PD511, which also indicates that a payment was
found in the PPR for the “missing payment” disputed policy. The two are different
in that PD511 is resolved through automated business rules, whereas PD942
required additional analysis, likely because multiple payments were made on
multiple segments within the policy.
– PD942 Issuer Action: Review the PPR or HIX 820 reports for payments on
the disputed policy. If the payments are incorrect, submit a dispute with the
FFM values and appropriate HICS Case ID for APTC or Total Premium
disputes.
• PD942 results in disposition code C6: Timing Issue – PPR Record Found.
20 WWW.REGTAP.INFOModified Detail Code for Policies to Be
Cancelled by the FFM
• PD533 applies to disputes where the issuer is reporting an unexpected
payment on a policy that will be cancelled by the FFM in the upcoming
cycle.
• PD533 modifications are as follows:
– Previously, PD533 only applied to disputes involving uneven or unexpected
RCNO records with record-level flags of F, G, W, or L.
– Going forward, PD533 will also be used for disputes involving uneven RCNO
records with record-level flags of V as well as instances where the issuer
reported an Issuer Premium Paid Indicator of C for the disputed record.
• PD533 results in disposition code I1: In Process.
21 WWW.REGTAP.INFOModified Detail Codes for Unexpected
Payments on Effectuated Policies
• PD645 and PY645 apply when the dispute is for an unexpected
payment and the issuer did not report the record as cancelled.
• PD645 and PY645 modifications are as follows:
– Previously, PD645 and PY645 applied to disputes where the issuer had not
sent in an RCNI record for the policy.
– Going forward, PD645 and PY645 will apply to all disputes of unexpected
payments where the RCNI did not contain a record or where the record is
present but does not have an Issuer Initial Premium Paid Indicator of C.
• PD645 results in disposition code R6: Dispute Not Supported By RCNI.
• PY645 results in disposition code R10: Dispute Not Supported By RCNI
– Prior Year.
• As a result of these changes, ER&R deactivated detail codes PD542,
PY542, PD621, and PY621.
22 WWW.REGTAP.INFOCommon Errors: Avoiding FV9
• ER&R has noticed an increase in the number of Payment Disputes
receiving the FV9 detail code, which results in the disposition code R3:
FFM Fields on Form do not Match PPR/HIX 820.
• Disputes are assigned the FV9 detail code when an issuer disputes an
unexpected or incorrect payment but the PPR/HIX 820 report does not
contain a record of a payment that matches the disputed data.
• Most disputes that receive the FV9 detail code have the wrong Payment
Cycle Month on the dispute.
• In order to avoid the FV9 detail code, issuers must ensure that the
Payment Cycle Month on the dispute matches the month in the Policy-
Based Transition Payment Month field of the PPR file and not the month
the coverage took place.
23 WWW.REGTAP.INFOCommon Errors: Avoiding FV9 (Cont.)
• Here is an example of a dispute that will receive an FV9 detail code:
• Other fields that can result in FV9 detail codes include:
– HIOS ID
– Exchange Assigned Policy ID
– Coverage Period Start Date (FFM)
– Coverage Period End Date (FFM)
24 WWW.REGTAP.INFOzONE Publications
• Disposition and Detail Code List v24 is available on zONE. This version
includes the new detail codes that were presented in the previous slides.
• The Combined Enrollment and Payment TRG v8.0 contains updates for
AM approvals on prior year disputes.
• UIR TRG v7.0 and UIR Master Guidance contain details regarding the
UIRY function code.
• Issuers can review the updated documentation on CMS zONE:
– https://zone.cms.gov/document/enrollment-resolution-and-reconciliation
25 WWW.REGTAP.INFOQuestions?
To submit or withdraw questions by phone:
• Dial *# (star-pound) on your phone’s keypad to ask a
question.
• Dial *# (star-pound) on your phone’s keypad to
withdraw your question.
To submit questions by webinar:
• Type your question in the text box under the ‘Q&A’ tab.
26 WWW.REGTAP.INFOAPPENDIX
WWW.REGTAP.INFOACCESS TO CMSzONE
Step 1: CMS Secure Portal Registration Process:
(Pre-requisite to CMSzONE Access)
1. Register for access at CMS Secure Portal Here: https://portal.cms.gov/
2. Click on “New User Registration” under CMS Secure Portal
3. Complete information and create User ID and Password
Step 2: CMS zONE Access Request:
1. Log in at https://portal.cms.gov/ with your CMS Secure Portal credentials
2. Click on “Request Access Now”
3. Scroll down the page to find “zONE” and click on “Request Access”
4. Complete information and wait for confirmation email
5. Once confirmation email is received, user may log -in to CMSzONE
Step 3: CMSzONE Private issuer Community Access:
(After being granted CMS zONE access)
1. Log into zONE; click on the Communities tab
2. Click Browse Private Communities
3. Click Issuer Community – Private
4. Click Join Community
5. Provide explanation of why you need access to this community; Include:
· name and contact information
· issuer POC contacts
· specific work for issuer (i.e. fill out QHP templates, processing 834’s, etc.)
User Access Quick Guide
A copy of the comprehensive User Access Quick Guide is posted on zONE @:
https://zone.cms.gov/document/zone-end-user-access-quick-guide (pre-log in required to access zONE links)
28 WWW.REGTAP.INFOReference Documents
• SBE Issuer Information page (all of the following documents are available on
this page): https://zone.cms.gov/wiki/sbm-Issuer-information
• SBE Issuer ICD: https://zone.cms.gov/document/sbe-Issuer-icd
• SBE PBP Transition Guide: https://zone.cms.gov/document/sbe-Issuer-
transition-guide
• SBE Issuer PBP FAQ: https://zone.cms.gov/document/policy-based-
payments-transition-faq
• CSR Operations FAQ: https://zone.cms.gov/document/csr-operations-faq
• Monthly Batch Cycle Calendars: https://zone.cms.gov/wiki/sbm-Issuer-
information
29 WWW.REGTAP.INFOReference Documents Continued
• Issuer Dispute Form: https://zone.cms.gov/document/Issuer-dispute-form
• Enrollment and Payment Files Chart: https://zone.cms.gov/document/sbm-
pbp-files-chart
• Managed File Transfers (MFT) Thin Client Help Guide:
https://www.regtap.info/reg_librarye.php?i=1778
• CMS Individual Market HIX 820 X12 Scenarios:
https://zone.cms.gov/document/cms-individual-market-hix-820-x12-
scenarios
• Payee Information Report (Function code: PNR) for Payee:
https://zone.cms.gov/document/payee-information-report
• Temporary Manual Adjustment Scenarios:
https://zone.cms.gov/document/temporary-manual-adjustments-scenarios
30 WWW.REGTAP.INFOSample Intent to Refer Letter
Initial Invoice FINAL REQUEST
Re: Program : Advance Payments of the Premium Tax Credit
Entity ID : A123456
Invoice Number : A1111A011001001
Invoice Date : 13-JUL-2018
Invoice Amount : $101.99
Interest Charge : $10.01
Administrative Fee : $15.00
Total Amount Due : $127.00
• The Program, Entity ID, Invoice Number, Invoice Date, and Invoice Amount are the same fields transmitted in
the Initial Invoice.
• Interest Charge – The interest charge is the interest owed and is calculated based on the original invoice
amount, number of months outstanding, and the current interest rate
• Interest is assessed on a monthly basis
• Administrative Fee – The administrative fee is a fixed fee of $15 that is applied only once when an invoice is
over 30 days old
• Total Amount Due – The total amount due is the sum of the invoice amount, interest charge, and
administrative fee
31 WWW.REGTAP.INFOContacting FMCC
When contacting the FMCC, issuers
should include their five (5)-digit Health
Insurance Oversight System (HIOS) ID
and their seven (7)-character Payee ID,
along with their request.
32 WWW.REGTAP.INFOAcronyms
Acronym Definition
DSH/HUB Data Services Hub
EFT Electronic File Transfer/Electronic FundsTransfer
EPS Enrollment and Payment System
FFE Federally-facilitated Exchange
FMCC Financial Management Coordination Center
HIOS Health Insurance Oversight System
HIX Health Insurance Exchange
PBP Policy-based Payments
PNR Payee Information Report
PPR Preliminary Payment Report
PSV Pipe-separated value
SBE State-based Exchange
SHOP Small Business Health Options Program
33 WWW.REGTAP.INFOResources
WWW.REGTAP.INFOResources
Inbound 834 Process (CMS zOne Dedicated Page):
• Production Overview, Technical Specifications, Reporting
• For further assistance, please contact: Inbound834@bah.com
Enrollment Reconciliation:
• For further assistance, please contact:recon_Issuer_support@bah.com
Dispute submission:
• Resources
• Payment dispute form:
https://zone.cms.gov/system/files/documents/ft_ppr_820_dispute_form_002.xls
x
• Combined Enrollment and Payment Dispute Technical Reference Guide:
https://www.regtap.info/reg_librarye.php?i=2664.
• For further assistance, please contact the ER&R Support Center at
errsupportcenter@cognosante.com or (855) 591-7113
35 WWW.REGTAP.INFOCombined Enrollment and Payment Dispute
Technical Reference Guide
• The Combined Enrollment and Payment Dispute
Technical Reference Guide (TRG) provides guidelines for
issuers regarding how to submit payment disputes.
• Issuers can access the TRG at the following links:
• https://www.regtap.info/reg_librarye.php?i=2664
• https://zone.cms.gov/system/files/documents/combined
_enrollment_and_payment_disputes_trg_v3.2.docx
36 WWW.REGTAP.INFOResources
Resource Resource Link
Centers for Medicare & Medicaid Services http://www.cms.gov/
(CMS)
U.S. Department of Health & Human Services http://www.hhs.gov/
(HHS)
The Center for Consumer Information & http://www.cms.gov/cciio
Insurance Oversight (CCIIO) web page
Consumer website on Health Reform http://www.healthcare.gov/
ASC X12Store http://store.x12.org/store/health-
insurance-exchanges
Registration for Technical Assistance Portal https://www.REGTAP.info
(REGTAP) - presentations, FAQs
CMS zONE – reference material https://zone.cms.gov
37 WWW.REGTAP.INFOInquiry Tracking and Management
System (ITMS)
Stakeholders can submit inquiries to ITMS at
https://www.REGTAP.info
Select “Submit
an Inquiry” or
to view
submitted
inquiries select
‘My Inquiries’
from My
Dashboard.
38 WWW.REGTAP.INFOFAQ Database on REGTAP
The FAQ Database allows users to search
FAQs by FAQ ID, Keyword/Phrase,
Program Area, Primary and Secondary
Categories, Benefit Year, Retired and
Current FAQs, and Publish Date.
FAQ Database is available at
https://www.regtap.info/
39 WWW.REGTAP.INFOClosing Remarks
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