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 us to know the appropriate cost to use for the benchmark plan for this coverage family. In order to do that, the Cúram 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 and get back a monthly premium for the benchmark plan (the second-lowest-cost silver plan available in the exchange). Customers have the ability to run the application without a plan management system in place, in which case 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 on different types of plans depending on their eligibility. Enrollment options like the household members selected as part of the enrollment group, and the primary member of the insurance plan are captured before passing to the plan management system.
An iFrame is used to display the plan management screens. In order to load the plan management screens, a unique 'enrollmentID' is passed in through the previously-configured plan management URL , which the plan management system then uses to call a web service we provide which returns information on each of the people involved in this enrollment and what kind of assistance they are eligible for, for example, what the maximum tax credit available to them is.
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. 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. 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.
On completion of an enrollment in a plan, the plan management system re-directs the iFrame to a URL we provide which will return the user automatically to the results page, which will be updated based on the enrollment details. In order to get these enrollment details, we call a web service provided by the plan management system passing in the enrollmentID and get back details about the plan they enrolled in, for example, the plan name, premium, tax credit used, or deductible associated with the plan.