When the Health Insurance Exchange (HIX) network went online in late 2013, the healthcare insurance industry was¬ challenged. They were tasked with reconciling¬ new benefit subscribers¬ to their related insurance premium payments and subsidies. Having the right EDI Software came in handy as health plans painstakingly assembled Excel eligibility extracts. They looked to invoice their Federally Facilitated Marketplace ¬ (FFM) or State-based Exchange (SBE) for tax credit reimbursement. However,¬ by the start of 2016, the FFM became the system of record for eligibility. Issuers were then required to accept a new variant of Electronica Data Exchange (EDI) data representing premium payments.
Traditionally, the 820-Payment Order / Remittance Advice ¬ transaction¬ (005010X218) has been¬ transmitted from payroll agencies and government healthcare organizations. These organization sent them to insurers in order to provide summary or¬ subscriber-level information regarding healthcare premium payments. With the advent of Affordable Care Act (ACA) exchanges, enough variations surfaced that a new version of the 820 was required.¬ The HIX 820 (005010X306) removes structures unnecessary for exchange reporting, and adds tracking segments. These segments are for the unique aspects of thes e plans, such as Advance Premium Tax Credits ¬ (APTC) and Cost Sharing Reductions (CSR)
As a starting point, it’s easier to see what has been removed in the HIX 820. A traditional 820 transaction contains a header section identifying the receiver, sender and any intermediaries. The detail section contains two parallel loops. The 2000A loop¬ (line 9 below< /strong>) is used to provide summary remittance advice, while the 2000B loop ( line 16 ) can be used to report on individual payments. Let’s take a closer look in our FREE EDI Editor – X12 Studio Toolbox.
The HIX 820 removes the 1000C Intermediary N1 set of loops, and collapses the 2000A and B detail loops into a single structure, making the 005010X306 variant quite streamlined, as far as EDI healthcare goes.
Some segments have been added to handle HIX business cases, however. The first category of changes relates to REF segments added to track Qualified Health Plan (QHP) Identifiers, Group and Policy IDs. These REF segments have proliferated¬ within the HIX 820 since the transaction set designers needed to allow for both the health exchanges and the plan issuers to potentially create their own identifiers for members and policies. Additionally, these segments may exist on a header or detail level, leaving us to account for the following qualified REF segments:
- REF*38 – Exchange Assigned QHP¬ ID
- REF*TV – Issuer Assigned QHP ID
- REF*18 – Exchange Assigned¬ Group ID
- REF*1L – Issuer Assigned Group ID
- REF*POL – Exchange Assigned Policy ID
- REF*AZ – Issuer Assigned Policy ID
The other REF segments added to the HIX 820 track subscribers and dependents, and CMS reimbursements. Under the ACA, there are two ways in which HIX plan costs¬ may be reduced. Both cost reductions¬ depend on where an individual or family adjusted gross income ¬ (AGI) falls in relational to the Federal Poverty Level (FPL). The low end of both ranges starts at 100% of the FPL or 138% for states that expanded Medicaid coverage.
Advance Premium Tax Credits – APTCs reduce the cost of premiums for plans of any metal tier. These tax credits scale based on AGI¬ from 100/138 – 400% of the FPL.¬ These credits may be immediately applied to health coverage¬ or received as refunds at the end of the tax year.
Cost Sharing Reductions – CSRs only apply to Silver plans¬ and individuals or families at 100/138 – 250% of the FPL. These subsidies reduce the cost of copays and other out-of-pocket expenses. The CSR funding mechanism was successfully challenged in court by House Republicans, although the verdict was put on hold following an appeal by the Obama administration. In October of 2017, the Trump administration dropped the appeal, resulting in CMS discontinuing these reimbursements to health plans. Insurers of Silver plans are still required to provide CSRs to eligible subscribers, however. Many health plans anticipated the administration’s direction¬ and raised premiums on Silver plans by up to 20% as a result. Ironically, since Premium Tax Credits are based on the cost of Silver plans, federal reimbursement has increased in many states in 2018 for APTCs.
These REF segments can be used to identify taxpayers and similarly allow for the assignment of values by the exchange or health plan:
- REF*4A – Exchange Assigned APTC Contributor
- REF*23 – Issuer Assigned APTC Contributor
SNIP 3 Balancing – Balancing the HIX 820 is¬ considerably simpler than balancing the standard HIPAA 820. The HIX 820 does not contain ADX segments¬ indicating payment adjustments,¬ so balancing is limited to summing RMR04 remittance amounts¬ for comparison against the header level total amount paid (BPR02). This can be expressed as:
1000-BPR02 = SUM(of each 2300-RMR04)
The T-Connect EDI Gateway is a robust EDI¬ platform for health plans and exchanges¬ can use to¬ manage the translation and reconciliation¬ of HIX 820 transactions with EDI 834 enrollments. We’re always happy to schedule a call to walk through EDI processing requirements. Feel free to contact¬ us for a free demo or consultation.