1 – TPA TPA Qualified TPAs will be certified by the Maryland Health Benefit Exchange (MHBE) to provide alternate online marketplaces for employers, brokers, and employees to compare, select, and purchase SHOP QHPs. Organizations interested in obtaining Program 1 certification must be able to demonstrate the capability to build and maintain an online retail shopping experience that meets the applicable standards and conditions established by the Affordable Care Act (ACA) and MHBE. Specifically, Program 1 organizations must have the ability to support both the employer choice and employee choice plan set-up and selection models. Additionally, companies interested in providing a Program 1 marketplace should indicate how their company’s approach will further the goals and objectives of the Maryland SHOP Exchange through innovative processes and techniques and ability to drive enrollment into SHOP QHPs. Program 1 is not currently envisioned as a stand-alone program and will include all the functional and technical requirements included in Program 2. Accordingly, all terms and conditions including performance metrics, service levels, and required technology and functions for Program 2 (described separately) will be adhered to by Program 1 participants. TPA Companies seeking certification for Program 1 must have an authorized company representative submit an application through Maryland Health Connection committing their organization to meeting all business and technical requirements of Program 1 as well as to the terms and conditions of the Program 1 business agreement if their company should receive certification. There is no application fee for the program. MHBE will determine whether to accept the company’s application based on the strength of the company’s capabilities, experience and expected innovations and contributions to enhancing and increasing participation in the Maryland SHOP Exchange. The estimated time from submission of an application to decision from MHBE about whether an organization can move to the certification process will be thirty (30) days. MHBE reserves the right to accept an organization’s application for certification as well as defer the applicant’s certification process by up to one year. The number of qualified applicants going through the certification process will be the driving force in any deferred application processes. TPA Companies seeking certification to participate in Program 1 must have an authorized company official sign a business agreement that commits them to meeting all business and technical
Employer Demographic Data Employee new Enrollment/Changes/ Termination Data Dependent new Enrollment/Changes/ Termination Data TPA Maryland Health Program 1/ Program 2 Employer Demographic Data Health TPA Program 2 getErrorReportFromMHBE Error Report Health TPA Program 1 sendErrorReportToMHBE Report TPA Maryland Health Program 2 Employer Demographic Data TPA Maryland Health Program 1 getBroker DemographicsFromMHBE Broker addition/ update/ termination Health TPA Program 1/ Program 2 TPA-Carrier (Batch) provides a summary of all transactions to support the various programs in batch mode between the TPA and Carrier, Carrier and TPA.
Transaction Data Exchanged Sender Receiver Applicable Program sendEnrollmentDataToCarrier Employee New Enrollment/ Changes/ Termination Dependents New Enrollment/ Changes/ Termination TPA Carrier Program 1 Health premium payment data TPA Carrier Program 1/ Program 2 Addresses effectuation of enrollment scenarios for "Add", "Reinstate", "Update" or "Terminate” of the Employee, dependents Carrier TPA Program 1/ Program 2 Maryland Health Connection -CMS(Batch) Transaction Data Exchanged Sender Receiver Applicable Program
Plan ID An automatically generated number assigned to a specific proposed QHP Varchar 30 Yes Plan Marketing Name Name of each plan Varchar 400 Yes HIOS Product ID The HIOS Product ID associated with each proposed Exchange plan. Varchar 25 Yes Exchange Market The HIOS Product ID associated with each proposed Exchange plan. Varchar 15 No
HSA/HRA Employer Contribution Indicate whether the employer contributes to HSA/HRA Varchar 1 No Y-Yes to HSA/HRA Employer Contribution. N-No to HSA/HRA Employer Contribution HSA/HRA Employer Contribution Amount Indicate employer contribution amount to HSA/HRA if applicable Varchar 15 No Indicate employer contribution amount to HSA/HRA if applicable Child–Only Offering Indicator of whether a specific plan will also be offered at a child–only rate or have a corresponding child–only plan Varchar 1 No Y-Yes to Child–Only Offering. N-No to Child–Only Offering. Plan ID number assigned to a child–only offering that corresponds to this plan Varchar 1 No Y-Yes to Child–Only Plan ID. N-No to Child–Only Plan ID.
Plan Type Network design for the product: Varchar 15 No Indemnity, preferred provider organization (PPO), health maintenance organization (HMO), point of service (POS), or exclusive provider organization (EPO). URL for Summary of Benefits & Coverage URL that provides a link to the Summary of Benefits and Coverage document that is required to be posted on the plan’s website Varchar 250 Yes
URL for Enrollment Payment URL for the location on the plan website where the enrollee will effectuate payment. Varchar 250 Yes New or Existing Plan Indicator Indicator of whether the proposed plan is a new or existing plan. Note: We expect most proposed plans submitted for the 2014 coverage year to be new plans. Varchar 1 No Plan Effective Date Effective date of the plan Date Yes Plan Expiration Date Date that a plan becomes closed and no longer accepts new enrollments. Date Yes
Out–of–Country Coverage A yes/no indication of whether care obtained outside the country is covered under the plan. This information may be critically important to consumers who travel internationally. Varchar 2 No Out–of–Country Coverage Description A short description of whether care obtained outside the country is covered under the plan. This information may be critically important to consumers who travel internationally. Varchar 15 No Out–of–Service Area Coverage A yes/no indication of whether care obtained outside the service area is covered under the plan. Varchar 2 No Y-Yes to Area Coverage. N-No to Area Coverage.
Out–of–Service Area Coverage Description A short description of whether care obtained outside the service area is covered under the plan. Varchar 15 No National Network A yes/no indication of whether a national network is available Varchar 2 No Y-Yes to National Network. N-No to National Network. Maximum Individual In–Network for EHBs— Maximum out–of–pocket (in–network) for EHBs Varchar 15 No Maximum Family for EHBs Maximum out–of–pocket (in–network) for EHBs Varchar 15 No In and Maximum Individual for EHBs— Individual maximum for EHBs combined for in– and Varchar 15 No In and Maximum Family for EHBs— Family maximum for EHBs combined for in and Varchar 15 No In–
Maximum Individual In–Network Total— Overall maximum total. Enter for integrated or, if separate, enter for medical. Varchar 15 No Maximum Family Total— Overall maximum total. Enter for integrated or, if separate, enter for medical Varchar 15 No Maximum Total— Overall maximum total. Varchar 15 No Maximum Family Out–of–Network Total Overall maximum total. Enter for integrated or, if separate, enter for medical Varchar 15 No Maximum Individual In– and Total combined maximum total. Enter for integrated or, if separate, enter for medical. Varchar 15 No
Wellness Program Offered (Y/N)? A yes/no response indicating whether the plan offers wellness program Varchar 1 No Identify disease management programs offered Select from dropdown: asthma, heart disease, depression, diabetes, high blood pressure and high cholesterol, low back pain, pain management, pregnancy Varchar 15 No Multiple Provider Tiers (Y/N)?— Do you have multiple provider tiers? Varchar 1 No Expected Utilization for Tier 1? What is the expected percentage of utilization for Tier 1? Varchar 15 No Plan Level Exclusions List all plan level exclusions. Varchar 15 No Cost–Sharing Reduction Plan Variation Changes in Cost Sharing Varchar 15 No
Is notice required for Pregnancy?— Select “yes” if notice is required for pregnancy, otherwise select “no.” Varchar 1 No Y-Notice required N-Notice not required Plan Brochure Enter the Plan Brochure URL. Varchar 15 No URL contains Plan Description, Plan Area, Plan Status, Plan Certification, Plan Crosswalk, Plan Year and Plan Version Federal Tax ID Enter the federal tax ID. Varchar 15 No Associated HPID Enter the associated HPID Varchar 15 No Employee choice in SHOP Identify if the issuer’s SHOP QHPs will be available to employees buying up a single level from the employer’s choice of metal level. Varchar 15 No