The Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) may have a requirement for Enrollment Resolution & Reconciliation, Form 1095-A Data Reporting.

The Affordable Care Act (ACA) established new health insurance Exchanges to facilitate the purchase of health insurance products and to offer financial assistance to qualified individuals (QIs) in the form of advanced payments of the premium tax credits (APTC) and cost-sharing reductions (CSR). The ACA requires integrated support to ensure individuals enrolled in Qualified Health Plans (QHPs) in the Exchanges are enrolled in the right QHP, at the right time, and with the correct amount of APTC and CSR.

The Federal Exchange Programs System (FEPS) is the processing system established to operate, coordinate, and associate the Exchange programs, including enrollment processing. In order to ensure accurate enrollment information, CMS is required to reconcile enrollment records with all participating issuers monthly, per 45 CFR part 155 Section 400(d). CMS has implemented processes, referred to as Enrollment Resolution and Reconciliation (ER&R), for identifying and reconciling gaps between issuer and Federally-facilitated Exchange (FFE) enrollment records and also for reconciliation between State Based Exchanges (SBEs) and CMS for the purposes of financial payment information reconciliation.

In addition, Section 1401 (a) of the Affordable Care Act requires that after the close of the tax year, the Individual Marketplace will report to the Tax Filer and IRS on individual market policies purchased through the Marketplace. The Exchange is required to file an annual report with the IRS and furnish the Health Insurance Marketplace statements, Form 1095-A, to individuals on or before January 31 each year.

There are three primary workloads:

• Enrollment Resolution & Reconciliation (ER&R): The purpose of the Enrollment Resolution & Reconciliation work is to provide the services necessary to reconcile discrepancies in enrollment and financial information shared between Exchanges, issuers, and the CMS in support of accurate enrollment data and financial payment data. The workload involves identifying, resolving, and communicating to stakeholders the root cause of enrollment and financial data discrepancies and resolving these discrepancies within the FFE. For State-based Exchanges (SBEs), the Contractor will coordinate with each SBE to help resolve discrepancies identified through the enrollment reconciliation process.
• Forms 1095-A Data Reconciliation and Reporting: The purpose of the Forms 1095-A Data Reconciliation and Reporting requirement is to provide the services necessary to research and resolve data discrepancies reported by FFE enrollees, issuers, the IRS, CMS, or any other allowable stakeholder regarding information that appears on FFE enrollees’ Forms 1095-A.
• Complex Case Help Center (CCHC): The purpose of the CCHC requirement is to assist consumers with complex enrollment and eligibility issues related to their coverage through the FFE. These services are critical to improve the consumer experience, specifically for those consumers with complex eligibility cases or members of difficult-to-enroll populations. This support will help to enhance and improve enrollment and retention in the Exchange for those consumers with complex cases.