On March 23, 2010, the President signed into law the Patient Protection and Affordable Care Act (P.L. 111-148). On March 30, 2010, the Health Care and Education Reconciliation Act of 2010 (P.L. 111-152) was signed into law. The two laws are collectively referred to as the Affordable Care Act. The ACA creates new competitive private health insurance markets, or Federally-Facilitated Marketplaces – FFMs that have given millions of Americans and small businesses access to affordable coverage. Marketplaces help individuals and small employers shop for, select, and enroll in high quality, private health plans that fit their needs at competitive prices. By providing a place for one-stop shopping, Marketplaces make purchasing health insurance easier and put greater control and more choice in the hands of individuals in the Marketplaces.
As with the ACA, Congress also recognized the need for stronger consumer and stakeholder protections related to pricing and billing in health care and passed Title I (No Surprises Act) and Title II (Transparency) of Division BB of the Consolidated Appropriations Act, 2021, collectively referred to throughout as the No Surprises Act 2 (NSA). The NSA was signed into law on December 27, 2020, and established new protections for consumers related to price transparency and surprise billing in health care. For example, plans and issuers are required to provide an Advance Explanation of Benefits prior to scheduled services to include, among other things, a good-faith estimate of the cost of the service. They must also offer price comparison information to allow enrollees to compare the cost sharing for items and services furnished by any participating provider. And, it introduces new requirements on providers to ask about the individual’s insurance coverage status and provide a good-faith estimate of the expected charges when an individual schedules an item or service. As a result, CMS is developing a patient-provider dispute resolution (PPDR) process for uninsured individuals who are billed substantially more than estimated charges.
The NSA also takes significant steps to end surprise billing by building on existing provisions that require group health plans and issuers of group and individual health insurance coverage to cover emergency services without prior authorization, and at the same cost sharing for out-of-network services that applies to in-network services. The legislation also sets forth methodologies for determining the out-of-network rate that plans and issuers must pay providers, including air ambulance providers, for claims subject to surprise billing protections. If the plan or issuer and provider cannot agree on an amount during a 30-day negotiation period, the parties may choose to enter an independent dispute resolution (IDR) process.
Consumers applying for coverage through the Marketplace are able to receive application assistance from in-person assisters. In-person assisters help consumers obtain eligibility determinations and help them through plan selection, thus increasing the number of consumers with health insurance coverage. One of the primary functions of in-person assisters is to facilitate enrollment into healthcare coverage by obtaining a determination for advanced payment of premium tax credit, cost-sharing reductions, Medicaid, CHIP, and the Basic Health Program from the Marketplace. In order to facilitate these processes, in-person assisters require training that provides a basic set of knowledge of health insurance and various forms of coverage as well as an introduction into the mechanics of obtaining Marketplace Eligibility and Enrollment determinations. Additionally, assisters need an array of resources to rely upon to ensure that they are adequately prepared to support consumers as quickly as possible.
Enrollment assistance helps ensure that as many consumers as possible have the understanding needed to apply and enroll in health coverage. For the purposes of this SSN, “in-person assisters” may include Navigators, Certified Application Counselors (CACs), and Agents and Brokers. This work would focus on in-person assisters in FFMs and the CMS IT systems that support them and the new PPDR and IDR processes. Much of the in-person assister support content is developed by this task order then automated, stored and made accessible for them on the MATS Salesforce instance. The MATS Salesforce instance provides automated Certified Application Counselor (CAC) application processing, inquiry response and tracking, assister WBT ID generation and storage, and supplemental interactive Micro learning trainings. This work will also support in-person assister help desk support, the development and provision of assister continuing education programs, and the maintenance of assister email inbox operations.
The MATS Salesforce instance is also currently under development to include a module for an automated assister community tool called the Marketplace Assister Community (MAC) module. This module supports in-person assister consumer efforts with the Public Health Emergency (PHE) unwinding of Medicaid eligibility expansion by enabling assisters to leverage enrollment data and automate enrollment assistance reporting to CMS. Another essential support service provided to FFM assisters by this task order is the annual delivery of an estimated twenty hours of interactive, mobile-compatible, Web Based Training (WBT) curricula to another CCIIO IT system called the Marketplace Learning Management System (MLMS). The MLMS system is hosted and made securely and publicly available on CMS’ enterprise-wide Identity Management (IDM) portal. MLMS verifies the in-person assister IDs that are generated and stored on the MATS Salesforce system and connected with MLMS though an Application Programming Interface (API).
The MATS Salesforce instance is one of many CCIIO Salesforce instances that must maintain its compliance with the CCIIO-wide Customer Relationship Management System (CCRMS) Salesforce system security protocol boundary. In order to maximize efficiencies for CCIIO, this task order also enhances and maintains the Marketplace Plan Management Group’s (MPMG) System for Plan and Issuer Data and Reporting (SPIDR) Salesforce instance and the Marketplace Eligibility & Enrollment Group (MEEG) Salesforce Community Portal instance in compliance with CCIIO’s CCRMS Salesforce system security protocol boundary. Along with the MATS, SPIDR, and MEEG Community Salesforce instances, this work will also continue to support development, system integration, implementation and maintenance across multiple CMS IT systems to create stronger consumer NSA protections related to health care pricing and billing in the newly created IDR and PPDR processes. The No Surprises Act directed CCIIO to implement a federal Independent Dispute Resolution (IDR) process to protect against surprise medical bills. This task order will work with CMS and other stakeholders, including the Departments of the Treasury and Labor, to design, develop, and implement an automated federal independent dispute resolution (IDR) process; collect data on user fees from individuals who use the federal IDR process and pass that data to the CCIIO RARI Salesforce instance; certify IDR entities (IDREs), organizations charged with carrying out disputes; and collect quarterly data on group health plans or health insurance issuers offering group or individual health insurance coverage or types of such plans or coverage that have a pattern or practice of routine denial, low payment, or down-coding of claims, or otherwise abuse the 90-day period.
