Health Insurance Reform: Standards for Electronic Transactions. e. Transaction Standard for Enrollment and Disenrollment in a Health Plan

10/16/2000

In subpart O, we proposed the ASC X12N 834 - Benefit Enrollment and Maintenance, Version 4010, Washington Publishing Company, (004010X095) as the standard for enrollment and disenrollment in a health plan.

Comments and Responses on the Transaction Standard for Enrollment and Disenrollment in a Health Plan

The majority of commenters expressed support for the selected standard.

i. Of those comments we referred to ASC X12N, the work groups determined that 124 comments identified areas where the implementation specification could be improved, and the appropriate changes were made.

ii. Ten comments identified business needs that ASC X12N judged could already be met within the current standard implementation specification. Detailed information on how the current implementation specifications can be used to meet these business needs has been provided by ASC X12N at the Internet site in §162.920.

iii. Twenty comments alleged technical or editorial errors in the standard implementation specification. A technical review of these issues was conducted by work groups within ASC X12N. The work groups determined that the 20 comments identified areas where the implementation specifications were in fact correct and that no changes were needed. Changes to the implementation specification were not required.

iv. There was one comment which identified a business need that ASC X12N judged could not be met directly within the current standard implementation specification. The implementation specifications could not be changed prior to the issuance of the final regulation because the X12 standards development process for modifying standards could not be completed in time. However, a review of the issue by the ASC X12N work groups has identified a means of meeting the business need within the existing implementation specification as an interim measure. Organizations and individuals who submitted such comments are encouraged to work with the DSMOs to submit a request to modify the national standard.

v. Comment: Several commenters said that health plans must be free to accept enrollment data in non-standard formats if that option is chosen by a sponsor. In the proposed rule we stated, we would require health plans to use only the standard specified in §142.1502 (63 FR 25293). Commenters suggested that we not include the word “only” in the final rule under health plan requirements. One commenter suggested the addition of the following language to the rule: “However, health plans may require trading partners to use the standard transaction to conduct business.”

Response: We recognize that entities that are not covered under HIPAA, such as sponsors of health plans, including employee welfare benefit plans, are not required to use the HIPAA standards to perform EDI with health plans. The proposed rule stated that health plans are required to use only the standard specified in §142.1502 for electronic enrollment and disenrollment in a health plan transactions. Sponsors, one of the primary trading partners with whom the health plans exchange enrollment and disenrollment in a health plan transactions, were proposed to be excluded from the requirements. Our reference to the requirements for health plans to accept “only” the standard specified was intended to preclude health plans from using data in formats other than the standard transaction when exchanging transactions with entities named in the law. It was not intended to impose requirements on sponsors. Thus, sponsors remain free to send enrollment data in nonstandard format if they choose, and health plans are free to accept the data.

We expect that sponsors may voluntarily accommodate a health plan’s request to use the ASC X12N 834 by directly submitting the transaction in standard format or by using a health care clearinghouse to translate non-standard data into the standard transaction.

vi. Comment: Several commenters said that the ASC X12N 834 should not be used to collect demographic data for public health and health data research. A number of other commenters said that the ASC X12N 834 should be used for this purpose. These commenters also recognized that the demographic data collected by the ASC X12N 834, such as address, could change frequently. Commenters noted that the data collected in the ASC X12N 834 is needed by the enrolling entity so that it can perform certain functions, such as determining the eligibility of a person for enrollment into their offered health plan.

Response: The ASC X12N 834 is used to enroll and disenroll subscribers in a particular health plan, and demographic data are included in the data content. The decision to include demographic data as required data content was made through the ASC X12N 834 work group following the usual standards development process. We support the inclusion of such data in the implementation standard. The collection of demographic data is a means of monitoring progress towards eliminating disparities in health care for populations that historically have experienced discrimination and differential treatment based on factors such as race and national origin. We recognize the ASC X12N 834 Benefit Enrollment and Maintenance transaction set as the most favorable vehicle for collecting these data due to the mostly static nature of demographic information. While the public health and health research community does not currently have access to the enrollment data, we support a secondary use of the ASC X12N 834 for public health and health research. We see this as a mechanism for opening the lines of communication between the health data research community and the holders of the data.

Current Departmental policy supports increasing the use of demographic data for researching disparities in health care among demographic groups. However, the research community generally does not have access to the data collected by sponsors on the ASC X12N 834. While the research community is not opposed to collecting demographic data on the ASC X12N 834, they have requested that this data also be collected on the ASC X12N 837. This request would make no change to the ASC X12N 834 implementation specification. Most of the demographic data in the ASC X12N 837 implementation specification is marked as not used. As stated above, most of the demographic data in the ASC X12N 834 is currently not available to the research community. The business needs of the research community must be presented to the X12N 837 work group for consideration in a future version of the implementation specification.

We recognize that the enrollment and disenrollment in a health plan transaction was designed for use mainly by sponsors, but sponsors are not required by HIPAA to use the standard. Additionally, the conditions for use of the demographic data are stringent, as follows: "This data should only be transmitted when such transmission is required under the insurance contract between the sponsor and payer and allowed by federal and state regulations." Therefore, we would not expect to see a widespread increase in the collection of demographic data when these standards are implemented for the first time. Nor would we expect that this arrangement would provide public health and researchers with increased access to demographic information because of the difficulty creating dependable linkages between enrollment and encounter data.

If demographic data were collected routinely, facilities would more easily demonstrate compliance with Title VII of the Civil Rights Act of 1964, the nondiscrimination provisions of health and social services block grant programs, and other program statutes and regulations which prohibit discrimination on the basis of race or national origin.

Therefore, the Department intends to work with the industry to support efforts to revise future versions of the Health Care Claims or Equivalent Encounter Information (ASC X12N 837) implementation specification to allow collection of demographic data. We also support conditions for collection of these data that are less stringent than specified in the enrollment and disenrollment in a health plan transaction implementation specification. Many claim transactions cannot be linked to their respective enrollment data. Allowing transmission of racial and ethnic data in both the enrollment and disenrollment in a health plan and the claim transaction sets will increase the probability that this important information is available for utilization review, quality of care initiatives, disparity and nondiscrimination monitoring, and research. The Secretary believes it is critical to collect these data for the following reasons, all of which are high priorities for the Department:

  • the need to measure racial and ethnic disparities in type, volume and appropriateness of care received.
  • the need to focus efforts in areas/populations/health plans where there is evidence of disparities based on race and national origin.
  • the need to monitor progress towards eliminating disparities in health and health care.
  • the need to monitor and enforce statutes and regulations that prohibit discrimination on the basis of race and national origin.

We strongly recommend that the health care industry, including the public health and research community, work with the appropriate content committees and standard setting organizations to come to consensus on an approach that will enhance the collection of demographic data as well as be acceptable to the entire health care community. Departmental representatives to these committees and organizations will participate actively in this process, including articulation of the essential business needs. A solution that has met the test of the consensus process may be adopted as a national standard under HIPAA. The solution should promote uniformity, comparability, and the increased availability of demographic data for entities that depend upon this data to monitor progress towards eliminating disparities in health care. As we work with the data content committees and standard setting organizations to reach consensus on an approach that will enhance the collection of demographic data, the Department plans to explore approaches, including demonstration projects, for promoting and facilitating the voluntary collection of high quality demographic data in the health care environment.

vii. Comment: We received several comments regarding the role and responsibility of State agencies’ use of the ASC X12N 834. One commenter stated we need to make it clear that if a State Health Agency does not participate in the enrollment function, it is not required to use the standard.

Response: Health plans, including State health agencies, are not required to conduct a standard transaction based solely on the fact that it is a standard transaction.

viii. Comment: Other commenters also asked what we recommend as a process and structure for the submission of monthly capitation claims from a managed care health plan to a State Medicaid agency.

Response: We interpret “process and structure” to mean implementation specification and standard transaction. Monthly capitation claims from a managed care organization (MCO) to a State Medicaid Agency do not fall within the rules we have established for transactions between health plans. The transaction does not meet the definition of a health care claim or equivalent encounter information transaction. It does not need to be conducted as a standard transaction.

ix. Comment: Another commenter said that an interface between a State and the State’s processing associate, specifically for data entry, should not be required to be in standard format.

Response: We agree. In this scenario, data entry does not fall within any of the definitions for standard transactions. Consequently, the communication for data entry purposes does not need to be in standard format.

x. Comment: Several commenters said that a State Medicaid program is excepted from using the ASC X12N 834 when contracting with a managed care health plan because it is functioning as a sponsor.

Response: A State Medicaid program is acting as a sponsor and is excepted from the HIPAA standard requirements only when purchasing coverage for its employees. The State Medicaid program is not acting as a sponsor when enrolling Medicaid recipients in contracted managed care health plans, and thus is not excepted from the law.

xi. Comment: Several commenters said that the ASC X12N 834 should not apply to the State “buy-in” process.

Response: The transmission between a State Medicaid Agency and HCFA for the purpose of buy-in is outside of the scope of this requirement. State buy-in, the process by which State Medicaid programs pay only the Medicare premium for certain categories of dually eligible individuals, is essentially a Medicaid subsidy, required under Federal law, of Medicare insurance. This transaction is neither an enrollment and disenrollment in a health plan nor a health plan premium payment transaction. It is a unique transaction created solely for the purpose of the buy-in program. States use a unique flat-file and coding structure for transmitting to HCFA a list of Medicaid beneficiaries who are already enrolled in Medicare whose income level entitles them to participate in the buy-in program for that month. HCFA then creates an internal billing file with accretions and deletions for each state. A paper billing notice, reflecting the total amount of premiums owed by the state for that month, is mailed to the state. The Medicaid agency sends premium payment to HCFA via Federal Wire to Treasury. No electronic health plan premium payment transaction occurs between HCFA and the Medicaid agency.