User:Jtest58/sandbox

= 52.  Federally Facilitated Marketplace and KOLEA = The State has made a decision to transition from a ‘State-Based Marketplace’ (SBM) to a ‘Supported State-Based Marketplace’ (SSBM). As a ‘SSBM’, the State remains an ‘SBM’ while using Federal technology for eligibility and enrollment. In managing the ‘SSBM’, the State relies on the ‘Federally Facilitated Marketplace’ (FFM) platform. Through the FFM, individuals can apply for ‘Advanced Premium Tax Credits’ (APTC), and purchase health plans without any assistance.

Applicants who apply through the FFM are first assessed for Medicaid eligibility. If potentially eligible, the FFM sends the individual’s application information to KOLEA. KOLEA also sends to the FFM information on individuals denied for, and beneficiaries terminated from, Medicaid. These transfer of files are called ‘Account Transfers’.

This chapter covers the following topics:

-       How the Interaction Works

-       Inbound Account Transfers

-       Outbound Account Transfers

-       FFM Transfers Tab

Other relevant sections that are referenced throughout this chapter include:

-    FFM Application Entry, which is how a user processes FFM applications in the

FFM Application Entry queue

-    Create N39 – Account Transfer Notice

52.1    How the Interaction Works
KOLEA and the FFM interact together using a two-way exchange of applicant files via a web service. The interaction allows the sharing of application information. The figure below summarizes how this interaction works.

Figure 217 – FFM and KOLEA Interaction Overview

An individual’s application information is shared between the FFM and KOLEA using Account Transfers. At the time an individual applies for a qualified health plan through the Federal Government’s www.healthcare.gov website, the FFM makes an assessment on Medicaid or CHIP eligibility. If found potentially eligible, the ‘FFM Applicant’s information is transferred to KOLEA using an Inbound Account Transfer.

In a similar fashion, when an ‘Applicant’ or ‘Contact’ is denied or terminated from Medicaid coverage within KOLEA, an Outbound Account Transfer containing the application details is sent to the FFM as a referral. KOLEA is also required to respond to the FFM with an eligibility determination for all ‘Inbound Account Transfers’. These transfers which communicate eligibility decisions are known as ‘Referral Status Updates’.

52.2    Inbound Account Transfers
Inbound Account Transfers are incoming application files from the FFM. At the time an individual applies for a qualified health plan through the FFM, an assessment is made on whether the individual is eligible for Medicaid or CHIP. If an individual is deemed potentially eligible, the FFM transfers the individual’s application file to KOLEA. An Inbound Account Transfer occurs when:

-                   A new application is received by the FFM and the applicant is assessed to be potentially eligible for Medicaid or CHIP.

-                   A new application is received by the FFM and the applicant is determined ineligible for Medicaid, but still requests a full Medicaid determination.

-                   An FFM applicant who is enrolled in a qualified health plan reports a change to the FFM, causing them to be potentially eligible for Medicaid or CHIP (e.g, a change in income).

-                   An FFM applicant changes their personal details from their FFM account and they have already been assessed as potentially eligible (i.e. the FFM resends their application information to KOLEA after the reported change).

The following figure describes the general process of ‘Inbound Account Transfers’.

Figure 218 – Inbound Account Transfer Process

As shown above, the process begins when an FFM applicant is assessed by the FFM to be potentially eligible for Medicaid or requests a full determination of Medicaid. The FFM automatically sends the application information to KOLEA with a unique identifier called the FFM Application ID. Upon receipt of the FFM application, KOLEA creates an application record and populates an electronic application PDF with the FFM application information.

52.3    Mapping of Information from Inbound Account Transfers to KOLEA
An ‘Inbound Account Transfer’ is sent from the FFM with information relating to the FFM applicant. When a case is automatically created from the ‘Inbound Account Transfer’, KOLEA populates the case with the information provided in the ‘Inbound Account Transfer’. Refer to FFM Application PDF Mapping, which contains a full list of fields and where they are mapped to in KOLEA.

The FFM may send information for which KOLEA does not have a specific use, or which does not exactly match a list of predefined values in KOLEA. In some situations, if the type of information sent by the FFM does not match KOLEA’s predefined list of values, then the type of information is mapped to a generic value. For example, if a type of income cannot be matched, then KOLEA maps the type to “Other Earned Income.” A full list of the values KOLEA maps to generic values is identified in the table below.

Table 278 – Generic Mappings for FFM Values

52.4    FFM Application Mapping Related to Citizenship
KOLEA only stores one ‘Immigration Document Type’ in relation to citizenship; the ‘Inbound Account Transfer’ may send multiple document types. If this occurs, KOLEA maps the document type with the highest priority to the ‘Immigration Document Type’ field in the ‘Identifying Documents’ screen. This list of priorities for citizenship documents is shown in the table below.

Table 279 – Citizenship Priority Mapping for FFM Applications In contrast to Immigration Document Type, KOLEA maps all provided document numbers (e.g, I-94, Alien number, Passport number) to the ‘Identifying Documents – More Info’ screen, under the ‘Verification Items’ tab. This is shown in the figure below.

Figure 221 – FFM Applications and Immigration Documentation

KOLEA attempts to map all citizenship types and sub-types as accurately as possible for FFM applications. If the ‘Inbound Account Transfer’ indicates that an applicant is not a U.S. citizen and is lawfully present, but there is not enough information to match the applicant to a specific citizenship sub-type within KOLEA, then the citizenship type is set to ‘Lawfully Present’ with a sub-type of ‘Unknown.’ In this situation the applicant receives an ‘N01 – Additional Information’ notice to verify their immigration status within 90 days.

52.5    FFM Application Mapping Related to Income
The FFM may send KOLEA externally provided and verified ‘Social Security Benefit’ (SSB) Income information. This income information is mapped in KOLEA. The ‘Inbound Account Transfer’ may send both attested SSB income along with externally provided SSB income. In this situation, the verified income is mapped to the ‘Income’ tab instead of the attested income. The attested income is still available to view in the ‘Additional Application Information’ section of the electronic pdf.

The FFM may provide an income that cannot be matched to any existing income type. In these circumstances, KOLEA maps the income to ‘Other Earned Income.’

As with normal processing, KOLEA gives the income a start date of 90 days before the start date of the application month. This ensures that no missing information is raised for the income start date.

52.6    Start and End Dates for FFM Applications
FFM applications may not contain the start or end dates which KOLEA requires to successfully determine eligibility accurately (e.g, ‘Expected Due Date for pregnancy’). To ensure a successful determination of eligibility, KOLEA automatically sets these dates. These dates are shown in the table below.

Table 280 – Start/End Date Assumptions

52.7    FFM Application PDF Mapping
This is to be used as a reference to assist users in the understanding of case information that will be received from ‘Inbound Account Transfers’ from the ‘Federally Facilitated Marketplace’ (FFM), and where the information can be found within KOLEA.

In addition to listing the location for each application element in KOLEA, symbols are also used to provide an alternate way to visualize the case information locations.

Table 281 – Key of Case Information Symbols * Elements marked as being in the ‘Case List’ are located outside of the case in KOLEA. They are found by searching for the case in the ‘Case List’ and viewing the relevant column in the case applet.

Figure 222 - FFM Electronic PDF Step 1

Figure 223 - FFM Electronic PDF Step 2

Figure 224 - FFM Electronic PDF Step 2

-        The location of question 6c in KOLEA varies, depending on the household composition of the applicant. If an applicant is being claimed as a tax dependent by a tax filer within the household, that information can be found under the ‘Application Data – Relationships’ screen. However, if an applicant is being claimed as a tax dependent by a tax filer outside of the household, that information can be found under the ‘Application Data – Additional Information’ screen.

-        ‘Pregnancy Expected Due Date’ is not sent by the FFM, however KOLEA sets this date as 9 months from the application date. This field is found under the ‘Change of Circumstance – Medical Condition’ screen. However, since this information is not sent by the FFM, the expected due date is not present on the pdf.

-        The FFM does not have a question on their application relating to citizens of COFA nations (question 12g). However, it is possible for a lawfully present non-citizen to have an ‘Immigration Document Type’ of an unexpired foreign passport issued by a COFA nation. In this case, the proper Immigration status and sub-status is set in KOLEA under the ‘Application Data – Additional Information’ screen. Question 12g on the pdf remains unmarked.

-        The FFM does not send an employer phone number (questions 19 and 23, and Appendix A question 6), though it is possible for an applicant to provide a work phone number as their contact number. If this is the case, the phone number is listed on the pdf, under question 14 or 15, and in KOLEA under ‘Application Data – Communication Preferences.’

Figure 225 – FFM Electronic PDF Step 3 and 4

-        KOLEA does not use the total annual household income provided by the FFM. Instead KOLEA calculates this figure itself based upon the sum of all attested income information.

Figure 226 – FFM Electronic PDF Step 5

Figure 227 – FFM Electronic PDF Appendix A

Figure 228 – FFM Electronic PDF Appendix B

Figure 229 – FFM Electronic PDF Appendix C

52.8    Outbound Account Transfers
Outbound Account Transfers are outgoing application files sent from KOLEA to the FFM. These transfers are only sent to the FFM during the overnight batch. An ‘Outbound Account Transfer’ occurs when:

-       An applicant is denied Medicaid at the time of application for coverage, or when an existing contact has their Medicaid coverage terminated subject to:

-      The applicant/contact having the appropriate denial/termination ‘Reason Code’ (see table below)

-      All applicants on the application or contacts on the case have had their eligibility determined (i.e. no ‘Pending Benefit Statuses’)

-      The ‘Retry Count’ field under the ‘FFM Transfers’ applet is less than four (refer to FFM Transfers Tab for more information on unsuccessful transfers and retry counts)

-      An FFM application has been fully determined by KOLEA. This acknowledgement of a decision made is known as a Referral Status Update.

The general ‘Outbound Account Transfer’ process is summarized in the figure below:

Figure 230 – Outbound Account Transfer Process

52.9    FFM Transfers Tab
The ‘FFM Transfers’ tab is located under the ‘Cases’ section in KOLEA, and tracks both Inbound and ‘Outbound Account Transfers’ between KOLEA and the FFM. Users can use the tab to view individual ‘Account Transfers’ and determine whether they were successfully transferred between KOLEA and the FFM. The figure below shows the ‘FFM Transfers’ tab.

Figure 231 – FFM Transfers Tab

The fields within the ‘FFM Transfers’ tab are explained in the table below. Table 283 – FFM Transfers Tab Elements The success of each transfer is identified through the ‘Response Code’ and ‘Response Description’ fields. When there is an error in the sending of an ‘Outbound Account Transfer’, KOLEA automatically decides to either resend the transfer or prompt the contact/applicant to manually apply for coverage from the FFM through the sending of the ‘N39 – Account Transfer’ notice. After four unsuccessful transfer attempts (as displayed in the ‘Retry Count’ field), KOLEA automatically sends the ‘N39 – Account Transfer’ notice to the contact/applicant. Refer to the Create N39 – Account Transfer for more details. The applicable Response Codes along with KOLEA’s actions is described in the table below.

Table 284 – Account Transfer Response Codes