Season 2 • Episode 4

Regulatory Concerns In Enrollment Technology


Show Notes

There is a distinct advantage to enrollment technologies that are built specifically for CMS's enrollment and dis-enrollment regulations for Medicare Advantage and Part D.  One such specification includes the Application Programming Interface (API) integration of the CMS MARX database for the validation of eligibility for Medicare Part A, B and D. This is a unique function that allows for real-time eligibility validation within the enrollment technology and avoids the less timely alternative of using batch processes for file submission to CMS. Additionally, special election periods are factored in to the technology logic and consists of low income subsidies from CMS, moving service areas, Chronic Condition Special Needs Plans (CSNPs), and members losing employer-sponsored group coverage. 

Another CMS rule set defines whether an enrollment is complete or incomplete. Certain elements must be present such as: member's signature, responses to questions about other sources of coverage, ensuring the member's permanent address is within the service area. Incomplete enrollments are funneled through automated workflows to obtain missing information, for example, a request for information letter may be triggered. Once the membership is complete, changes in membership status or updates to information are initiated through the enrollment technology and flows to impacted systems. 

Because enrollment is the member's first touchpoint with the health plan, enrollment technologies should also enable other downstream activities like claims processing, vendor integration, and member correspondence so each aspect of the member experience feels seamless and promotes a cohesive brand identity for the health plan. 

About Our Guest

Dave Laity is the Product Director for Advantasure's Enrollment and Billing products. Dave has nearly 20 years of healthcare experience that include the development of enrollment solutions that focus on Medicare Advantage and Part D. 

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