Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: March 12, 2015

Program Area: Distributed Data Collection (DDC) for RA Including HCRP/EDGE Server

Question: How should issuers submit External Data Gathering Environment (EDGE) Server Enrollment Submissions (ESES) so terminated enrollee claims are not considered orphaned claims?

Answer: Under Marketplace rules, issuers are required to maintain a person as an enrolled member for 90 days if the member has financial assistance, and after 90 days of non-payment the person is terminated back to the 31st day. That member is enrolled for those 30 days and the issuer must pay all claims in that 30-day period. The issuer owes no money for claims outside that 30-day period of coverage. If there is a state grace period for a non-financial assistance member, the answer lies in whether or not the state requires coverage for the 30 days without retroactive termination. If the answer is yes (the person is covered without retroactive termination), then the person is considered to be enrolled even though the issuer did not receive a premium payment. If the answer is that the person is retroactively terminated, then the person is not enrolled and the claims should ultimately be rejected. Only report periods for which the person is considered enrolled, which is 30 days in Marketplace and up to state law period for outside the Marketplace. In all cases, when a person is considered to be enrolled despite non-payment of premium, the premium to be reported is the premium owed.

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