CMS Releases FAQ On Its New Proxy Direct Enrollment Pathway

In May of 2017, the Centers for Medicare and Medicaid Services (CMS) announced that it intended to make a new proxy direct enrollment pathway available for HealthCare.gov enrollees for 2018. The guidance provided that direct enrollment (DE) entities would have to be audited by third-party auditors for operational readiness before they could begin offering proxy DE. On July 18, 2017, CMS released at its REGTAP.info website (registration required) a series of frequently asked questions regarding the Third Party Operational Readiness Reviews (ORRs) for the Proxy Direct Enrollment Pathway.

In response to the first FAQ, CMS states that if an entity that hires an auditor to conduct an ORR for its approved proxy DE pathway, the same report can produce audit findings that could be used for all DE entities using the identical version of the entities approved proxy DE pathway. The secondary DE entity will have to attest to the accuracy and completeness of the ORR submitted by the entity that is providing the proxy DE pathway, sign the proxy DE agreement, and be responsible for complying with all applicable regulations and guidance, as well as its agreement. If a DE entity using another entity’s approved proxy DE pathway adds additional functionality, it will need to conduct and resubmit the original ORR report with additional findings for the additional functionality.

A second FAQ states that a DE entity may allow third-party agents and brokers who are registered with the federally facilitated exchange to use its approved proxy DE pathways to assist consumers in applying for premium tax credits and cost-sharing reduction payments and for selecting qualified health plans, but only if the third-party has its own proxy DE agreement with CMS. A DE entity may not embed tools or programming techniques in its proxy DE website directing consumers to unapproved websites. Each DE entity is responsible for ensuring compliance with the terms and conditions of its proxy DE agreement by all downstream third-party agents and brokers using its proxy DE pathway.

A third FAQ reiterates CMS guidance that proxy DE enrollment is only available for simple enrollments, and not for complex situations like multi-tax filer households, applications where a Social Security Number is not provided, or applications with non-United States-born citizens.

Finally, a fourth FAQ states that DE entities participating in the proxy pathway must support all household scenarios supported by the streamline application user interface. If in its readiness testing a DE entity identifies an eligibility scenario it cannot support in the proxy DE pathway, it must notify CMS and provide an alternate way for consumers to have their eligibility determined, such as using the exchange, marketplace call center, or the traditional direct enrollment pathway.

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