A quick background on HIX: In March 2010, US President Obama signed two reforms one known as the “Patient Protection and Affordable Care Act” (PPACA) and the other known as Health Care and Education Reconciliation Act of 2010. Collectively these are referred to as Affordable Care Act or simply ACA. The reform is intended to reduce the overall costs of preventive care to individuals and governments and make healthcare accessible/affordable to all US citizens. Put simply, Health Insurance Exchange (HIX) offers an online marketplace for individuals and small businesses to purchase Qualified Health Plans (QHP) from various insurance companies to ensure the prices are fair and competitive to individuals and small businesses. ACA enables US states to build a such an exchanges as run by the State (State Based Exchanges or SBE), partner with one or more other states, or have the federal government build and run the Exchange or Marketplace (Federally Facilitated Exchange or FFE). You can read more about HIX from pointers in the References section.

From the technical side of things, there are two key EDI transactions which enable the exchange of information during enrolment and remittance by the user with a FFE or SBE. Below are both the flows:

Enrollment using EDI 834

In EDI 834, the ST03/GS08 segment remains 005010X220A1 after HIPAA Errata installation. The existing schema in BizTalk Server 2010 and later for HIPAA 834 can be used for HIX interactions.

For 834, the flow is as follow:

  • Individual logs-in to the FFE website, compares plans and selects a plan (QHP)
  • Individual or a broker on their behalf may also update member information, cancel, terminate or change an existing health plan
  • For the above updates, FFE will send the 834 transaction with enrollment information to the QHP provider
  • QHP Issuer responds back with a TA1 and 999 acknowledgements to confirm the transaction
  • QHP Issuer also responds back with 834 Confirmation transaction
  • With SBE, the SBE sends a copy of the 834 notification to the FFE

Remittance using EDI HIX 820

The current transaction used to communicate payment-related information, the HIPAA ASC X12 005010X218 (820), cannot provide the program-level payment information and does not meet the business requirements of the Affordable Care Act. As a result, the ASC X12 standards body has finalized the ASC X12 005010X306 (820), referred to as the "HIX 820" for use with remittance.

For 820, the flow is as follows:

  • Individual initiates a payment towards a plan
  • The exchange will send a 820 transaction with remittance information/premiums from the individual to the QHP provider
  • QHP Issuer responds back with a TA1 and 999 acknowledgement to confirm the transaction

BizTalk Server 2013 ships the new HIX 820 schema in the CU2 update from http://support.microsoft.com/kb/2892599. For earlier versions including BizTalk Server 2009 and BizTalk Server 2010, the schemas can be obtained by contacting Microsoft Customer Support Services per http://support.microsoft.com/kb/2882453.

References

-Karthik Bharathy

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