Enhanced Direct Enrollment (EDE) API Companion Guide

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CMS FFECompanion GuideCenters for Medicare & Medicaid ServicesFederally Facilitated MarketplaceContract HHSM-500-2015-00246CEnhanced Direct Enrollment (EDE) APICompanion GuideVersion 5.6August 17, 2020i

CMS FFECompanion GuideDocument ControlAuthorVersionRev. dateSummary of a, SeanSong1/23/2018Initial VersionAllAllScott Bickle, 2.0AlexandraAstarita, SeanSong3/15/2018Incorporated Client FeedbackAllAllNikita Veera, 3.0Abigail Flock10/22/2018 Updated Notice Retrieval SectionAdded HCV Section8.213,14,23, 24JoshuaHalsey4.012/27/2018 Updates Throughout and AddedAdditional SectionsAllAllJoshuaHalsey4.11/25/2019Added additional clarification toSection , JoshuaHalsey5/10/2019Added Section 9.1.1, Added Section12.1, Updated Section 15.1, AddedSection 15.1.1, Added Section 15.2.1,Added Section 16, Added Section 179.1.1,12.1, 15.1,15.1.1,15.2.1, 16,1720, 21,24, 27,28, 29,30, 31,32JoshuaHalsey4.37/11/2019Updated Section 16.2, Added Section16.2.1, Added Section 16.2.2, AddedSection 47/19/2019Updated Section 5.1, Added Section7.4.25.1, 7.4.27, 8,19JoshuaHalsey4.58/5/2019Added Section 9.1.19.1.121-23JoshuaHalsey4.69/9/2019Added Sections 14.3 and 15.1.214.3,15.1.231,33-34ii

CMS FFEAuthorCompanion GuideVersionRev. dateSummary of ChangesSectionPageJoshuaHalsey4.712/3/2019Added updated EDE end-to-end flowdocument to Section 1.2.11.2.11-2JoshuaHalsey4.81/13/2020Added Update Policy API to Section1.2.4. Added Section 17 for theUpdate Policy API.1.2.4, 175, 4041JoshuaHalsey4.91/14/2020Updated Section 17 to includeadditional information related tocancellation/termination dates.1741JoshuaHalsey5.01/16/2020Updated Section 17 to includeadditional information related to PPScancellation dates.1741JoshuaHalsey5.13/24/2020Added Section 3, includingSubsections 3.1, 3.2, 3.3, and 3.4.Added Sections 6.1.1.1 and 17.3.Updated Sections 6.1.1, 15.2.1, and17.2.3, 3.1, 3.2, 5-11,3.3, 3.4,16, 42,47-516.1.1,6.1.1.1,15.2.1,17.2, 17.3JoshuaHalsey5.24/1/2020Added updated EDE flow document,including cancel/term and BAR optout functionality to Section 1.2.1.Clarifications to BAR opt-out businessrules in Section 17.3. Added newRIDP and FARS endpoints to Sections3.2.1.3 and /5/2020Updated Section 9.1.1, to add9.1.1clarification around allowable optionsfor display of active and ed Section 17.3.1, which includes 17.3.1example BAR opt-out messaging.51-53JoshuaHalsey5.57/19/2020Made a number of updates to Section15, including adding Section 15.1.1.1and correcting guidance in Section15.1.4.1539-42JoshuaHalsey5.68/17/2020Added Section 12.3, which includesguidance on SES optimistic lockingerrors.12.3361, 8, 9,49-51iii

CMS FFECompanion GuideTable of Contents12345678Introduction . 11.1 Purpose. 11.2 Overview . 11.2.1 High-level End-to-End Flow . 11.2.2 Consumer APIs . 21.2.3 Eligibility APIs . 31.2.4 Enrollment APIs . 4Assumptions. 5Basic API Usage Information . 53.1 Data Services Hub (DSH) Onboarding . 53.2 API Endpoints . 53.3 API Headers . 103.3.1 Role ID . 103.3.2 User ID . 113.3.3 Role ID and User ID for API Calls Made on Behalf of the EDE Entity . 113.4 API Requests that Require a Prerequisite Store Permission or Store ID Proofing APIRequests . 11ID Proofing . 124.1 ID Proofing Overview . 124.2 Store ID Proofing Service Flow. 13Permission . 145.1 Permission Overview . 145.2 Store Permission Record Service Flow . 145.3 Consumer Revoke Permission . 15EDE Person Search . 156.1 Person Search Overview . 156.1.1 Agent/Broker (UI) Search vs. Consumer (Back-End) Search . 166.2 Search Combinations . 176.2.1 Minimum Search Criteria – EDE Consumer Flow . 176.2.2 Minimum Search Criteria – EDE Agent/Broker Flow . 176.3 Search Results . 186.3.1 Person Search Response Data Elements . 196.4 Determining Whether a New Application Needs to Be Created or Whether an ExistingApplication Should Be Used. 206.4.1 When to Use an Existing Application . 206.4.2 When to Create a New Application. 21Notice Retrieval . 227.1 Notice Retrieval Overview . 227.2 Searching for Metadata Record – Retrieving DSRS ID . 227.3 Retrieving Notices . 247.4 Form 1095-A Overview . 247.4.1 Retrieving and Displaying Form 1095-A . 257.4.2 Form 1095-A Notice Retrieval Testing . 25Document Upload . 25iv

CMS FFE91011121314151617Companion Guide8.1 Document Upload Overview . 258.2 Uploading a Document . 268.3 Providing Document Feedback to Consumer . 26Get Enrollment . 269.1 Get Enrollment Overview . 269.1.1 UI Display of Get Enrollment Data. 279.1.2 EDE Issuers – Using Get Enrollment as a Standalone Tool . 30DMI . 3210.1 DMI Overview . 3210.2 Consolidated Status. 33SVI . 3311.1 SVI Overview . 3311.2 Consolidated Status. 34Standalone Eligibility Services (SES) . 3512.1 SES Overview . 3512.2 Health Coverage Verification . 3512.3 Optimistic Locking . 36Payment Redirect . 3713.1 Payment Redirect Overview . 3713.2 Payment Redirect Response. 3713.3 Payment Redirect Integration Requirements . 38Legacy DE Services – Fetch Eligibility and Submit Enrollment . 3914.1 Fetch Eligibility . 3914.1.1 Variable Eligibility Data . 3914.1.2 Plan Category Limitations (aka Metal Level Plan Restrictions) . 4014.1.3 Get App Address Requirement – Phase 3 EDE Entities Only . 4114.1.4 Allocation of APTC to Enrollment Groups. 4114.2 Submit Enrollment . 42Event-Based Processing (EBP) . 4215.1 Event-Based Processing Overview . 4215.2 Email Toggle Functionality . 4315.2.1 EDE Requests to Disable FFM-Generated Emails . 4315.2.2 EDE Entity Email Requirements and Recommended Best Practices . 4415.2.3 Email Groups. 46Update Policy . 4716.1 Update Policy Overview . 4716.2 Update Policy API – Cancellation/Termination Business Rules . 4816.3 Update Policy API – BAR Opt-Out Business Rules . 4916.3.1 BAR Opt-Out Messaging . 51Performance Testing . 5417.1 Performance Testing Overview . 54v

1 Introduction1.1 PurposeThe Enhanced Direct Enrollment (EDE) API Companion Guide serves as a reference guide toassist an EDE entity with their EDE Application Program Interface (API) integration process.This document will outline the intent of the EDE initiative as well provide high-level, and insome instances detailed, information on the use of each EDE API. This document is notintended to be the sole source of documentation outlining EDE API integration requirements,and instead is intended to serve as a compliment to the other EDE integration documentation thatis available on zONE at llment-ededocuments-and-materials.1.2 OverviewClassic Direct Enrollment (DE) is a means by which private entities, such as web-brokers andissuers, provide a plan shopping and enrollment experience for consumers as an alternative toHealthCare.gov, while offering the same benefits and subsidies as the Marketplace. Currently,DE entities use the HealthCare.gov Classic DE program to facilitate enrollments in two ways: 1)they provide a shopping and enrollment experience directly to consumers through their ownbranded website, or 2) they provide a platform or type of portal for agents or brokers to use whenassisting consumers in shopping for and enrolling in coverage. When using Classic DE, theeligibility application is completed on Healthcare.gov, and then the consumer or agent/brokeruses plan comparison tools on the DE entity’s site to shop for and select a plan. This currentprocess is referred to as a “double-redirect” because when an eligibility determination isrequired, the consumer is first directed from the DE entity website to HealthCare.gov, and thenwhen the eligibility information is entered and the eligibility determination made, the consumeris redirected back to the DE entity website for plan selection and enrollment.Enhanced Direct Enrollment addresses the pain points faced in the current Classic “doubleredirect” DE process. EDE uses an API-based approach, which allows EDE entities to facilitatenot only the plan shopping and enrollment experience, but also allows EDE entities to facilitatethe eligibility application process and post-enrollment activities. Below, readers will findinformation pertaining to each EDE API.1.2.1 High-level End-to-End FlowBelow is the high-level end-to-end workflow for the EDE process. This process depicts thevarious frontend and backend interactions for EDE. The flow represents the recommended highlevel process for the EDE user experience.EDE FEBEflows 20200320.pdf1

1.2.2 Consumer APIsConsumer APIs enable stakeholders to search for, modify, store, upload, and retrieve consumerdata. These APIs are not specific to the eligibility application or enrollment.The table below outlines the consumer APIs that are available.Table 1-1 - Consumer APIsAPIBusiness CapabilityPersonSearchThis service allows for a stakeholder to search for a consumer’s existing applicationwithin the FFE. A user may search for a person using a specific set of data, outlinedlater in this document.Get DMIThis service provides a high-level overview of any Data Matching Issues (DMIs) tied toa consumer. A DMI is created when a consumer attestation does not match datareturned from a trusted data source during eligibility determinations. A DMI may affect aconsumer’s ability to enroll in a Qualified Health Plan (QHP). Consumers have a certaintimeframe in which to resolve DMIs, which is captured in a timer.Get SVIThis service provides a high-level overview of any Special Enrollment Period (SEP)Verification Issues (SVIs) tied to a consumer. An SVI is created when a consumerattests to being eligible for a SEP that requires verification. A consumer may berequired to upload documentation proving that he or she is eligible to be granted theSEP. Consumers have a certain timeframe in which to resolve SVIs, which is capturedin a timer.StorePermissionThis service is used to store a set of required data when a consumer has authorized anEDE entity or agent/broker to submit API transactions on his or her behalf.RevokePermissionThis service is used when a consumer wants to revoke the authorization for an EDEentity or agent/broker to submit API transactions on his or her behalfStore IDProofingThis service is used to store a set of required data when a consumer has successfullyID proofed at the EDE entity.DocumentUploadThis service provides the capability to store documents and corresponding metadata.For EDE, consumers may upload documents through an EDE entity to resolve either aDMI or an SVI.NoticeRetrievalThis service allows authorized EDE entities to retrieve consumer notices directly fromthe FFE document storage via a time-expiring URL.MetadataSearchThis service provides the capability to search for metadata records tied to a consumer.This service will return metadata for notices tied to a consumer.2

APIBusiness CapabilityPaymentRedirectThis API allows stakeholders to redirect a consumer to their issuer’s payment websitefor their binder payment.Event-BasedProcessingThis API allows EDE entities to ingest certain events for consumers as they occur, andsubsequently enables EDE entities to distribute corresponding communications to theirconsumers.1.2.3 Eligibility APIsEligibility API’s enable stakeholders to create, update, view, or submit a Consumer’s applicationwithout ever going to the Exchange. The Eligibility API’s also enable stakeholders to retrieveand determine eligibility for Exchange coverage; this includes eligibility for Medicaid,Children’s Health Insurance Program (CHIP), Advance Premium Tax Credits (APTC), CostSharing Reductions (CSR), and Qualified Health Plans (QHPs). These APIs are primarily meantfor EDE flows, but some APIs may be exposed to additional external stakeholders.Table 1-2 - Eligibility APIsAPIBusiness CapabilityCreate ApplicationThis API is used to create an initial application for a consumer.Create Applicationfrom Prior YearApplicationThis API is used to create a prepopulated application for a consumer from a prioryear application.Update ApplicationThis API to modify or update an existing application, based on updates toattestations by the requestor.Add MemberThis API is used to add members to an application.Remove MemberThis API is used to remove members from an application.Submit ApplicationThis API allows a user to finalize and submit an application. The servicecomputes and/or re-computes events to ensure that all required fields are presentand valid as required to submit the application. Upon successful submission, theservice generates a submitted application that is immutable and can be used toprocess enrollment and other downstream processes.3

APIBusiness CapabilityGet ApplicationSummaryThis API provides a summ

Contract HHSM-500-2015-00246C ; Enhanced Direct Enrollment (EDE) API Companion Guide Version 5.6 August 17, 2020 : CMS FFE Companion Guide ii . Document Control . Author Versio n Rev. date Summary of Changes Section Page Abigail Flock, Alexandra Astarita, Sean Song 1.0 . 1/23/2018 . Initial Version . All . All . Scott Bickle, Alexandra Astarita, Sean Song 2.0 . 3/15/2018 . Incorporated Client .

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