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The staff has been very busy until very late last night and making copies of everything so it is available. They will be on the website. The testimony that is not for the presentations from the presenters will be on the website later on.

Everyone will have access to that. That will be from the public in the audience. We also have Michelle monitoring on the website if there are any questions so that she can present those questions as well. That will be followed by questions and answers from the Review Committee members.

We also ask that you return to the audience once you are done doing your presentation and that the next panel gets ready to make that exchange in a timely manner.

We also ask that at the end of every break and at the end of lunch that you please return on time because we will be starting on time.

We will not be presenting any written testimony at the hearing. It will be only — testimony. We have had some plane issues. Some of our speakers may not be able to get here in time. We are seeing if we can ask them to do their presentations by phone. If they cannot, we are going to ask for written testimonies so that we will be able to have that available to everyone.

Also if there is a delay. Apparently, there is some problem on the trains. We will try to make movement on each of the panels. We may ask that you not follow the order that we have here because we want to accommodate those that are having difficulty in getting here. I just also want to say that we ask you all to please silence your mobile devices and move them away from the microphones. I already talked about speaking directly.

Restrooms are located to the left towards the lobby. Take your belongings with you at the end of the day. Leave your visitor passes at the security desk. I also want to alert you all that there are going to be fire alarms being tested throughout the day.

Do not leave. They are just being tested. We may have to take some pause as the fire alarms go. I apologize, but that is the fact that we have no control over. Thank you all very much. I just wanted to let you know on behalf of the Review Committee, we greatly appreciate your input and your perspective on these important topics. We are looking forward to it.

Thank you. I just wanted to say a couple of very brief words. As a new incoming chair of the National Committee, it is truly very exciting and incredible opportunity for the National Committee to take on this new role and start this journey.

In reality, this is a journey to looking to how to improve the effectiveness and the efficiency of the efforts that we all have undertaken over last 15 years on administrative simplification and make that a real two-word action rather than anything else.

It is very exciting. As I think Ob and Alix mentioned, we are starting this journey with this very extensive review of all the transactions.

In many ways, this will serve as the baseline for what we will be doing over the next several years as the National Committee acting as a Review Committee. I just wanted to say a few words and thank everyone again for your involvement and participation. I know this has been one of the most exciting and interesting areas in which the National Committee has engaged. And the interest in the industry has been quite overwhelming to say the least. Normally, we would have to look hard to find testifiers in many ways to come to do this.

This time I think they found us. Thank you very much. I will turn it back to the chairs. Thank you, Walter. Thank you, Terri and Alix. Very briefly, I do want to acknowledge and recognize Walter and Terri for their hard work, leading up to this point. I have participated in some of the planning, but between Terri and Walter, they really helped shape the Review Committee activities as well as panelists, especially Terri, who has been spending the past — is it two months or two years now in preparation for this.

Thank you both very much. Of course, my co-chair Alix for being here and being my sidekick and helping us along here. Without further ado, we are going to start right away. If you hear the fire alarm, it is not reflection on your testimony. It is not planned. We will go down the list with Don from — could you introduce yourself? My name is Don Petry. We do not participate on any state-based exchanges. The use of the and the standards in the exchanges is an interesting, evolving paradigm.

The implementations were required to be able to pass or exchange enrollment information between the exchanges and the issuers. As depicted in the overview, that starts the whole process flow. Currently, it is scheduled for January of The use of the transactions is mandatory. If you participate on the exchange, you have to adopt and use these. There is percent participation. The biggest barrier that we have seen or challenge from the issuer perspective is how to integrate the data that is being conveyed from the exchange to the issuer and how it reflects the regulatory or the business processes of the exchanges.

That has varied dramatically from what our normal commercial or other lines of business those requirements. It starts the whole flow. And it feeds for all the downstream exchanges that support that whole continuum of health care service delivery. But again, the differences between the exchanges and our normal business practices has been rather dramatically different. It requires issuers to track and reconcile data that is unique to the exchanges. That includes data for IRS reporting now.

These transactions have been used in addition to approximately a dozen different tactical proprietary file formats that have been developed to handle shall we say nonstandard issues as the exchanges have come on line and business processes have sprung up and been evolving. I am going to go through just a few quick differences. One of the things is the exchange coverage includes financial data with the enrollment. We now had to track advanced premium tax credits, cost-sharing reductions, user fees, things that we normally would not see in a standard The FFM does not generate maintenance transactions at this point.

It opens up a whole process of having to do an enrollment, termination, enrollment again, termination to add even the simplest change such as a phone number or correcting a typo in your name. This requirement forced issuers to have to save all of the data on the original transactions in order to be able to generate those back to the exchange. As things are evolving, the roadmap is being developed and it is a long-term development process. We would recommend that any formal assessment, revision or recommendations on the policies, processes, or transactions be held until we have an entire year operating with a stable set of policies and procedures from the exchange.

At that point then we have the information to truly go back and look at efficiencies. We are a national federation of 36 independent, community-based and locally operated Blue Cross and Blue Shield companies that collectively provide health care coverage for more than million members.

I did want to mention in this section that one contextual observation that we have is that there is a barrier that is applicable to all transactions due to the inherent distinction within administrative simplification of who is a covered entity and who is not.

That is, where the health care provider is a covered entity only when they choose to conduct the standard electronic transactions. We also run into this with the and transactions because many of our group customers are not covered entities as well. With respect to providers, they can continue to utilize paper, telephone, and other non-electronic methods. We also found it difficult to separate opportunities, barriers, and alternatives because in many cases, they really directly relate to each other.

With respect to the health plan enrollment and disenrollment and premium payment transactions, we think this is one set of standards where the value is not as directly related to the opportunities and barriers of the other standards to contradict what I just said.

Plans in general indicated that the value proposition would increase simply by a greater adoption of use by their trading partners. A significant barrier here is that many group health plans are not themselves a covered entity and therefore moving them to the use of the and standards is achieved only through the contractual portion of our relationship. It is not surprising that these employer groups do not have the technology infrastructure within their entity to implement an EDI transaction and spreadsheets or proprietary flat files are often more efficient for their business model.

Many of these groups have no other business functions, which utilize the X12 formats, and so development for an or is not prioritized for implementation. Plans have indicated that the value of these transactions would increase simply by more trading partners adopting them. We encourage NCVHS and HHS to examine approaches, which would increase adoption, thereby avoiding the maintenance associated with multiple channels of data input into enrollment systems.

Multiple input channels often result in increased customization of vendor tools, which increases costs as well as impacts resources needed for implementation. Use of the HIPAA-adopted standards by all trading partners regardless of covered entity status, enables the member data protections afforded by the HIPAA privacy and security rules to flow with that data as it moves through other hands and into other uses.

Those expectations are set and defined when the data is collected, created or possessed by a covered entity through the use of the HIPAA privacy notices. That these defined and explained privacy protections and permitted uses would continue being applied as the data moves through the health care information continuum is a reasonable expectation on the part of consumers and one that is better achieved through broader usage of the standard transactions through EDI channels.

The introduction of the and into the insurance exchange environment has been helpful, but it has also presented additional challenges due to the differences between the business of traditional group enrollment and the individual marketplace enrollment processes. The greater standardization that can be utilized across all enrollment processes will enable improvements to downstream processes such as eligibility claims, et cetera.

I am with Xerox Health Services. Xerox supports a number of different entities. We have a fair amount of commercial business that we are a clearinghouse for. That is the processing system. Four PBMs and two other. In the commercial, we are processing about 83 million transactions per year and on the Medicaid PBM side, we are processing about million transactions a year. There are a lot of transactions that are going through. I went through and I asked our staff about our enrollment participation.

And what I noticed was from a commercial perspective, we had — this is processing the 83 million transactions — zero enrollment transactions and zero payment transactions on the commercial side.

Interestingly enough, on the Medicaid side, I was actually very surprised to see that we actually had 34 million HIE enrollment transactions. That was on the exchanges. It is a very interesting thing when you talk about the impact of these transactions. The 51 million premium payments also were an interesting statistic. It is actually more than the enrollment transaction.

They are in use, but these are the exchange transactions. From a traditional use perspective and we have heard this. The enrollment transaction is generally used between employer groups to a payer for the purpose of enrolling their members.

It is easy. Deb Strickland. Here is her social security number. She is going to go in a group health plan with a whole list of other people. Generally, also spreadsheets can be used and other things. At one point, I heard one payer had different formats that they were able to receive enrollments, which of course is unruly, which is probably why this transaction was created in the first place. The downfall to that is that the enrollment sender is not a covered entity.

Some payers I have heard through my solicitation for this panel actually use third parties or TPAs that they have hired to collect all those different peripheral types of enrollments, turn it into an and then send it to them which is actually a pretty good model if you have a lot of disparate formats. Then we come upon the health care exchanges, which boosted the transaction flow considerably because all of the exchanges started using the with the layered CCIIOO Companion Guide on top of that.

This is in addition to your normal transaction. There was a companion guide that was worked on that had a lot of different other features and components to it that everybody had to abide by in order to interact with the federal exchanges. And also then they used the HIX guide. That was because it was designed for this purpose. To the point made earlier, these transactions that are being exchanged in the federal exchanges or from a Medicaid to a qualified benefit health plan or an MCO, there is a lot of different information that has to be communicated through the transactions.

It is not just Deb Strickland, her social security number, and what group they want you in. There is the deductibles, co-pays, cost share, lots of other things that have not evolved yet in the transactions that it needs to. There is an HIX guide that should be considered and to see if that makes up for any of the gaps that we have in the industry today. We have the HIPAA transaction that does not have a lot uptake because the fact that the other entity — sending it is not a covered entity.

But if you want to participate in the exchanges, that is a backwards requirement. But interestingly enough, that has actually had a larger impact than actually making a HIPAA regulation.

The motivation to participate on a marketplace resulted in higher yields and many people are participating and exchanging these transactions. Payers have a lot of other transactions that they need to focus on. There are a lot of changes in this next group. Is it worth putting forward another version of the that does not have a lot of adoption?

But I would say that consideration should be done to see if the HIX guide is a better match for the exchanges and may lessen the need for some of the additional tweaking and things that the industry has done on the marketplace. I would like to thank the committee for inviting ASC X12 to present. We feel that the transactions both enrollment and premium payment meet the majority of the needs of the industry. ASC X12 itself has not conducted any studies to determine the overall use so we cannot comment on that specific question.

From a barriers perspective and I think Gail has hit on it and Debra hit on it as well, there is a group that are not covered entities under the transaction. It causes issues with the adoption of the transaction. There are different difficulties and ease based on the fact that they are not covered entities and a lot of proprietary formats being used in many different formats. Where we see some opportunities is that through change requests brought forward to X12, we have made significant changes in some of the transactions and being able to automate the matching between the two transactions, between the enrollment and the premium payment to allow for a better exchange of the information and data.

We have also created the group enrollment, allowing for specific focused on individual markets enrollments. Again, there have been changes that have been made to allow for data matching between the two transactions. As previously stated, expanding the mandate to include all health enrollments and premium payment use would improve the efficiency and effectiveness of the transactions. ASC X12 has a change request process in place that allows for online submission for the industry and the stakeholders to submit change requests.

ASX X12 bases improvements and enhancements based on change requests that are brought forward. From the exchange perspective and the specific question, every enrolled individual in the FFM and the small members in the FF small health options program were enrolled using the enrollment and disenrollment transactions.

Most if not all of the state-based marketplace enrollments also used the enrollment and disenrollment transaction. Some of the small business marketplaces and the FF SHOPs use the actually premium payment transaction developed specifically for the health insurance exchange, the HIX The FFM scheduled date for implementation is January My name is Annette Gabel.

They have approximately members and they were named in the HIPAA transaction standards regulation as an entity that would create transaction standards for the pharmacy industry. They represent a number of entities. We have drug manufacturers, chain and independent pharmacies, drug wholesalers, insurers, mail order prescription companies, pharmaceutical claims processors, pharmacy benefit managers, physician services organizations, prescription drug providers, software vendors, telecommunication vendors, service organizations, government agencies, professional societies, and any other parties that are interested in electronic standardization within the pharmacy sector of the health care industry.

I am going to go through some of the responses. As far as the transaction, for the NCPDP community, the pharmacy benefit managers and the payer members use the X12 benefit enrollment standard, but it is not really being used for enrollment purposes.

We are using it or getting it from some of the health plans in the Blue Cross Blue Shield agencies to provide their eligibility information. They do that because they are using the for other purposes so it makes it easier for them to submit the information in a standard format that they are using for the rest of their business.

As far as the goes, there is very little use of the in the pharmacy industry. Some of the entities that were participating in the Medicare Part D program are using the for premium payment.

But the majority of that is being handled by a vendor. The from a processor, pharmacy benefit manager perspective is received from employers and from Blue Cross Blue Shield organizations. As stated earlier, some of those entities are not considered covered entities.

While we get the , it is not a required transaction for the purpose and because some of the individual companies are not considered covered entities. Going through the question, as far as the value of the and I am going to speak specifically to the because there is not a lot of use on the For the most part, the pharmacy industry, those that are using the , believe that it meets the pharmacy needs.

Any additional changes that we needed, we have submitted on behalf of the pharmacy industry and they are being accommodated in future versions. As far as the volume goes, the entities that did respond and I have to say we had a low response on this survey, but the entities that did respond say that they were receiving anywhere between 26 million and 28 million transactions per month, but that is a transaction.

It is not a total file. As far as barriers, most of the trading partners again the barrier being that they are not considered HIPAA-covered entities. It is not a standard that is used across the book of business. Again, it is an enrollment standard. It is not specifically to provide eligibility, but we do use it to get the eligibility information. As it relates to changes, as I said earlier, if there were changes, they have already been submitted to X12 for any changes that needed to be made.

They will be accommodated in the next version. And then you asked the question about enrollment and disenrollment and the premium payment as it relates to the health care exchanges. We are ahead so that is great. Are there any public comments? Are there any questions? It is very telling of the slide that is on the screen right now. It is the slide that tells enrollment transactions chose commercial business. Zero enrollment transactions. Zero premium payment. And then when it comes to MMIS and PBMs and others, there are a lot of health insurance exchange transactions being performed, enrollment and premium payment transactions.

I think, as it has been said, it was partly of course because that is a required transaction really in most insurance exchanges. Compared to the fact that in the commercial market, as has been said, one of the two ends of the transaction is not entity. My question — a couple of questions about that. Number one, into the future, do you see the continued separation between the enrollment and premium payment standard for the commercial business versus the standard that has been developed for the insurance exchange.

I think Stacey mentioned the possibility of bringing the two together. Do you see the opportunity into the future consider that the — there should be one for the entire industry rather than one for commercial and one for insurance exchanges. That is one question. And then the other question is for X What would be the timeframe for the next version of the transactions that have been referred to as there are several improvements and enhancements being made to the transaction?

What would be the timeframe for those? ASC X12 is currently in the process of working to change requests that we have received and to our change request system, evaluating the change request and developing business requirements and technical solutions. We have selected the next version for development, which will be at this time. That base standard will be published at the end of this year at which time we will be able to load that standard into our development tool that we use for creating the TR3s and start applying the changes that have already been developed through the process.

We are taking a look right now at our timeline that we had created for the next version, looking at the different milestones that are necessary, what has already been completed within that timeline, what still needs to be completed. We have not revised the timeline yet so I cannot give you an exact date, but we are working on it. And hopefully coming out of the fall standing meeting, we will have made the revisions that were necessary to that timeline to give a date of when we would be able to publish the next version, which is targeted at this time.

Again, they could be on a bar napkin. They could be on an Excel sheet. They could be being faxed so they go around our processing. To speak to the Medicaids and the way that the transactions are being used similar to eligibility. So a Medicaid that does business say with an MCO, they would want to send that information about all of the covered members that they have within the Medicaid to the MCO and say you are going to administer the plan on behalf of these people.

It is almost like an eligibility, but it is an enrollment. It is almost like a cross between them. I am almost thinking it has a different business use because of that nature because it is going from a payer to another payer to communicate additional information about what members, what deductibles, what types of plan attributes they have. Are they indigent in care?

Are they foster? There is different information that has to be communicated from a payer to an MCO or a payer to a QHP versus just an employer group who is just — to the payer to say enroll my employees.

Perhaps it might be an interesting thing to take a look at whether or not we need a different guide for the business. Maybe the HIX guide is that guide that does the business of both HIX and the unique business of payer-to-payer sort of enrollment, eligibility, what have you. I think from the perspective of can we do it in one guide, I think that is a question that has yet to be answered.

The business processes are different and exchange enrollment is always going to have a slightly different business rules than traditional commercial enrollment. Whether meeting those needs can be accomplished through one guide or it is easier to do two guides is something I think the standards organization will need to take a look at and I think they are prepared to take a look at that if I am correct. They are never going to be completely the same because enrolling an individual through a marketplace is very different than enrolling a group through a traditional group market.

We may see more alignment on the SHOP side, but definitely that straight FFM individual market is never going to completely align with how we do business in the commercial world. Predominantly it is on the large group side.

To the points that Gail raised earlier, your small groups are not going to do an EDI transactions are not something that they would do. That would be a barrier if that was imposed on them because they may be two people as a small group.

Definitely the question regarding is it an But that again is not what is now needed. It is a bit of a hybrid between an enrollment and an eligibility roster. It is somewhere between those two transactions. They created their own requirements for eligibility. Some of the information that is being required for the exchanges is very similar to what was required for Medicare Part D because there is all low income subsidy and very similar.

CMS created their own eligibility file for the prescription drug plan. If we are going to take a look at standards, we need to look at that as well and see how we can bring all of this together. I have heard some perspectives about covered entity dynamics, how do you motivate people to come to the table, some incentives are better than others to get compliance and use.

But I am not really clear from the commentary that I have heard from you whether you think you are looking for new regulations, clarifying regulation or if it is more about industry guidance to create if you are doing this, go down this path, if you are doing this, go down path. Does anybody have any commentary on that? The one concern I would have especially as it pertains to exchanges is they are evolving given the fact in two weeks they could be changing dramatically with the Supreme Court ruling.

It is going to be a number of years before all of the functionality is built out, implemented and has had a chance to settle. Through this right now, mandating anything on that is going to just make it more difficult because the business rules — that is why we have those tactical proprietary files that are being used right now until they can formalize and implement standard procedures to address how that data needs to be conveyed.

The and the are just the messengers. They are just conveying all of the data. It is the business processes and the regulations and the policies on either side that are needing to come into alignment.

The transactions that may need to have some additional code values or some functionality to add an additional looping structure, et cetera. But it is settling all of the policies and the regs on either side is really what needs to settle out and then you can look at how can the standards be most efficient whether it is an implementation guide specific to the exchanges or there is actual transactions and changes that are necessary or possibly even a hybrid transaction, a new transaction that addresses some of the needs.

Debra, I think we owe you for your comments. We will come back — five more minutes before next panel. I think we need to consider whether or not transactions are worth being pushed forward as the next HIPAA standard.

Is the enrollment transaction, the normal HIPAA enrollment transaction worth its value or should it be adopted on a voluntary type of perspective? If it is worth your while, you will do it voluntarily. If you are doing it now, it is fine to continue to do that voluntarily. But once those things are set, we do need to do a survey in an understanding of the things that are not working with the current transaction.

What with the transaction that they are using now is not working and what has to change. And then perhaps give that information to ASC X12 in order to decide do the transactions that exist today meet the need or do we need another transaction that serves different business needs that might be a hybrid to align with what the industry is demanding at this point.

GOSS: With regards to that, it sounds to me like if industry really has issues that they need to be participating in the business process or business requirement definition at X12 now to make sure that if they want the changes from their experiences although it sounds like we have some experiences to go through until this all settles out, but the industry needs to participate in the standards development organization efforts if they really want to make meet their long-term needs.

This is Walter Suarez. To that last point, I just wanted to ask this question because it has been in the news, not so much lately, but a few months ago the concerns and some ways strong concerns that industry-to-industry was expressing about the enrollment transaction in the health insurance exchanges with respect to yes, we have a very large amount of individuals being enrolled in plans.

The front end seems to be working now of course the websites for enrolling people. But in the back end apparently, the enrollment transaction was showing some issues and health plans were having to resort to some manual processing of some of those and obtaining information by phone and very fine information that was not being reported.

I just wanted to ask what is the perspective of the panel on the status of the use of in the insurance exchanges. Is it a much better experience now? Is it improving? Do you see still issues with respect to the use of that transaction in the insurance exchanges? We are seeing gaps in the transaction. There is data we cannot communicate because of the structure of the transaction. One example might be that a foster child is a covered member under our plan and they are the subscriber because all of our members are subscribers.

But I cannot identify that child as a foster because that qualifier does not reside at the subscriber level. Logistically, things of that nature have been found and there is different creative ways being done to get that information to the health plans and to the marketplace.

Applying a little creativity, you can get the data needed over to the entities, but that is not the spirit of the transaction. That is where we need to take all of those things and say where did we make these little one off changes and where did we put things that could just go into INS or something that is a very generic segment and what other information do we need to support in these transactions because there are gaps in the transactions.

And then it results in the plans not having the data they need at the end of the day. There are gaps. To the point, there are some gaps in the transactions. As mentioned earlier, that is something that can come through and go through the standards process to make recommendations for changes.

Where we have seen issues have been with either the business processes or the systems upstream from actually creating the transactions. An example of — if a consumer has filed an appeal and they are eligible for coverage with a retro-effective date, the can convey that retro-effective date for an earlier date of coverage. That is not an issue. The front-end systems being able to populate that date in the eligibility system.

That is where there may be an issue. That creates a gap in that you get an enrollment with a effective date that should have been a effective date. There are alternate, tactical approaches that have been created to be able to convey that information so that we can get the consumer with the correct coverage, the correct dates, et cetera.

That is part of what I was speaking to earlier as it is evolving and you have regulations. You have policy. You have systems that are all in a state of development and flux that once that settles out then it will be able to truly look back and say is it transactional.

What do we need to address? Is it an operational issue we need to address? Relating to CCIIOO of folks who are actually defining the upstream rules and capabilities of the exchanges, how are they engaged? How do they engage with X12 or the stakeholders to make sure that those changes are affected in the standards?

They are involved with the issuer community. They hold regular industry-wide calls with exchange participants. They have individuals within their organization that do work with X12 as far as Mike Cabral phonetic and others, that are knowledgeable in the transaction sets and bring that to X And then they also work with a smaller group of issuers to help bounce things off of and look at what is an appropriate solution or approach as well as they work extensively with the associations and the trades of the Blue Cross Blue Shield Association, AHIP, as far as that to have industry participation and input working with them.

That is from our perspective as to what I have seen. KOCHER: I think they have done an excellent job of really engaging with the stakeholders that are going to conduct the transaction. Our home care agency partners are in the Bronx, Manhattan and Westchester County and offer immediate employment opportunities to program graduates.

The program creates opportunities for Temporary Assistance for Needy Families TANF recipients and other low-income individuals by offering support and workforce skills needed to progress on a career pathway in the healthcare field. Services are available if you are selected to participate in HPOG and enroll with a partner agency. Eligible applicants will be selected by lottery to participate in HPOG.

Not all eligible applicants will be selected to participate in these opportunities. Your Montefiore Vocational Counselor will help you identify obstacles you are facing that interfere with your ability to get and keep a job as a home health aide. The Vocational Counselor can help you in removing these obstacles to help you succeed and advance in your new career.

Yes, Montefiore vocational counselors can help improve your current skills and refer you to additional training programs so that you have the opportunity to advance within the healthcare industry.

Yes, Montefiore vocational counselors will refer you to outside agencies that offer assistance with a variety of helpful services, including but not limited to childcare, transportation, financial assistance, housing, food pantries, clothing needs and more.

Your counselor will stay in contact with you throughout your Home Health Aide training. Vocational Counselors also stay in contact with your training agency and staff to ensure successful training completion and job placement. Your counselor will provide contact information so can you text, phone or set up an in-person appointment. Edith Bolanos Phone: Email: ebolanos montefiore.

 
 

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