Finding previously unidentified insurance coverage can feel a little like a game of hide and seek. Patients may not always be aware of their insurance or eligibility for Medicare and Medicaid, and, in an effort to both improve the patient financial experience and simultaneously improve collections, providers are often tasked with finding this information on the spot. Historically, providers have used demographic information like Social Security Numbers (SSN) as a means to verify patient identities and locate this information, but that tactic is increasingly unreliable as it is possible for more than one person to use the same SSN and SSNs are a lucrative route to stealing someone’s identity.
With this in mind, many health plans are no longer using SSNs as an identifying number for insurance coverage. In fact, the Centers for Medicare & Medicaid Services recently removed SSN-based Health Insurance Claim Numbers (HICNs) from Medicare cards and are now using Medicare Beneficiary Identifiers (MBIs) for Medicare transactions like billing, eligibility status, and claim status.
The latest health plans to remove this piece of demographic information is Health Net Medi-Cal and Health Net National. Effective September 25, 2020, the search options for eligibility for this plan have changed. Providers will ONLY be able to find and verify coverage with a subscriber ID.
“Providers are often tasked with finding this information on the spot.”
While Health Net Medi-Cal and Health Net National are the latest health plans to do away with demographic searches, it’s certainly not a surprising trend and more will likely follow suit.
Bridging the gap with historical data
Uncovering previously unidentified coverage is critical for providers as it helps to eliminate costly self-pay situations, bad debt write-offs and unwarranted charity designations. And, without the proper insurance information, patients also risk delayed access to care and other financial hardships.
With demographic searches on the decline, providers will need a more efficient and reliable way to search for coverage. As a data-driven company with a historical repository of claims data, Experian Health is uniquely positioned to help providers search for coverage.
Combining search best practices, multiple proprietary databases and historical information, Experian Health’s Coverage Discovery locates patients’ billable commercial insurances that were unknown or forgotten, and combs through Medicare and Medicaid coverage. This flags accounts that may have been destined as a write-off or charity and maximizes reimbursement revenue by identifying primary, secondary and tertiary coverage. Not only do fewer accounts go to bad-debt collections, but providers can automate the self-pay scrubbing process.
A tool like Coverage Discovery is even more beneficial for providers during COVID-19, where limitations of face-to-face contact make it more difficult to complete the usual coverage checks. Coverage Discovery empowers providers to facilitate coverage checks remotely, avoiding delayed reimbursements during a time when revenue streams are already feeling pressure.
“As a data-driven company with a historical repository of data, Experian Health is uniquely positioned to help providers search for coverage.”
Want to learn more? Contact us to see how Coverage Discovery can help find previously unidentified coverage and reduce bad debt.
Learn more about how your individual Marketplace information is used
This fact sheet provides more information about how your information is being used in the Health Insurance Marketplace® run by CMS, your rights to access records that are maintained about you, your right to file an appeal, and other helpful information. Review it carefully.
Click on the following to learn more about:
What is the Marketplace?
How does the Marketplace use my information?
Who can my Marketplace information be shared with and why?
Do I have to answer the questions on my Marketplace application?
Do I have to provide Social Security Numbers (SSN) for people listed on my application?
Can people who aren't U.S. Citizens apply for health coverage through the Marketplace?
What should I do if I think my eligibility results are wrong?
What are my rights regarding the information CMS has about me?
Read the official Privacy Act Statement required by the Privacy Act of 1974.
Read the Privacy Policy for how this web site operates.
What is the Marketplace?
The Marketplace is a resource where you can learn about your health coverage options, compare health insurance plans based on costs, benefits, and other important features, choose a plan, and enroll in coverage. The Marketplace also provides information on programs that help people with low to moderate income and resources pay for coverage. This includes ways to save on the monthly premiums and out-of-pocket costs of coverage available through the Marketplace, and information about other programs, including Medicaid and the Children’s Health Insurance Program (CHIP). In some states, the Marketplace is run by the state. In others it is run by the Centers for Medicare & Medicaid Services (CMS), a component of the U.S. Department of Health and Human Services (HHS). If you’re applying for health coverage in a state running its own Marketplace, visit HealthCare.gov and you’ll be directed to your state’s marketplace. This page describes how the Marketplaces run by CMS use your information, and does not apply to Marketplaces run by states.
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How does the Marketplace use my information?
As a federal agency operating the Marketplace and associated programs, CMS is required to protect the information it collects and maintains. CMS respects your right to privacy and will protect the information it maintains about you in the ongoing operation of the Marketplace in accordance with all required laws, regulations and standards. “You” refers to any person whose information is entered on your application, or those acting on such a person’s behalf.
CMS needs your information to determine eligibility for:
- Enrollment in a Marketplace plan, also known as a Qualified Health Plan
- Insurance affordability programs
- Certifications of exemption from the individual responsibility requirement
When you apply for health coverage or an exemption, your information may be used to:
- Help you with the application process
- Verify information like your identity and any income history you provide
- Give you accurate information about as many different cost-saving programs as possible
- Help you resolve questions about the results of your application, including an appeal if you decide to file one
- Communicate with you during the eligibility process
When you enroll in health coverage, your information may be used to:
- Help you enroll
- Report and manage the advance payments of premium tax credit and cost-sharing reductions to the issuer of your Marketplace plan, if you’re eligible
- Communicate with you throughout the enrollment process
After you enroll in health coverage, your information may be used to:
- Continue communications with you
- Help you keep your coverage up to date
- Verify your continued eligibility
- Perform ongoing execution of the functions of the Marketplace, such as operation of insurance affordability programs for those who are enrolled, and oversight of issuers of Marketplace Health Plans
- Respond to any consumer feedback or complaints you file
- Combat fraud and abuse in the federal health care system
- Respond to suspected or confirmed breaches of Marketplace security or confidentiality of information
Also, federal law (like the Privacy Act and Social Security Act) may require or permit CMS to share information we collect or maintain about you for other purposes. More information on the ways your information is allowed to be used and shared can be found in the System of Records Notice.
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Who can my Marketplace information be shared with and why?
CMS will only share your information as needed and allowed by the System of Records Notice or as authorized or required by law. Examples of when CMS may disclose your information to agencies or people who need the information for specific reasons are provided below. For more information, review the System of Records Notice.
When you apply, CMS verifies the information you provide with these organizations and agencies to determine your eligibility to purchase a qualified health plan through the Marketplace and, if you choose, for help paying for health coverage:
- Social Security may verify your Social Security numbers (SSNs) and citizenship status.
- The U.S. Department of Homeland Security may verify your immigration status and/or naturalized citizenship status.
- The Internal Revenue Service (IRS) may verify your household income and family size; the income of household members may also be verified with the Social Security Administration and with a consumer credit reporting agency
- A consumer credit reporting agency may verify your employment information.
- The employers listed on your application may verify your eligibility for employer-sponsored health plans.
- The State Medical Assistance (Medicaid) office, the Children’s Health Insurance Program (CHIP), the U.S. Department of Veterans Affairs, Medicare, Peace Corps, U.S. Department of Defense (for TRICARE), U.S. Department of Health and Human Services, the Office of Personnel Management (OPM), and the Small Business Health Option Programs (SHOP) that operate in your state may verify your eligibility for and/or enrollment in health coverage programs.
Not all applicants will need to provide all of this information. For example, you’ll be asked about your employment, income, and enrollment in health coverage only if you want help paying for health coverage.
You may decide to give permission to organizations or people who can communicate with the Marketplace about your application for such needs as resolving inconsistencies, or ensuring complete and accurate applications. Depending on your permission, they may include:
- Your authorized representatives
- Your CMS-certified agents, brokers, or the insurance company that issues your Marketplace health plan
Each application filer confirms that he or she is authorized to share information for everyone on the application. That way, the Marketplace has permission to share your information with your application filer.
Once you select coverage, CMS will use your information for purposes such as:
- Notifying employers on your application if you’re eligible for certain insurance affordability programs (advance payment of the premium tax credit or cost-sharing reductions).
- Transferring your enrollment information to the appropriate organization or agency. This might be the issuer of the Marketplace plan that you selected, or a Medicaid or CHIP agency.
- Making reports to the Internal Revenue Service about your enrollment in a qualified health plan through the Marketplace and about your eligibility for advance payment of the premium tax credit, cost-sharing reductions, and/or a certification of exemption from the individual responsibility requirement(s)
If you choose to submit an appeal, the information from your application and your appeal may be shared with federal and state agencies listed under #1 above in order to process your appeal.
To maintain Marketplace operation, CMS works with the following groups and may therefore share your information with:
- Contractors that perform functions for the Marketplace to accomplish the specific functions they’re engaged to perform.
- Other federal, state, or local government agencies to combat fraud, waste, and abuse and to respond to concerns about the security or confidentiality of information.
- Insurance companies that issue Marketplace plans and also the IRS, for the ongoing administration of advance payment of premium tax credits and cost-sharing reductions, if applicable to you.
- Issuers of qualified health plans and states, if you complain to us about a qualified health plan or an issuer, to notify the issuers and state about the complaints.
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Do I have to answer the questions on my Marketplace application?
You don’t have to give personally identifiable information (PII), including Social Security numbers. However, if you don’t give this information, it may delay or prevent the Marketplace from performing all functions, like telling you about getting help paying for coverage, or determining your eligibility for benefits, programs or exemptions.
If you aren’t exempt from the shared responsibility payment and don’t maintain qualifying health coverage for 3 months or longer during the year, you may be subject to a penalty.
Be sure to provide correct information. Anyone who fails to provide correct information or who knowingly and willfully provides false or untrue information to the Marketplace may be subject to a penalty and other law enforcement action.
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Do I have to provide Social Security numbers (SSNs) for people listed on my application?
People who apply for health coverage need to provide an SSN if they have one. An application filer must also provide the SSN of any tax filer who isn’t applying for health coverage if the tax filer’s tax information will be used to verify the household’s eligibility for help with paying for health coverage. Other people not applying for health coverage are encouraged to provide their SSNs to speed up the application process, but aren’t required to provide one. We use SSNs to check income and other information to see who’s eligible for help with health coverage costs. If someone wants help getting an SSN, they can visit socialsecurity.gov, or call 1-800-772-1213. TTY users should call 1-800-325-0778.
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Can people who aren't U.S. citizens apply for health coverage through the Marketplace?
Lawfully present immigrants can apply for health coverage. Applying or enrolling doesn’t make someone a “public charge”. This means it won’t affect their chances of becoming a Lawful Permanent Resident or U.S. citizen. (Exception: People receiving long-term care in an institution at government expense, like in a nursing facility, may face barriers getting a green card).
Immigration information entered into the Marketplace will be used for administration of the Marketplace and insurance affordability programs only. People who aren’t applying for health coverage don’t need to provide their citizenship or immigration status.
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What should I do if I think my eligibility results are wrong?
If you don’t agree with what you qualify for, in many cases you may be able to file an appeal.
You can appeal eligibility to buy Marketplace plans and also for enrollment periods. If you’re applying for help paying for coverage, you may also have the right to appeal eligibility for tax credits, cost-sharing reductions, Medicaid eligibility, and CHIP eligibility. If you qualify for tax credits or cost-sharing reductions, you can appeal the amount you’re eligible for.
Review your eligibility notice to find appeals instructions for each person in your household, including the number of days you have to file an appeal. Here’s important information to consider when filing an appeal:
- You can have someone file or participate in your appeal. That person can be a friend, relative, lawyer, or other person. Or, you can file and participate in your appeal on your own.
- If you file an appeal, you may be able to keep your eligibility for coverage while your appeal is pending.
- The outcome of an appeal could change the eligibility of other members of your household.
- Depending on your state and your eligibility results, you may be able to file an appeal through the Marketplace or you may have to file an appeal with your state Medicaid or CHIP agency.
To appeal your Marketplace eligibility results, you can mail an appeal form or your own letter to Health Insurance Marketplace, 465 Industrial Blvd, London, KY 40750-0061. For more information call the Marketplace Call Center at 1-800-318-2596. TTY users should call 1-855-889-4325.
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What are my rights regarding my information in the Marketplace?
- You, and people you give permission to, may see and request a copy of the personally identifiable information the Marketplace collects and maintains about you.
- You may question if the information CMS has about you is correct.
- You have the right to ask for an accounting of the entities or people to whom the Marketplace has disclosed your information.
- If you don’t understand the information on this page, you may contact the Marketplace for an explanation, and you can ask the Marketplace for a copy of this notice.