Continued Maintenance
Digitally manage members
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Digitally manage members
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In order to manage members, the group and members must first be loaded. Refer to the Existing Business flow for loading groups and members.
Subscribers and dependents can be added throughout the year after the open enrollment window closes and a group is established with a carrier. In order to accurately represent a subscriber and dependents we require all members of the familial unit with each request if they are part of the subscriber's coverage. When performing the addition of a subscriber (with or without family) send the enrollment data via a POST to /subscribers. Additionally, if there has been a qualifying life event, and one or more dependents needs to be added to an existing subscriber send a PUT to /subscribers.
When a subscriber has not been previously enrolled with the carrier through their employer (plan sponsor) you are adding the subscriber. In order to add the subscriber, you will send the subscriber's enrollment data via a POST to /subscribers. If the subscriber does have dependents as part of their familial unit, then these dependents and their coverage elections should be sent along with the subscriber in the same transaction. Some scenarios and QLE that can lead to the initial enrollment of a subscriber include:
New Hire
Loss of health coverage
Losing existing health coverage, including job-based, individual, and student plans
Losing eligibility for Medicare, Medicaid, or CHIP
Turning 26 and losing coverage through a parent’s plan
Changes in household composition (divorce)
Changes in residence
Becoming a U.S. citizen
Subscriber and dependent changes have a few nuances. For example: adding a dependent is a change to a subscriber but the addition of a new member! This scenario was showcased in the previous section for adding dependent. Subscribers and dependent changes are reported to carriers in a nearly identical fashion. A few of the supported scenarios include:
Location Changes
Plan Changes
Demographic Changes
In all scenarios where changes occur the entire familial unit should be sent via a PUT to /subscribers.
Don't forget that a change within a familial unit can impact multiple members in the same family. For example: terminating a dependent as the result of a divorce is a change to the marital status of the subscriber. This scenario and others like it will be addressed in a following section on terminations.
Dependents can be added during the initial enrollment of a subscriber or as part of an update to a subscriber as the result of a qualifying life event. If the dependent is to be included in the subscriber's initial enrollment refer to the section above. If the dependent is to be added to an existing subscriber then you will be sending the subscriber and dependent(s) dat via a PUT to /subscribers. Qualifying life events that can lead to the addition of a dependent include:
Marriage
Birth
Adoption
Loss of Coverage
Subscribers and dependents can be terminated from coverage as the result of a qualifying life event including a divorce, termination of employment, or a reduction in work hours. Subscribers who are terminating should be send along with their last date of termination and all active coverages should reflect the benefit end date.