Benefits Enrollment

Recommendation, 2007 April 15

Editors:

Suneel Mendiratta, Employease

Kelly Cohen, Hewitt Associates

Kim Bartkus, HR-XML Consortium

Schema Editors:

Dan Diman, eBenX

Kim Bartkus, HR-XML Consortium

Contributors:

Members of the Benefits Enrollment workgroup

Abstract

This document describes an XML Schema that supports the transfer of benefits enrollment data between organizations (for example, a benefits administrator and an insurance carrier). This schema is part of the HR-XML Consortium effort to define an XML vocabulary to support business transactions in the Human Resource domain.

Table of Contents

1 Overview.. 4

1.1 Objective. 4

1.1.1 Changes in This Version. 4

1.1.2 Domain Issues. 5

1.1.3 Business Reasons. 5

1.2 Scope. 6

1.2.1 Major Components. 6

2 Supported Business Processes. 6

2.1 Trading Partner Roles. 6

2.2 Business Process Name. 7

2.2.1 Summary. 7

2.2.2 Use Case Scenarios. 7

2.2.3 Diagrams. 7

3 Schema Design. 9

3.1 Component Schemas. 9

3.2 Overview.. 10

3.3 The Enrollment Element 11

3.4 The BenefitsAdiminstrativeAffiliate Element 14

3.5 The Subscriber Element 15

3.6 Global Types. 18

3.6.1 The Coordination of Benefits Info Global Type. 18

3.6.2 The Dependent Data Global Type. 19

3.6.3 The Coverage Global Type. 23

3.6.4 The USTierCoverage Global Type. 24

3.6.5 The USSpendingAccountCoverage Global Type. 33

3.6.6 The USRateBasedCoverage Global Type. 38

3.6.7 The EmploymentData Global Type. 44

3.6.8 The MedicareData Global Type. 47

3.6.8.1 MedicarePartA.. 49

3.6.8.2 MedicarePartB.. 49

3.6.8.3 MedicarePartD.. 50

3.6.9 The MedicaidData Global Type. 50

3.6.10 The HIPAAData Global Type. 51

3.6.11 The PersonData Global Type. 51

3.6.12 The LanguageData Global Type. 56

3.6.13 The CarrierData Global Type. 57

3.6.14 The IdCardData Global Type. 57

3.6.15 The SchoolData Global Type. 58

4 Implementation Considerations. 59

4.1 Introduction. 59

4.2 Update versus Replacement File Reporting. 59

4.3 Complete Family Reporting versus Individual Changes Only. 60

4.4 Correcting Person Identifier, Name and Demographic Data. 60

4.5 Coverage Level for Dependents. 61

4.6 COBRA Eligible; Not Enrolled. 61

4.7 COBRA Enrolled; Premium Not Paid. 61

4.8 COBRA Enrolled; Premium Paid. 61

4.9 Receiving System Derives Group or Policy Numbers. 62

4.10 Coverage Terminations. 62

4.11 Split Family Enrollment 62

4.12 Originating SSN for Surviving Dependents. 63

4.13 Spending Account Enrollments. 63

4.14 Healthcare Spending Accounts (HSAs) 63

4.15 Dependent Life Enrollments. 64

4.16 Optional Information – not known by source system.. 64

4.17 Required Date Information – not known by source system.. 64

4.18 Current vs. Historical Tier Coverage. 64

4.19 Contact Information Use. 64

5 Appendix A - Document Version History. 64

6 Appendix B – Related Documents. 66

7 Appendix C - Business and Life Events. 67

8 Appendix D – Benefit Enrollment Glossary. 70

9 Appendix E – Component Enumerations. 71

10 Appendix F - Messaging Considerations. 74

1 Overview

1.1 Objective

This document describes HR-XML’s Enrollment schema, which is designed to support the transfer of benefits enrollment data between organizations (see Section 2, Supported Business Processes). A second document, Enrollment Reference Examples (see Appendix B – Related Documents), contains annotated examples illustrating how the specification can be used.

The current specification is largely focused on employee benefit plan enrollment scenarios within the United States. Some initial steps to localize US-only content have been taken in this version of the schema. As demand dictates, the workgroup (working with relevant HR-XML chapters) will add support for enrollment scenarios elsewhere in the Americas, Europe, Japan, or in other jurisdictions. The non-backwardly compatible changes for full localization will be made as additional jurisdiction-specific content is identified and added.

1.1.1 Changes in This Version

This version of the HR-XML Enrollment specification includes the following changes:

1. Gave names to certain anonymous types. This allows for better modularization, reuse, and handling by class generation tools.

2. Added “HSAVendor” element to “TierCoverage”.to better support enrollments in Healthcare Spending Account (HSA) programs. See Section 4.14, Healthcare Spending Accounts (HSAs) and Section 3.6.4, USTierCoverage Global Type. HSAVendorType extends the existing CarrierData data type. In addition to OrganizationName, OrganizationCode, and ContactMethod available in CarrierData, the HSAVendorType adds a UseDefaultAccountSponsor and a SignatureDate. The UseDefaultAccountSponsor is a Boolean that may be used to indicate whether the subscriber has elected the health plan’s default HSA vendor. SignatureDate indicates that the benefits administrator has obtained and has on file, the beneficiary’s signed election of the designated HSA vendor.

3. Added “Health Reimbursement Account” to existing enumerated SpendingAccountCoverage types. Existing enumerations were: FSA Health Care and FSA Dependent Care.

4. Added optional PlanStartDate and PlanEndDate elements under SpendingAccountCoverage. These elements are intended to be used when finer-grained “plan year” information is required. This might be necessary to handle special circumstances such as when the plan year may be less than a full year.

5. Within ContributionData, made the following changes:

· Made GoalAmount element optional (not relevant for all spending account coverage types)

· Added optional StartDate (LocalDateType). This is the date on which contribution changes become effective.

· Added optional FirstPayrollDate (LocalDateType). This would be an indication of the first payroll date on which contributions would start.

6. Added an optional AutoReimbursementIndicator element. This has enumerated values of “all”; “none”; and “byClaim”.

1.1.2 Domain Issues

Systems that store benefits enrollment data belong to many different types of organizations. The