Direct Enrollment and Enhanced Direct Enrollment

Direct Enrollment and Enhanced Direct Enrollment

The Center for Consumer Information & Insurance Oversight

Direct Enrollment/Enhanced Direct Enrollment Resources for the Federally-facilitated Exchange

Welcome

This page provides information about Direct Enrollment (DE) and Enhanced Direct Enrollment (EDE), and provides additional guidance and resources for web-brokers and issuers using or interested in these enrollment pathways. The DE and EDE pathways are only available for states that use HealthCare.gov to apply for and enroll in health coverage (states that use the Federally-facilitated Exchange [FFE], also known as the Marketplace, or State-based Exchange on the Federal Platform [SBE-FP] models). 

Introduction 

What Is Direct Enrollment (DE)? 

Direct Enrollment is a service that allows approved Qualified Health Plan (QHP) issuers and third-party web-brokers (online insurance sellers) to enroll consumers in Exchange coverage, with or without the assistance of an agent/broker, directly from their websites. 

In the “Classic” DE experience (as opposed to the newer EDE program described below), consumers start on a DE entity’s (e.g., issuer or web-broker) website by indicating they are interested in Exchange coverage. The issuer or web-broker redirects users to HealthCare.gov to complete the eligibility application portion of the process. After completing their eligibility application, HealthCare.gov redirects the user back to the issuer or web-broker website to shop for a plan and enroll in Exchange coverage. Issuer-specific and web-broker-specific information about DE is provided below.


What Is Enhanced Direct Enrollment (EDE)?

The Enhanced Direct Enrollment user experience goes well beyond the plan shopping and enrollment experience that is available via Classic DE. EDE is a service that allows approved EDE entities (e.g., QHP issuers and web-brokers approved to participate in EDE) to provide a comprehensive consumer experience including the eligibility application, Exchange enrollment, and post-enrollment year-round customer service capabilities for consumers and agents/brokers working on behalf of consumers, directly on issuer and web-broker websites. Through EDE, approved EDE Entities build and host a version of the HealthCare.gov eligibility application directly on their websites that securely integrates with a back-end suite of FFE application programing interfaces (APIs) to support application, enrollment and more. 
Please review the chart for more key differences. 

Key Differences: Comparing Classic DE to EDE

Functionality

Classic DE

EDE

Consumers start their Exchange shopping experience by visiting the DE entity website.XX
Consumers must visit HealthCare.gov at key points during the process to complete their application before enrolling in an Exchange planX 
Consumers stay on the DE entity site throughout the entire application and enrollment process. X
DE entities can customize the consumer Exchange eligibility application (within guardrails) on their websites. X
Consumers can return to the DE entity website to update their application when information changes throughout the year and update their coverage if they’re eligible for a Special Enrollment Period (SEP) due to certain life events. X
Consumers can upload documentation to resolve SEP Verification Issues (SVIs)/Data Matching Issues (DMIs) on the DE entity website. The Exchange retains responsibility for reviewing and determining the outcome of DMIs or SVIs regardless of how consumers send in documents (i.e., EDE website upload, HealthCare.gov upload, or mailed in). X
Consumers can view the status of their enrollment, SVIs, and DMIs on the DE entity website. X
Consumers can download Marketplace notices directly from the DE entity website. X
DE entities own and manage all communications directly with the consumer (rather than via HealthCare.gov) wherever feasible. X

How Do Issuers and Web-brokers Implement EDE?

Issuers and web-brokers can participate in EDE as a primary EDE entity, or as an upstream EDE entity. Primary EDE entities build the EDE platform, whereas upstream EDE entities leverage a primary EDE entity’s platform, usually with customized branding for the upstream entity. 

  • Primary EDE entities that build an EDE platform are required to integrate with a suite of more than 20 APIs that facilitate the eligibility, enrollment, and post-enrollment experience.
  • Primary EDE entities must undergo an extensive third-party audit of their EDE application and privacy/security structure, along with a CMS approval process and ongoing monitoring.
  • Upstream EDE entities that leverage a primary EDE entity’s platform, with only minor branding changes, are generally not subject to an audit of their application and privacy/security structure. However, if an upstream EDE entity wishes to make other deviations from an approved primary EDE entity's platform, the upstream EDE entity may also be subject to an audit. Upstream EDE entities that do not intend to build their own EDE pathway should refer to the list of approved EDE entities (PDF) to identify potential partners.

It is important to note that the Exchange retains responsibility for making eligibility determinations. The Exchange will communicate those eligibility determinations to the EDE entity via the EDE APIs, and the EDE entity will display the results to the user on the EDE entity’s website. 

In addition, the issuer will continue to receive its 834 enrollment transactions for all enrollments from the Exchange regardless of whether the enrollment is completed on an EDE entity website or on HealthCare.gov. (Note: 834 files aren’t sent to the primary EDE entity unless that entity is the actual issuer associated with the enrollments.) 

How Should Issuers and Web-brokers Initiate the EDE Onboarding Process?

DE entities who wish to offer EDE should take the following steps:

Approved EDE Entities List

The following document contains additional information on all approved EDE web-brokers and issuers including primary and upstream entities: Entities Approved to Use Enhanced Direct Enrollment (PDF)

DE Web-brokers in the Federal Health Insurance Exchange

What Is the Process for Web-brokers to Offer Direct Enrollment (DE)? 

Prospective web-brokers can request approval to enroll consumers in Exchange coverage through DE or EDE by initiating the web-broker onboarding process; web-brokers may onboard year-round. A web-broker may be an individual agent or broker, group of agents or brokers, or business entity. 

Prospective web-brokers must build a website that complies with CMS requirements, pass a pre-approval website review conducted by CMS, and implement the technical requirements to connect with FFE through the DE pathway. These technical requirements include understanding how to create and digitally sign Security Assertion Markup Language (SAML) responses and how to invoke Simple Object Access Protocol (SOAP) web services. In addition, prospective web-brokers must complete operational readiness review requirements, including the privacy and security assessment and business requirements described in the Web-broker Operational Readiness Reviews for the Classic Direct Enrollment and Enhanced Direct Enrollment Pathways and Related Oversight Requirements (PDF); business requirements include completing a data request form, completing end-to-end testing with the CMS Data Services Hub, having a designated representative complete FFE registration, and signing a Web-broker Agreement with CMS.

For more information on the web-broker requirements and onboarding process:
•    Review Web-broker Operational Readiness Reviews for the Classic Direct Enrollment and Enhanced Direct Enrollment Pathways and Related Oversight Requirements (published in January 2024) (PDF) 
•    Then contact CMS at directenrollment@cms.hhs.gov to move forward with the process 

DE QHP Issuers in the Federal Health Insurance Exchange

What Is the Process for QHP Issuers to Offer Direct Enrollment (DE)?    

At any time, issuers that are providing QHPs on the FFE can request to participate in DE by submitting a Hub Onboarding Form, according to the instructions on the form, located on CMS zONE at https://zone.cms.gov/document/hub-onboarding-form. Once the Hub Onboarding Form is submitted, CMS will provide additional instructions. 

Issuers must meet CMS’ regulatory requirements, have a secure website, sign a QHP certification agreement with CMS and be able to implement the technical requirements to connect with the FFE through the DE pathway. These technical requirements include understanding how to create and digitally sign SAML responses and how to invoke SOAP web services.

For more information on the DE issuer requirements, review the Enrollment Manual for Federally-facilitated Exchange and Federally-facilitated Small Business Health Options Program.


Approved DE Entity Lists 

The FFE Direct Enrollment Web-broker List (PDF) contains the names of web-brokers participating in the FFE that have signed 2023 Web-broker Agreements with CMS and completed FFE registration for the 2023 plan year. This list contains web-brokers whose requirements have been verified to use the classic DE pathway. CMS will update this list on a periodic basis.

Consumers may find information about issuers and web-brokers offering DE and/or EDE in their state on HealthCare.gov at https://www.healthcare.gov/direct-enrollment/.   

Key Resources
Direct Enrollment Guidance (Issuers and Web-brokers)

Additional resources are available on CMS zONE, accessible via the CMS Enterprise Portal. New users must request access through the CMS Enterprise Portal. CMS zONE site access is restricted to participating web-brokers, issuers, and affiliated auditors only.

Enhanced Direct Enrollment Resources (Issuers and Web-brokers)

Web-broker-only Guidance

Additional resources for agents and brokers can be found on the Agents and Brokers Resources webpage.

Direct Enrollment Help Desk

Please contact directenrollment@cms.hhs.gov with any questions regarding web-broker onboarding, DE and EDE policy, compliance, or operational questions.

 

 

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Page Last Modified:
09/30/2024 10:58 AM
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