General Integrations

What's the benefit of integrating with Oscar?

An ICHRA integration with Oscar allows ICHRA Admin Platforms to:

• automate their initial enrollment and payment setup
• automate change enrollment transactions: adding dependents, policy changes, address changes, terminations to coverage
• Real-time enrollment and payment data reconciliation (via API) or weekly data reconciliation snapshots (via flat file).

What types of integrations does Oscar support for ICHRA administrators?

For off-exchange ICHRA enrollments, Oscar supports the following methods of integration for enrollment and payment data:

1. ICHRA Connect API
   • Membership endpoint for managing enrollments and member data.
   • Payment endpoint for configuring member payments.
2. Combined File CSV Integration
   • Single combined enrollment & payment CSV file - daily batch (Oscar Inbound)
     • Payment instrument details (bank account information) is passed to Oscar with the enrollment data and binder payments and auto-payments are automatically enabled.
   • Oscar CSV Acknowledgement file - daily (Oscar Outbound)
   • Oscar CSV Enrollment Status file (Oscar Outbound)
3. Dual-file EDI Integration
   • Enrollment: Daily batch 834 EDI - inbound and outbound
     • TA1/999 Acknowledgement & Error response
     • CSV Reconciliation
   • Payment: Batch 820 EDI for payment remittance with ACH direct deposit For both the enrollment 834 EDI and 820 EDI implementation, we use the CMS implementation standards, with a modification to the 834 EDI standard to include employer information in the 2100D employer loop.

Implementations include error handling and both automated and manual reconciliation flows managed by our operations teams.

Can I request changes to the integration specification?

Yes. We are open to making changes to the integration specification to support your requirements. Reach out to us to discuss further.

Does Oscar have a REST API I can use?

Yes! See the API Documentation section for more details.

What is the typical timeline for integration?

Oscar works with each ICHRA administrator directly to identify their unique integration needs. This process can vary depending on the complexity of your system and the method of integration chosen. On average, it can take anywhere from a few weeks to a couple of months.

How can I integrate my ICHRA administrator platform with Oscar?

Thanks for your interest in ICHRA at Oscar! Please reach out to [email protected] to set up an integration or ask any other questions about ICHRA Connect.

Enrollment

General Enrollment

What’s the difference between enrollment.external_policy_id, enrollment.application_id and enrollee.external_member_id?

• enrollment.external_policy_id is the primary key. It’s the vendor’s identifier for a policy that remains constant across policy updates and is shared by all members on a policy. For example, a change sequence such as INITIAL ENROLL -> ADD_DEPENDENT -> UPDATE DEMOGRAPHIC should maintain the same external_policy_id for all members on the policy. However, the ID SHOULD change for situations such as policy change, e.g. due to a renewal.
• enrollment.application_id is vendor’s identifier for a specific enrollment application, and therefore only unique amongst initial enrollment and changes. This field is used by Oscar in a tracking capacity to augment the enrollment.external_policy_id. For example, if there is a change transaction for a family, there will be a new application_id, but the external_policy_id will remain the same.
• enrollee.external_member_id is the vendor's identifier for an enrolled member. This is used to ensure parity between vendor’s and Oscar’s identification of a member. Each member has their own ID (unlike external_policy_id) and the ID remains constant across time.

SEP and QLE

How do Special Enrollment Period (SEP) enrollments work through the integration?

For net-new enrollments, send an initial enrollment including the relevant Qualifying Life Event (QLE). For additions and changes to an existing enrollment, send a change transaction with the relevant QLE.

Is QLE documentation required for SEP enrollments?

Yes, QLE documentation is required for all enrollments.

Is QLE document upload supported through the integration?

Yes, you can automate QLE documentation uploads via SFTP. Oscar's process is documented here.

Renewals

Does Oscar support passive renewals?

Yes. Oscar will auto-generate passive renewal spans for eligible off-exchange members that have continuous coverage through the end of the year. Oscar will send a reconciliation file to all vendors after 11/1 to confirm members that have been passively renewed.

What happens if a member with a passive renewal makes changes to their upcoming year coverage?

If a vendor sends an active renewal due to member updates to coverage, it will overwrite Oscar's existing passive renewal.

What about members who don’t want to renew?

Oscar will need to be informed of their intent to terminate. Members can call Oscar directly or vendors can send a termination change transaction through direct integration.

If you need to terminate several policies in bulk and don’t have this function automated through the integration, Oscar can accommodate ad hoc requests during Open Enrollment. Please reach out to [email protected] with the list of members to terminate. Please attach a csv file and include the following fields for each member: Oscar ID, First Name, Last Name, SSN, DOB, HIOS ID, Termination effective Date, QLE (if not VOLUNTARY_WITHDRAWAL).

What about members who want to add dependents or make policy changes?

Adding dependents or making a plan change would be considered an active renewal. So vendors should send new applications for these scenarios.

How do I send active renewals to Oscar?

For CSV integrations, include ACTIVE in the enrollment.renewal_type field (column 26) if you are sending an active renewal.

Billing & Payments

Does Oscar accept credit or debit card information in the CSV enrollment file?

Oscar accepts ACH (Automated Clearinghouse) bank account numbers in the combined CSV enrollment and payment files, and ACH or debit card via API.

How can I update payment instruments?

Please include the new payment instrument in a subsequent CSV file. You must indicate on the row that the payment instrument is net-new. Oscar stores payment instruments as encrypted hashes and has no way of comparing them. If an eligibility change includes a new instrument, please specify this in the CSV.

How can I enable autopay?

Autopay is automatically enabled for all enrollments submitted via directly integrated partners.

How and when are payments made with autopay enabled?

Oscar will automatically draft the upcoming month’s billed amount from the provided payment instruments on the dates of your choosing. We recommend setting 2 autopay dates per month:

• Draft Date 1: mid-month
• Draft Date 2: end of month

This enables administrators to resolve any payment errors before the 1st of the month when unpaid members enter Grace Period. Remaining amounts can result from failed payments or amount changes. If members owe $0 at the end of the month, Oscar will not draft a second time.

Oscar drafts binder payments (aka first month bills) daily to ensure members are enrolled and effectuated promptly.

Where can I view upcoming autopay payment amounts?

Autopay will draft the amount in the balance column in the reconciliation file. Amounts are available at the member level, and may be summed for the total upcoming draft amount.

The balance column is more relevant than the total_premium column, because balance will include both overdue and upcoming premium amounts.

To view balance for a distinct family, filter on unique contract_ids. All members in a family will share the same contract_id.

Where can I check payment status?

In Oscar’s weekly reconciliation files. As a reminder, payments are automatically drafted from payment instruments shared via CSVs. The past_due_balance column will be populated if autopay failed or payments were not received.

One common reason for autopay payment failure is insufficient funds. This most often happens when monthly premium amounts increase above administrator payment thresholds.

Please inform Oscar if there is any risk of insufficient funds to cover retroactive premium changes. If you identify a risk, please share your allowed threshold for drafts $X over your expected amount.

How can I identify premium changes?

Example: A member’s premium increases mid-month after giving birth and adding their child to their Oscar plan.

Administrators can view amount changes in the weekly reconciliation file.

1. Identifying a premium change
   1. total_premium on the reconciliation file would change
   2. To understand the dollar amount change, you can compare total_premium across time periods for a member
2. Identifying the effective date of the premium change
   1. If it’s due to a dependent addition, effectuation_date for the dependent would tell you the date of the premium change
   2. Note: There is a row for each member. If 3 members are on the same policy, they will have 3 rows in the reconciliation file.
3. However, not all premium changes are due to a dependent add (e.g. member has a health change like adding tobacco use), and therefore won’t have a precise effective date. We do send the reconciliation file weekly, but if you need a more precise effective date for the premium change, you can contact Oscar.

How can I get a bigger picture of a member’s eligibility based on payments (or lack thereof)?

Oscar includes a policy_status column in our outbound enrollment file. These statuses represent member coverage eligibility. They can be reviewed with amounts in Oscar’s outbound reconciliation file to get a full picture of a member’s coverage status and why a member is in Grace Period, Cancelled, or Terminated if due to nonpayment.

Below is a complete list of statuses:

What is Oscar’s Grace Period policy for nonpayment?

ICHRA enrollees have the same Grace Period policy as non-ICHRA off exchange members. Members have a 30 day grace period after their first missed monthly payment.

If members do not pay their bill beyond the 30 day Grace Period, they are terminated on the first of the month following their missed payment to the last date of paid coverage.

I overpaid. How can I request a refund?

Overpayments will automatically be applied to the member’s future ICHRA bills. Refunds will be sent to the original payment method. If that payment method is no longer valid, Oscar will issue the refund to the administrator’s general account.