Administrative Simplification Basics: Health Plan Enrollment and Disenrollment

Administrative Simplification Basics Series: 

Health Plan Enrollment and Disenrollment

Administrative Simplification includes standards for health care electronic transactions. Widespread use of the electronic standards for administrative transactions—where everyone uses the same language, format, and codes—can lead to substantial savings across the health care ecosystem.

Today, we’ll review one of the transactions: health plan enrollment and disenrollment.

This transaction helps keep health plans updated when plan members join, leave, or change their plan and/or benefits coverage.

The enrollment and disenrollment transaction is used when a health insurance sponsor—such as an employer that offers insurance for its employees—tells a health plan about changes to a member’s insurance coverage or benefits.

The enrollment and disenrollment transaction can be used when a health insurance sponsor has:

• Enrolled a new member 
• Changed a member’s enrollment (e.g., a change of insurance plans)
• Reinstated a member’s enrollment
• Terminated a member’s insurance

The goal of standardized enrollment and disenrollment transactions is to avoid any confusion about the status of a member’s coverage. Visit the enrollment and disenrollment page on the CMS Administrative Simplification website to learn more.