90-day notice
Under the Affordable Care Act, market- place regulations give patients with subsidized health insurance coverage three
months to pay their premiums and allow health plans to deny or later recoup payments from doctors for services provided to patients who are delinquent. The patients must have paid their first month’s premium at least to be eligible for that 90-day grace period. A marketplace patient’s failure to make a premium payment triggers the so-called “90-day grace period.” Health plans must give the patient 90 days to catch up. Insurers must pay physicians for services provided in the first 30 days of the grace period. Federal rules, however, allow health plans to pay, hold, deny, or later recoup claims payments for ser- vices incurred in the second or third month of that window if patients are delinquent on premium pay- ments. TMA officials say health plans must comply with Texas’ prompt pay law for claims submitted at any point in the grace period. Federal regulations require exchange plans to noti-
fy affected physicians “as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.” Notification includes where the enrollee is in the grace period and the names of everyone covered by the policy. The no- tice must tell doctors the health plan may ultimately deny payment. The Centers for Medicare & Medicaid Services
(CMS) says federal rules don’t specify when or how insurers have to send the notification. TMA officials caution that health plans’ practices will vary. Blue Cross and Blue Shield of Texas (BCBSTX) and
Aetna told Texas Medicine they instituted notification measures for physician practices and other educa- tional resources for patients. The Blues says its members are eligible for covered
services under their plan during the grace period. Services rendered during the first month of the grace period will be the responsibility of BCBSTX, subject
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to member cost sharing. During the second and third months of the grace period, BCBSTX will pay, rather than hold, claims.
“If the member does not pay the outstanding
premium in full within the grace period, BCBSTX will send a request for refund to the provider for claims paid for services rendered in months two and three,” officials said. The Blues will notify physicians when patients
enter the second or third month of the grace period through its electronic and phone eligibility and ben- efits verification systems. All preauthorization let- ters will encourage providers to confirm whether the member is in a grace period. Officials say physicians also may notify members that if their health care cov- erage terminates at the end of the grace period, the member is responsible for payment for the full cost of services rendered, up to billed charges. Aetna says it will inform physicians if an exchange member is delinquent, and “any claims submitted for a service date after 30 days’ delinquency will result in an EOB [explanation of benefits] to the provider which indicates the claim is being pended because the member …” is delinquent. Patients are responsible for payment if their coverage ends due to lack of pre- mium payment. If patients pay the owed premiums before the end of the 90 days, Aetna says it will pay the claim. Aetna also published a Q&A for physicians and providers online,
http://bit.ly/LYe6yz. Humana says during the first 30 days of the grace period, it will process claims “as normal.” During months two and three, it will hold claims and send a letter to physicians notifying them of a patient’s sta- tus. Humana will deny claims and terminate coverage for patients who end up delinquent, in which case physicians may collect payment from the patient.
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