Jan. 8, 2015

Affordable Care Act in Action: Grace Periods

The second open enrollment period for consumers shopping on the Health Insurance Marketplace began Nov. 15, 2014, and enrollment for 2015 will remain open through Feb. 15, 2015. The Affordable Care Act (ACA) has opened the door for many Americans to obtain health insurance coverage, even if they have been unable to secure coverage in the past due to pre-existing conditions or financial constraints.

Under ACA, members who purchase coverage on the Marketplace and receive the advance premium tax credit (APTC) are allowed a 90-day grace period for payment of their health care insurance premiums, as long as they have already paid one month’s premium in full within the benefit year. It is important to note that not all members who purchase coverage on the Marketplace will receive the APTC.

The information below provides guidelines to assist you with identifying when a Blue Cross and Blue Shield of Oklahoma (BCBSOK) member is in a grace period, along with important reminders on claim processing, supporting patient awareness and maintaining compliance with your provider contract.

Eligibility and Benefits
As always, it is important to check eligibility and benefits for every patient at the start of every visit. When a BCBSOK member is in the second or third month of a grace period, we will provide notification of the member’s status during electronic response or telephone verification to indicate the member’s grace period status, including the date the grace period began.

Claims Processing

• Medical Claims – All allowable services provided during the first month of the grace period will be the responsibility of BCBSOK, subject to member cost sharing. BCBSOK will pend claims for covered services rendered during the second and third months of the grace period. However, if the member has not paid premiums in full by the end of the grace period, BCBSOK will deny claims for services provided during the second or third months of the grace period. In this case, the patient is responsible for paying the entire bill for services rendered during the second and third months.
• Pharmacy Claims – A member’s pharmacy claims will be denied during months two and three. If the member retroactively pays the premium in full, they may submit claims for prescriptions dispensed during this time to BCBSOK. If a member elects to receive a 90-day supply of a prescription during month one of the grace period, the member will receive the full 90-day prescription and BCBSOK will pay this claim.

Patient Awareness
You may notify your patients that they will be responsible for payment for the full cost of provided services, up to billed charges, if their health care coverage terminates at the end of the grace period. You may encourage your patients to make their premium payments to avoid termination of their health insurance policies.

Provider Responsibility
As a reminder, the terms of your network contract prevent you from refusing to provide services to a BCBSOK member, regardless of where they purchased their coverage. Your contract with BCBSOK requires the provision of services to members and prohibits advance payment for such covered services except for the member’s required cost sharing, if any.

Checking eligibility and/or benefit information is not a guarantee of payment. Benefits will be determined once a claim has been received, and will be based upon, among other things, the member’s eligibility, any claims received during the interim period and the terms of the member’s certificate of coverage applicable on the date services were rendered.