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What You Need to Know About Health Exchanges and Individual Grace Periods

At Blue Cross and Blue Shield of North Carolina (BCBSNC), we understand that North Carolina’s health care providers need to know how the Patient Protection and Affordable Care Act (ACA) affects you and your patients, and we’re committed to keeping you informed. 

Health Insurance Marketplace (a.ka. the Exchange)

The ACA of 2010 provided for the establishment of online health insurance marketplaces in each state, where individuals and small businesses (up to 50 employees) can purchase qualified coverage for an effective date of January 1, 2014, from a variety of health insurers.  The exchange creates a more competitive marketplace for health insurance by offering members a choice of health plans, establishes common rules regarding the offering and pricing of insurance, as well as provides information to help consumers better understand the options available to them. 

Blue Plans that offer products on the federal exchange, as BCBSNC does, will collaborate with both state and federal governments to ensure that consumers can seamlessly enroll in individual and employer-sponsored health insurance plans. 

Individual Three-Month Grace Period

Under the Affordable Care Act, individual members who receive a premium subsidy from the government and are delinquent in paying their portion of their premium are given a three-month grace period.  This federally mandated grace period applies as long as the individual has previously paid at least one month’s premium within the benefit year. 

The health insurance plan is only obligated to pay claims for services rendered during the first month of the grace period.  The ACA also stipulates that the health insurer may either suspend claims during the second and third months of the grace period or pay them in the event the premium is not paid.  Consequently, if a member is within the last two months of the grace period, providers may receive a notification from the member’s health insurer indicating that the member is in the grace period.  BCBSNC will include a remark code on the Electronic Notification of Payment or electronic remittance to let you know if the grace period is a factor in the processing of a claim for a premium-subsidy eligible member. 

If the premium is paid in full by the end of the grace period, any pended claims will be processed in accordance with the terms of the member’s health plan.  If the premium is not paid in full by the end of the grace period, any claims incurred in the second and/or third months may be denied. 

No More Pre-Existing Waiting Periods

Another key provision of the ACA for 2014 eliminates pre-existing condition waiting periods from all health plans for all members, regardless of age.  Please note that this provision applies to health plans upon their renewal dates on or after January 1, 2014. 

After January 1, please continue to verify eligibility and benefits for all members.  This verification process will provide you with member-specific benefit information and whether or not pre-existing waiting periods may still be applicable based on the member’s health plan renewal date for 2014. 

What Else Do I Need to Know?

Providers should continue to follow current practices with BCBSNC for claims processing, eligibility and benefits verification, medical policies, contracting, prior review when applicable, customer service, etc.  Here are some additional resources you may find helpful:

 If you have any questions, please contact the Provider Blue LineSM at 1.800.214.4844.