Under the rules of the Affordable Care Act (ACA), a patient on an exchange product who receives a premium subsidy from the government has a grace period of up to three months to pay premiums before their coverage is cancelled. Health plans may not disenroll members during this grace period, and are not obligated to pay claims incurred during the second and third month if a member's premium is unpaid.
Health plans are required to notify providers in the second and third month of the grace period about the possibility that claims may be delayed or denied in the event that the premium is not paid.
For members on our exchange products, providers will receive notifications only via 271 transactions. You can either submit a 270 HIPAA-compliant transaction and receive a 271 response or view individual eligibility status on the Availity Provider Portal.
On the 271 transaction, the message that will appear for exchange members who are in their grace period will be: MSG*HIX GRACE PERIOD.
On the Availity Portal, the message that will appear on the Patient Information page, under Plan/Product Information for exchange members who are in their grace period will be: HIX GRACE PERIOD. The coverage information for exchange members who are in their first month of delinquency will show "Active." Members who are in their second or third month of delinquency will show as "Active – Pending Investigation."
Notifications to providers will meet state and federal requirements, including the claim number, name of plan, explanation of the three-month grace period, purpose of the notice and Provider Contact Center phone numbers.
If the member's outstanding 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 contract.