Providers will soon be receiving information in the Blue Cross and Blue Shield of Texas (BCBSTX) provider newsletter and on their provider websites about the Affordable Care Act (ACA) provision that allows Health Insurance Marketplace enrollees who receive the advance premium tax credit (APTC) a three-month grace period to pay their premium - provided they have already paid at least one month's premium in full. It is important to note that this will affect only individuals who purchase coverage on the HHS.gov Marketplace and receive a premium tax credit (subsidy).

During the three-month grace period, individuals are eligible for covered services under their plan.

• During the initial month of coverage (day 0-30), premium is collected and claims are processed and paid.
• The ACA requires all insurance carriers to complete and pay claims (for covered services rendered) in the first month of the grace period (day 31-60).
• For covered services rendered during months two and three of the grace period, payers must either pay or pend claims (day 61-120).

So an individual who purchases a plan in the Marketplace and receives a premium subsidy, can pay their portion of one month's premium and receive medical services for 120 days and Rx services for 120 days. The risk for medical services provided between days 61-120 will be transferred to the provider, who will be responsible to determine if the individual is in the grace period and deny services without some form of guaranteed payment.

  

BCBSTX, is implementing this provision as follows:

• All allowable services provided during the first month of the grace period (day 31-60) will be the responsibility of BCBSTX, subject to member cost sharing.
• During the second and third months of the grace period (day 61-120), BCBSTX will process and pay claims the member incurs during this period.
• If the member has not paid premiums in full by the end of the grace period, BCBSTX will terminate the member's policy retroactive to the first day of month two of the grace period (day 61). BCBSTX will send a request for refund to the provider for claims paid for services rendered in months two and three. The provider may then seek payment for services rendered in months two and three of the grace period from the former member, up to billed charges.
• Pharmacy claims will be processed and paid by BCBSTX during months two and three.
• 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 BCBSTX will pay this claim.

BCBSTX processes will allow providers to access information and updates about those members who are in the second and third months of their grace period.

• Providers will receive notifications that the member has entered into a grace period when checking eligibility and benefits online and by phone during the last two months of the grace period.
• All preauthorization letters will encourage providers to confirm whether the member is in a grace period.
• Provider implications of the ACA grace period will not begin until March 2014.

This information will be shared with BCBSTX providers, and you might find it useful should you receive questions from your employees. This may also explain why there is limited participation by the insurance industry and medical providers in the HHS.gov subsidized marketplace.