Individual Health Insurance Exchange (Marketplace) Subscribers and the 90 Day Grace Period to Pay Your Premium

Below is how BCBS of IL will handle claims for those people who have gotten a health insurance plan on the Exchange (Marketplace) AND receive a subsidy (Advance Premium Tax Credit).

It is my understanding that most other insurance carriers will be following a similar methodology, hence why I am posting this.

This is NOT for Small Group SHOP plans.

Blue Cross and Blue Shield of Illinois Providers Notified of ACA Grace Period Provision Providers will be receiving information in the Blue Cross and Blue Shield of Illinois (BCBSIL) provider newsletter 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 not all members who purchase coverage on the Marketplace will receive the tax credit. During the three-month grace period, members are eligible for covered services under their plan.

The provision requires all payers to complete claims (for covered services rendered) in the first month of the grace period. For covered services rendered during months two and three, payers must either pay or hold claims for processing once the payments have been received. Notification of Eligibility Providers will be informed through eligibility and benefits verification when a member has entered into a grace period during months two and three of the grace period. All preauthorization letters will encourage providers to confirm whether the member is in a grace period prior to providing services. Claims Processing Payment for all allowable services provided during the first month of the grace period will be the responsibility of BCBSIL, subject to member cost sharing. During the second and third months of the grace period, BCBSIL will pend the claims the member incurs during this period. If the member pays all outstanding premium payment(s) in full, claims incurred during this period will process according to the member’s benefits. If the member has not paid premiums in full by the end of the grace period, BCBSIL will terminate the member’s policy retroactive to the first day of month two of the grace period. BCBSIL will deny any claims pended in months two and three of the grace period. 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 BCBSIL. 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 BCBSIL will pay this claim. Member Responsibility for Payment We are encouraging providers to notify their patients that they will be responsible for payment of any outstanding claims for the full cost of provided services, if their health care coverage terminates at the end of the grace period.

New World, New Rates for Obamacare (Affordable Care Act). How it impacts Me.

The first thing I did this morning when I got to the office was to try to get into healthcare.gov. When that didn't work, I knew I could still get rates via each individual carrier. So I worked and got the three closest plans to what I have now to compare current plans and rates to plans and rates 1/1/2014. Here is what I found.

My current plan is a $5200 family deductible HSA plan via Blue Cross Blue Shield of Illinois. It pays 100% after I meet the deductible. My current premium is about $600/month for a family of 4.

Below is a snapshot of the three closest plans I could find. (Land of Lincoln, BCBS of IL, and Aetna respectively).

The first thing I noticed was that I COULD NOT find a plan similar to what I have now. Furthermore, the smallest out of pocket maximum for a family was OVER $12,000 for an HSA compatible plan.

You may say that $758.97/month is reasonable, but please remember that I was paying less than $600/month for better coverage ($5200 maximum out of pocket for everything instead of $12,700 maximum out of pocket).

I tried quoting Coventry, but their website said there were no plans available and Health Alliance's rates were high and not as graphic as above because they just have rate sheets. Of course those two carriers are not available in DuPage County, so that is another reason I didn't list them here. DuPage County only has BCBS of Illinois, Aetna, and Land of Lincoln.

Now you may be saying that these are unsubsidized rates and you'd be correct. We need to keep in mind that SOMEBODY is paying for the plan, even if your share is at 50%. Note also that two out of 3 plans are Bronze level plans meaning that the costs are less than a Silver plan. Unfortunately, there were no Silver plans that were similar to what I have now. They just weren't offered. 

I'll be curious to see the comparison once the government website is up and running. More posts as the time goes on.

How to Navigate the Health Insurance Exchanges (Marketplace)

As we haven't been allow to see the steps involved with the Marketplace website (healthcare.gov, in Illinois you can also try getcoveredillinois.gov), here are some general ideas for you to be aware of.

1. You can go directly to each health insurer's website (that is in the Exchange) and look for health insurance both within the Exchange and outside of the Exchange.

2. You can go to healthcare.gov for any Federally Facilitated Marketplace or State/Federal Marketplace.

3. You will need an idea of what you think you will make in 2014. The rules state income is based upon Modified Adjusted Gross Income. They did not give details as to what that means, but for all practical purposes, think "Adjusted Gross Income." Estimate conservatively. If your income is much greater, then inform the Exchange to dial back your subsidy. The reason to do this is because the subsidies are actually forward looking tax credits. This means that the IRS will settle up with you at the end of the year. If the government has overpaid for your health insurance, they will ask for the money back! Of course if you had a bad year, the opposite is true too.

4. BE CAREFUL OF THE PLAN DESIGNS!!!!! I cannot stress this enough. The plans you will be viewing will be DIFFERENT that what you are used to.

• Some will include extremely high prescription drug deductibles (for example, you pay a $1500 drug deductible before the drug copay kicks in). 
• Others will include PER OCCURRENCE DEDUCTIBLES. Simply put, you pay this IN ADDITION to your normal deductible for things such as hospitalization, outpatient surgery, etc. An example would be you'd pay an extra $1000 each time you were admitted into a hospital, then you'd pay your deductible. 
• Silver level plans will have HIGH DEDUCTIBLES. Insurance companies did this to keep the costs down. You will need to choose between having a $4000+ individual deductible for a reasonable premium or a higher premium and lower deductible.
• THERE IS LESS CHOICE in the Exchange. If you do not qualify for a subsidy (you and your family make over 400% of Federal Poverty Level), then search for NON-EXCHANGE plans. In DuPage County, there are 3 insurance companies on the Exchange. Off-Exchange there are at least 5 with many more plans available. The rates for the same plan on and off the exchange will be exactly the same.
• PEDIATRIC DENTAL will be a question on the applications. If you say you do not have a dental plan, then they will charge you extra for including dental coverage for children. My best guess is that if you do not have children on the health insurance plan and don't have dental, you shouldn't be charged extra, but we won't know until tomorrow.
• IF YOU DON'T QUALIFY FOR A SUBSIDY consider getting a plan that starts 12/1/2013 with one of the insurance companies that will allow you to keep the plan for 1 full year. This will delay the increase in costs due to Health Reform for that much longer.
• PLEASE - USE AN AGENT!!! There is no cost to use an insurance agent certified to sell in the exchange. The rates are exactly the same and they will be able to help you avoid the pitfalls of choosing a plan that doesn't work for you. What you don't know WILL hurt you.

Please call me if you want help. My phone is 630-779-1144.

Thanks,

Robert Slayton