Health insurance plans are required to cover essential health benefits or essential care and services as defined by each state. To learn more about essential health benefits, go to healthcare.gov.
Plans offered on the Exchange are grouped into four metal levels based on the actuarial value: Bronze, Silver, Gold, and Platinum. Each level covers the same set of essential health benefits, but differs by how much the member pays in premium and total cost share.
Cost per visit/prescription
The member’s ID card will identify the metal level and plan name. See the Health plan ID card section of this chapter.
People who purchase coverage on the Individual Exchange may qualify for financial assistance to help lower their premium or cost-share amounts. These individuals must inform their state Exchange when financial changes occur, so they can adjust their subsidy accordingly. As a member’s qualifications change, so does their cost-share amount and their Medicaid eligibility. These changes can occur within the same calendar year. Care providers should verify eligibility at the point of service to confirm coverage and benefits.
The Patient Protection and Affordable Care Act (ACA) requires health insurers to provide a 3-month grace period before terminating coverage for people who have not paid their premium. The grace period applies to those who receive an advanced premium tax credit and have paid at least one full month’s premium within the benefit year. Members are required to pay
the first month’s premium before coverage goes into effect. Additionally, for individuals who do not receive federal subsidy assistance, plans are required to provide a grace period that is consistent with state law (typically 30 or 31 days) before terminating coverage.
There are 3 ways to verify if the member is in a grace period:
1. EDI 271 Response Transactions - We will return the following information:
2. Online Secure Provider Portal
The Online Secure Provider Portal will indicate if the member is within a grace period and at what month. The portal also includes an informational icon message where the user can hover to understand what each period means to them and the member.
3. Contact Us
Verify member eligibility by calling Provider Services at 1-888-478-4760.