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Health Insurance Exchanges Q&A for Health Care Professionals

Caring for exchange members

What is a qualified health plan (QHP)?

QHP means that the plan meets certain requirements under the Affordable Care Act. It also means the plan is certified by the Centers for Medicare and Medicaid Services (CMS). QHPs have networks that are unique to these plans. Often these networks have a smaller number of participating providers, compared to our traditional networks. 

How can I identify an exchange member?

Member ID cards will have “QHP” on them. However, some members with QHP on their cards may have bought their individual plans off-exchange. The product name and the plan name are on the right side of the card. There is a dedicated member services toll-free number.

Are the precertification, authorization and referral processes the same for exchange plans?

Yes, the processes are the same.

Are the payer ID and claim address the same for exchange plans?

Yes, the payer ID and claim address are the same.

Will Aetna’s online eligibility and benefits verification system tell providers if the patient is on a state exchange plan?

You will verify benefits or eligibility in the same way regardless of where the member bought the plan.

Do I have to refer patients to other providers within an exchange?

QHP plans typically offer unique networks. The networks are often smaller than those for other plans. Make sure the provider you are recommending is in your patient’s plan network. Use our DocFind online referral directory to find providers in the exchange network. Remember, members pay more for out-of-network services. Some members have no out-of-network coverage except for emergencies.

Reimbursement for health care professionals

How will health care professionals in the network be reimbursed?

For information, refer to your Aetna, Coventry or Coventry Medicaid agreement/amendment.

How will Aetna reimburse health care professionals who are out of network?

We'll process the claim according to the plan benefits. If the member has assigned benefits, Aetna will pay you directly. Note: Some plans don't have out-of-network benefits, except for coverage of emergency services.

Grace period for non-payment of premiums

I understand that some exchange members qualify for a three-month “grace period” if they don’t pay their premiums. What does that mean?

Some members who buy insurance on a public exchange will qualify for a subsidy to help pay the cost of their coverage. Members who receive a subsidy and have paid at least one full month's premium during the benefit year will qualify for a three-month grace period. This means that if they can’t pay their premiums, they will have three months to pay before insurers can cancel their coverage.

If an exchange member with a subsidy stops paying the premium, how will health care professionals be reimbursed?

Individual members who have not paid their monthly premium are considered delinquent.

  • Health care professionals will be paid for services received during the first 30 days of delinquency.
  • The carrier is allowed to pend claims for services provided during the second and third months of the grace period.
  • If full payment is not received by the end of the third month, the member's coverage will be terminated. This action is retroactive to the end of the first month of the grace period. If coverage is terminated, Aetna will not pay any pended claims for months two or three.

Will Aetna inform health care professionals when exchange members are one month delinquent paying their premiums?

Health care professionals will follow the same process they use today to verify a patient’s eligibility. This process will let you know if the patient is delinquent. If you submit claims for a service date after the first month of delinquency, the explanation of benefits (EOB) you receive will indicate the claim is being pended because the member is delinquent. If coverage is terminated due to lack of premium payment, the member will become responsible for paying you. If a member pays the entire delinquent premium before the end of the three-month grace period, Aetna will pay the claim.

Will Aetna tell me how much longer a member will be in the grace period?

We can confirm that a member’s claims have been pended. We also can tell you whether the member is in month two or month three of the grace period.

Can a member be in a grace period multiple times in a plan year?

Yes. Members who have received a premium subsidy and paid at least one full month's premium during the benefit year will qualify for a three-month grace period. This means a member could be in multiple grace periods during the year. As long as members make their full premium payment before their grace period ends, their coverage won't be affected.

Are members’ prescriptions covered if they're in their grace period?

If a member’s payment is in delinquent status, claims for prescriptions filled during this period would be denied. Members would need to cover the full cost of their medications during this period.

Members can submit prescription claims again if they pay their full outstanding premium before the end of the grace period.

Note: this information is not meant as legal or tax advice. Please talk to your legal or tax advisor about any questions.

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