Premium Payment Grace Periods PDF

Job Aid Audience: CC IFB Location: Billing/Premium Payments System: N/A Updated: 9.22.23 Reviewed: 3.15.23 Premium Payment Grace Periods Introduction A Grace...

Job Aid Audience: CC IFB Location: Billing/Premium Payments System: N/A Updated: 9.22.23 Reviewed: 3.15.23 Premium Payment Grace Periods Introduction A Grace Period is the time allotted for a member to pay their premium after the due date. This can vary from state to state and be dictated by other factors, such as whether or not a member has a subsidy, also known as the Advanced Premium Tax Credit (APTC). Table of The following topics are included in this document: contents Premium Payment Grace Periods APTC Grace Periods General Grace Periods Grace periods The grace period timeframe for AZ, IA, IL, KS, MN, MO, ND, NE, OK, and WI is 31 days for Off-Exchange members, and also for On-Exchange members who do NOT have APTC. If they do not pay in full by the end of that time, they will be terminated back to their paid through date. On-Exchange members who have APTC are entitled to three consecutive months of grace. If they do not pay in full by the end of that time, the following will occur: 1. Claims for the first month will be paid. 2. Claims for months two and three will be denied. 3. The member will be terminated back to the start of the second month. Claims When a subscription is in a three-month grace period, medical claims will be denied after the first month; however, if the member pays in full by the end of the grace period timeframe, claims will then be re-processed and paid. Pharmacy claims will be denied immediately for the subscription once they fall behind on premiums, as a grace hold is placed on their pharmacy record. The member will have to pay full cost for their prescriptions without insurance. Notes: If a member calls to pay in full through the current month and needs to fill a prescription that day, the pharmacy timeline will need to be re-opened manually. Otherwise, the hold is released once the payment has been processed. Once the grace period is lifted: − Medica: Express Scripts will send the member a check for the difference of what insurance would have covered on out-of- pocket medications. − Dean: The member must submit a request using a Pharmacy Reimbursement Form and their receipts in order to be reimbursed for denied claims. See Pharmacy Grace Periods (IFB) for additional details. Letters Member Grace Period Warning: Sent to APTC members when they fall into grace period. It details the applicable dates and responsibilities if they do not pay in full. Term for Non-Payment: Sent when a subscription is termed for non-payment of premium (grace period ended). It explains that they’ve been terminated and cannot re-enroll until Open Enrollment, or unless they have a special enrollment reason. Phone Calls: When a member calls in and they are in a Grace Period, you are required to inform the caller of: 1. If they are currently in a grace period. 2. When the grace period ends. 3. How much they owe to get out of the grace period. Exceptions For members with no APTC that are On-Exchange, as well as Direct Members regardless if they have exhausted the 30-day grace, HPS can accept payment as long as the policy is still ACTIVE in HealthRules. The past due and current month must be paid in full immediately on the call. If payment is not made in full by day of contact, re-educate the member that they are on a report and may be terminated at any time. Example: An On-Exchange, NON-APTC member owes $150.00 that is past due for June and it is now July 9th. The policy has not been terminated yet. If the member calls today, they would need to pay $300, which would be for past due and current month to stay active, not just the $150 for June. If the $150 is collected, the plan will be terminated back. Continued on next page 1 of 5 Premium Payment Grace Periods, Continued Reinstatements Medica will allow Off-Exchange members to reinstate their policy one time per calendar year for terminations due to non- payment. On-Exchange members will NOT be eligible for reinstatement. The request for reinstatement and payment requirements must be received by the 15th day after the termination was processed. See IFB Non-Pay Reinstatement for additional details. Type Scenario On-Exchange Premium is due 3.1 for March. Billy didn’t pay by 3.1, so in early April a letter will be generated shortly member after the bill run to let the member know they are in their grace period. If they pay March and April by 4.30, grace is cancelled If they pay March, April and May by 5.31, grace is cancelled If they pay March but fail to pay April and May before 5.31 their policy will be terminated as of 4.1 and we will keep the March premium payment If they pay March and part of April before 5.31 their policy will be terminated as of 4.1. We will keep the March premium payment and refund the portion of April’s payment to them If they pay March, April and part of May before 5.31 their policy will be terminated as of 4.1, we will keep the March premium payment and refund April’s payment and the portion paid towards May. If the member calls 6.6 and wants to pay for March, April and May, do not take a payment and advise them they will be cancelled Can this member be reinstated? NO. On-Exchange members cannot be reinstated if terminated for non-payment. Off-Exchange Premium is due 3.1 for March. Billy didn’t pay by 3.1, so he enters into a 31 day grace period and member payment is due before 3.31 or he will be terminated for non-payment. If they pay March by 3.31, grace is cancelled; however April is then due and would put them into a new grace period if not received If they pay only part of March, their policy will be terminated as of 3.1. Can this member be reinstated? YES. As long as the member calls and pays in full by the 15th business day after the termination for non-payment was processed in the system. Document The document history for the past 12 months is outlined below. history Date Description 9.22.23 Grace periods – Added IL. Claims – Added Dean info to notes. 3.15.23 Refreshed due to age. Added Table of contents block. 2 of 5 APTC Grace Periods Introduction This section is for an example and questions related to APTC grace periods. Example Review the example below. Member pays Q) What happens if the member pays March and April before 4.30? March and April A) Grace is cancelled. Claims for the month of March are paid upon receipt. Claims for the month of April are denied initially, before 4.30 but when payment is made for March and April, the claims are reprocessed and paid. Member pays Q) What happens if the member pays March, April, and May before 5.31? March, April A) Grace is cancelled. Claims for the month of March are paid upon receipt. Claims for the months of April and May are denied and May before initially, but when payment is made for March, April, and May, the claims are reprocessed and paid. 5.31 Member pays Q) What if the member pays March, but fails to pay April and May before 5.31? March, but not A) In early June, the policy will be terminated as of 4.1 and Medica will keep the March premium payment. April and May before 5.31 Member pays Q) What if the member pays March and part of April before 5.31? March and part A) The policy will be terminated as of 4.1. Medica will keep the March premium payment and refund the portion of April’s of April before premium to the member. 5.31 Member pays Q) What happens if the member pays March, April, and part of May before 5.31? March, April, A) The policy will be terminated as of 4.1. Medica will keep the March premium payment and refund the April premium and part of May payment and the portion of May’s premium to the member. before 5.31 Member pays Q) What happens if the member pays part of March but fails to pay April and May? part of March, A) The policy will be terminated as of 4.1 and Medica will keep the partial payment made for the month of March. but not April or May Member calls to Q) What happens if the member calls to make payment on 6.5 and their account has not yet been terminated? make a A) Do not take the payment. Advise the member that their policy will be cancelled and submit a workbasket to the Billing payment on team. 6.5, account not terminated yet Continued on next page 3 of 5 APTC Grace Periods, Continued Can an APTC Q) Can an APTC member be reinstated? member be A) No. On-Exchange members cannot be reinstated unless Medica is directed to do so by the Exchange. reinstated? Doesn’t have Q) What happens if an enrollee didn’t have APTC at first, but gains APTC during the time when they are in their state- APTC, but gains provided 31 day grace period? it during state- A) Advise the member additional research is needed and submit a workbasket to the Billing team for review. provided 31 day grace period In APTC grace Q) What happens if an enrollee is already in their APTC grace of 3 consecutive months and they lose APTC in the midst of the period of 3 grace period? months, lose A) Advise the member additional research is needed and submit a workbasket to the Billing team for review. APTC during grace period Member Q) What happens if a member voluntarily terminates their policy during the second month of the APTC grace period? voluntarily A) Advise the member additional research is needed and submit a workbasket to the Billing team for review. terminates their policy during second month of APTC grace period Member hasn’t Q) Does the grace period apply to new policies where the members haven’t paid their binder payment yet? paid their A) No. Grace is not afforded to someone until they have made their policy active by making their first month’s binder payment. binder payment yet; does grace period apply to new policy? Additional Q) What happens if I have a situation that does not fall into the previously outlined questions? situations A) Advise the member additional research is needed and submit a workbasket to the Billing team for review. Document The document history for the past 12 months is outlined below. history Date Description 3.15.23 Refreshed due to age. 4 of 5 General Grace Periods Introduction This section is for an example and questions related to general (or-Non-APTC) grace periods. Example Review the example below: Member pays Q) What happens if the member pays the March premium before 3.31? the March A) Grace is cancelled. Claims with dates of service that may have been denied initially between the date of the last payment premium and the current payment are reviewed and processed. before 3.31 Member makes Q) What happens if the member calls to make a payment on 4.6 and their account has not yet been terminated? a payment on A) Take the payment and educate the member that they need to be paying in a timely manner in the future. Claims with dates 4.6 and account of service that may have been denied initially between the last payment and the current payment are reviewed and has not yet reprocessed. been terminated Member is Q) What happens if the member is terminated for non-payment of premium and would like to be reinstated? terminated for A) If the member is Off-Exchange, they are allowed to be reinstated once per calendar year. However, they must bring their non-payment of account current by paying all outstanding premium amounts (past and present) that are due. Review IFB Non-Pay premium and Reinstatement for additional details. would like to be reinstated New policies Q) Does the grace period apply to new policies where the members have not paid their binder payment yet? when members A) No. Grace is not afforded to someone until they have made their policy active by making their first month’s binder payment. have not paid their binder payment yet Document The document history for the past 12 months is outlined below. history Date Description 3.15.23 Refreshed due to age. 5 of 5