The Affordable Care Act (ACA) mandates a three-month grace period for individual members who:
- Purchase an ACA-compliant health plan on the exchange,
- Receive a government-subsidized Advanced Premium Tax Credit or APTC (often referred to as a premium subsidy), and
- Are delinquent in paying their portion of premiums.
In cases where the member has not paid their premium, Anthem Blue Cross and Blue Shield (Anthem) will take the following steps, as defined by the legislation:
- Anthem will process claims for services received during the first month.
- Anthem will pend claims for services received during the second and third months of the grace period, until the full premium is received. Providers will receive a notification on their remittance indicating that the claim cannot be paid until the premium is received; information regarding the possibility of denied claims if the premium is not received by the end of the three-month grace period will be issued.
- After the third month, if the member’s premium is not received, the member’s health plan will be terminated and the claims for services received during the second and third month will be denied. The member will be responsible for payment of services received during this time.
In 2014, Anthem Blue Cross and Blue Shield (Anthem) implemented a unique eligibility status message to help providers identify members in the second or third month of a grace period when using our real time electronic 271 eligibility and benefit transaction available on Availity or EDI. Members in the second or third month of a member grace period display the eligibility status “INACTIVE – PENDING INVESTIGATION.”
Anthem will now provide an expanded level of detail available to providers related to member grace periods. The following information is available via the electronic 271 transaction for members in a grace period:
- 2100C/D DTP:
- DTP01 =”343″ (Premium Paid to Date End)
- DTP03 = This message provides the date for which the premium is paid through (the last day of coverage for which a premium payment has been received).This is the last day of the month before the beginning of the grace period.
- 2110C/D DTP (1st iteration):
- DTP01 = “193” (Period Start)
- DTP03 = This message provides the date that represents the first day of the first month of the grace period.
- 2110C/D DTP (2nd iteration):
- DTP01 = “194” (Period End)
- DTP03 = This message provides the date that is the last day of the third month of the grace period.
- 2110C/D MSG:
- MSG01 = “Health Insurance Exchange – HIX GRACE PERIOD.” This message indicates that a member is in the second or third month of a grace period, and that claims for this member will pend until premium is paid.
If you previously called Anthem’s Provider Service department to confirm grace period status for a member, you may save valuable time by accessing member grace period information electronically via Availity or EDI.