Minnesota Medical Group Management Association’s (MMGMA) 4th annual Day with the Payers event provided an educational opportunity for clinical and business/operations team members. It was a great opportunity to network with payers as well as administrators. The event was well attended by major Minnesota payers including NGS, BCBS, HealthPartners, PreferredOne, Medica, UCare, Humana and America’s PPO. Each payer provided updates on programs, products/networks, medical and payment policies and claims filing tips. There was also an update on ICD-10 from the Minnesota ICD-10 Collaborative.
The MNSURE plans are individual plans where consumers pay their premiums on a monthly basis. If the consumer does not pay their premiums on time, they will hold claims from processing until the premium is met. There is a 90 day grace period. Once the consumer pays the premium, the claims will be released for processing. Each payer has a policy on how they are handling this. Here are just two examples:
Medica:
Medica has a new product line through MNSURE called IFB Products (Individual and Family Business)
- Group numbers all start with IFB or are IFB alone
- The electronic Payer ID is different than all of the other Medica Plans. The payer id for IFB is 12422 and the mailing address is also different: Medica, PO Box 981647, El Paso, TX 79998-1647
- IFB remittance advices are coming on paper right now. They are almost done with their ERA testing.
- Grace Period Policy: Claim ‘grace period’ determined for exchange-purchased plans applies for those receiving federal subsidy for private plan. Medica has been consulting with other health plans and providers on how to establish a timeline for handling claims for exchange-purchased plans if member premiums are not paid in a timely fashion. This applies for members who receive a federal premium subsidy but do not pay more than the first premium. If a member with a subsidy through an exchange has made a first payment after enrolling with a carrier, and is thus an active member with coverage, but then fails to make the payment for the next month, the member will enter a “premium grace period.” This means any claims for services incurred after the first month will be pended and the member will have until day 90 to pay in full for months 2 and 3 or otherwise be terminated from coverage by the carrier and thus no longer active. This situation can occur at any time during open enrollment on an exchange but only applies to those members who have received a federal subsidy for premium payment. If a grace period goes into effect for a member who has received services, and providers have submitted claims for those services, providers will be notified that these claims are pended in the first 30 days of the grace period, while the member will receive a missed-payment letter from Medica. If the member fails to fully pay premiums by day 90, providers will be notified by provider remittance advice (PRA) or HIPAA 835 transaction that the pended claims ultimately denied after day 90, after the grace period has ended. The member also receives a final explanation of benefits (EOB) if premiums remain unpaid and pending claims have been denied. This is the process for the premium grace period for Medica members receiving subsidies through an exchange like MNsure:
- Month (days) Claims Impact Notification
- (days 0-30) Pended Provider receives letter re: pended status of claims; member receives missed-payment letter
- (days 31-60) Pended Member receives invoice notice
- (days 61-90) Pended Member receives invoice notice
- (days >90) Denied Provider PRA or 835 transaction indicates that pended claims denied for lack of premium payment; member receives final EOB
UCare:
- Payment of Claims During the Grace Period: Federal law specifies a three month grace period for members receiving Advanced Premium Tax Credit (APTC) subsidies who fail to make their premium payments. During the first month of the grace period, we are required to pay claims for covered services received during that month. If the member fails to make premium payments in full within the second or third month of the grace period, we will pend or hold those claims. If the member fails to pay the unpaid premium amount in full by the end of the three month grace period, claims incurred for month two and month three will be denied. The member is 60 2014 Contract/Evidence of Coverage financially responsible for the full cost of services in months two and three of the grace period if the member fails to pay its premium amount by the end of the grace period. For all other members, UCare provides a 31‑day grace period during which claims are paid for covered services. If the member fails to pay the unpaid premium amount in full before the end of the 31-day grace period, UCare will seek to recover payments directly from members for claims paid on a member’s behalf during the grace period. The member is financially responsible for the full cost of services received during the grace period if the member fails to pay its premium amount by the end of the grace period.