Affordable Care Act

  • Individual and Small Group (Metallic) Plans: What Providers Need to Know

    New individual and small group or metallic plans have a number of important changes due to regulations brought on by the Affordable Care Act (ACA). Here you can learn more about the changes for these ACA-compliant plans.

  • Many of our new, ACA-compliant individual and small group plans encourage members to select a primary care provider (PCP) when they enroll in the plan. Members pay a lower copay when they visit their designated PCP. Members pay a higher copay if they don't select a PCP or if they visit a different Premera provider or group. The split copay amounts are listed on the member's ID card. Providers need to confirm a member's eligibility and benefits in advance of the patient's visit to determine the correct copay.

    Members can:

    • Designate a unique PCP for every family member
    • Change their PCP as often as they like
    • Go to a specialist without a PCP referral

    How to verify a member's PCP:

    • Check the PCP's name and phone number online via our benefits and eligibility tool (if the member selected a PCP).
    • Check the ID card and look for the network called Heritage.
    • Contact Customer Service by calling the number on the back of the card.
    • If the PCP is incorrect, it is the member's responsibility to make the correction online through the member website or by calling customer service.

    Types of PCPs:

    • General doctor
    • Internist
    • Family doctor
    • Naturopath
    • Pediatrician
    • Nurse Practitioner/ARNP
    • Doctor's Assistant
    • Gynecologist
    • Obstetrician
    • Geriatrician
    • Women's Health (for women, gynecologist services always result in a lower copay, including midwives)

    A provision under the Affordable Care Act requires plans to give members who receive the Advance Premium Tax Credit subsidy a three-month grace period to pay for their coverage. They cannot be terminated for non-payment during this period and are eligible to receive services as Premera members.

    Here's how it works:

    • During the first month of delinquency, the member's claims are paid by the carrier. If no payment is received during the second and third months, the member's claims are held and not paid.
    • If premiums are not paid in full by the end of the grace period, any claims incurred in the second and third months are denied due to non-payment.
    • Premera notifies providers by letter of their patient's claim status when the patient enters the second month of the grace period.
    • Providers may seek reimbursement directly from the member at the end of the three-month grace period.
    • This extended grace period applies only to members who use the Advance Premium Tax Credit subsidy to purchase a health plan and have paid one full month's coverage.

    Three-month grace period timeline example for members eligible for the Advance Premium Tax Credit:


    Under the Affordable Care Act, everyone has access to health insurance regardless of health status. To create a system in which payers are compensated for the risk associated with the members they cover (known as risk-adjusted payments), complete and accurate diagnosis coding is necessary to capture the risk profile of each patient. Learn more about Commercial Risk Adjustment.