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.
How to verify a member's PCP:
Types of PCPs:
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:
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.
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