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

    We developed new tiering standards for our contracted hospitals, facilities and providers. The standards include the addition of a new tier (Tier 4), effective Jan. 1, 2014. Tier 4 includes two new networks that support our new 2014 plans: The new networks are: Heritage Signature and Heritage Prime.

    Here are some key things to note about the Heritage Signature and Heritage Prime networks:

    • Not all contracted providers and facilities are included in the new Tier 4 networks.
    • A provider or facility assigned to Tier 2 or 3 is still considered a Premera-contracted provider or facility and is in-network for the products associated with their tier assignment.
    • Many of our large group commercial plans will continue to use Tier 2 and Tier 3 networks.
    • Out-of-network benefits are available, but if members visit a provider or facility outside of their network, they may have higher out-of-pocket expenses.

    Tips for Tier Assignment and the Member’s Network

    • Know your tier assignment and check the member’s network to ensure that your patient receives maximum benefits and lower out-of-pocket costs
    • Check the member’s ID card to verify the member’s network
    • Locate in-network providers and facilities via our online Find a Doctor tool
    • Call Physician and Provider Relations at 877-342-5258, option 4, if you have questions about your tier assignment

    A new 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.

    With accurate diagnosis coding, disruption will be minimal for medical practices. However, if diagnosis coding is inaccurate, it's more likely that we will request medical records due to the U.S. Department of Health and Human Services' (HHS) documentation requirements to support insurers' risk score submission.

    Getting Your Practice Ready

    Improving coding processes now and implementing checks will help to ensure your practice is ready. It will also help your transition to ICD-10 in 2015.

    Here are some things you can do today to prepare:

    • Engage in improvement initiatives for accurate and complete capture of primary conditions and presenting co-morbidities, particularly in more complex cases.
    • Educate coders and office staff to ensure the use of coding best practices.
    • Standardize medical documentation and coding processes to best integrate with your billing workflow.
    • Adopt technologies like electronic medical records (EMRs) or voice translation software to improve accuracy and efficiency.
    • Implement system reviews and checkpoints to ensure codes pass through claims systems from your practice to health plans.