The Healthcare rules as of 1/1/2014 require that providers be notified of grace period for Individual Exchange members. The 5010 TR3 does not provide a code allowing notification on a 271 that patients are under a grace period due to lack of premium payment. HCSC is looking for suggestions to return this information by using the codes currently available. Would this solution be appropriate?
2100C/D Loop: DTP01 = 291 - Plan Date - Returned as a date range with the begin and end date; DTP01 = 343 - Premium Paid to Date End - The last date the member's premium is paid to; DTP01 = 540 - Policy Expiration - Calculated based on the Paid to Date End and the length of the Member's Grace Period.
2110C/D Loop: EB01 = 1 Active - The membership is still listed as active in our membership system ; DTP01 = 357 - Eligibility End - The date calculated when the grace period is added to the Premium Paid to Date; MSG01 = A message will be added to alert the provider of the grace period. (Specific wording TBD)
The guide is silent on specifics for this business situation. See the recommendation below, which we believe is the best practice compliant with the current implementation guide.
There is a difference under the regulations when a health insurance exchange (HIX) member (assumed below to be the subscriber) is in the first month versus the last two months of the grace period for non-payment of premiums. When a member currently in a premium payment grace period is the subject of the eligibility and benefit response and the requested eligibility and status information date (Plan Date) is within the grace period, the following should be reported in the 271 response (in addition to any other 271 reporting requirements):
2100C DTP – DTP01 =”343” (Premium Paid to Date End), DTP03 = Date for which premium is paid through (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 EB – For the EB segment identifying the coverage status (per guide 005010X279 section 1.4.7.1, 271 section, requirement # 2) report EB01 = "1” (Active) when the Plan Date is during the first month of the grace period, and ”5” (Active – Pending Investigation) when the Plan Date is during the second and third months of the grace period.
2110C DTP – DTP01 = “193” (Period Start), DTP03 = First day of the first month of the grace period. This is in the same 2110C loop.
2110C DTP – DTP01 = “194” (Period End), DTP03 = Last day of the third month of the grace. This is in the same 2110C loop.
2110 MSG – MSG01 = ”HIX Grace Period.” (note – health plans can add additional verbiage as deemed appropriate to this base MSG content). This is included in the same 2110C loop.
Note: After the end of the grace period, once the premium has either been paid or not paid, requests for Plan Dates during the expired grace period no longer reflect grace period information.
Prior Related RFIs - 1778