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Insurer says:
The Insured is in a 90 day grace period (per Affordable Care Act)…we are pending the claim until premiums are paid.
Your response:
The Affordable Care Act state under Title 45 Code of Federal Regulations Section 156.270 (d) states that Insurers must “pay all appropriate claims for services rendered to the enrollee during the first month of the grace period…” Even claims filed during the second and third months of the grace period are still subject to Texas Prompt Payment laws.
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45 CFR ยง 156.270
(d) Grace period for recipients of advance payments of the premium tax credit. A QHP issuer must provide a grace period of three consecutive months if an enrollee receiving advance payments of the premium tax credit has previously paid at least one full month’s premium during the benefit year. During the grace period, the QHP issuer must:
(1) Pay all appropriate claims for services rendered to the enrollee during the first month of the grace period and may pend claims for services rendered to the enrollee in the second and third months of the grace period;
(2) Notify HHS of such non-payment; and,
(3) Notify providers of the possibility for denied claims when an enrollee is in the second and third months of the grace period
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