For those patients who have obtained their policies through the health care insurance exchanges, where they qualify for federal premium tax credits, under 45 C.F.R. §156.270(d), the insurers are required to keep the policies in effect for a three month grace period should the beneficiary fail to make the premium payments.  The insurers, however, are only required to pay the claims arising during that first month.  They are permitted to “pend” claims during the second and third month.  If the premium is not paid for that three month period, the insurers then ultimately can deny payment of those “pended” claims to the providers.

This is not a philosophical issue.  This is not a liberal or conservative issue.  This is simply shifting the risk of loss to the providers, which will adversely affect the provider’s cash flow.

The provider will be providing services with the assumption that the patient is covered by insurance.  Should the provision of those services occur during the second or third month, and the individual does not pay the premium to continue the policy, the insurer will be authorized to deny payment.  It will be up to the provider to obtain payment directly from the patient or more likely not to be paid for those services.  This issue is being vigorously contested by organizations representing the providers.

If this position is not resolved before January 1, providers should expect during 2014 to run into situations where claims are denied because certain patients will not keep their insurance coverage current.