The COVID-19 pandemic brought unprecedented challenges to healthcare providers, particularly concerning uninsured individuals needing testing and treatment. The CARES Act aimed to alleviate some of these burdens, leading to the establishment of programs designed to reimburse providers for services rendered to the uninsured. Understanding the nuances of these programs, especially in relation to health insurance grace periods and COVID diagnosis, is crucial for healthcare providers to ensure proper claim submission and reimbursement.
Understanding the Grace Period for Health Insurance & Uninsured Programs
A key aspect to consider when dealing with claims for uninsured individuals under programs related to the CARES Act and COVID diagnosis is the health insurance grace period. It’s essential to recognize that even when an individual has enrolled in a qualified health plan and is receiving advance payments of premium tax credits (APTC), a grace period exists for premium payments. During this grace period, typically spanning three months, coverage technically remains active in the initial month.
However, during the second and third months of this grace period, health plans may pend claims. This means they might withhold payment, awaiting the enrollee’s payment of outstanding premiums. Despite this pending status, the health coverage is still considered in force during the grace period’s duration. If the enrollee resolves their outstanding payments before the grace period concludes, the plan is obligated to pay the claims.
HRSA COVID-19 Uninsured Program: Claim Submission Guidelines
The HRSA COVID-19 Uninsured Program is a critical resource for providers who have offered services related to COVID-19, including testing, treatment for those diagnosed with COVID-19, and vaccine administration, to individuals without health insurance. This program ensures that providers can receive reimbursement for these essential services.
However, a crucial stipulation exists concerning claim submission in relation to the health insurance grace period. Providers must not submit claims to the HRSA COVID-19 Uninsured Program while an individual is within their health insurance grace period, as long as the coverage remains potentially active.
When to Submit a Claim for COVID Diagnosis & Uninsured Services
The appropriate time to submit a claim to the HRSA COVID-19 Uninsured Program is specifically after the health insurance grace period has been completely exhausted, and the individual’s coverage has been officially terminated retroactively. This retroactive termination means the coverage is cancelled back to the end of the first month of the grace period. In such cases, for the purposes of the Provider Relief Fund and HRSA Uninsured Program, the individual is considered uninsured for the second and third months of the grace period. Only then can providers submit claims for services rendered during those months to the HRSA program.
This same principle applies even if services were provided while an individual was in a state-specific grace period, but their coverage was subsequently terminated retroactively due to non-payment. This leaves the individual uninsured at the time the service was administered, making them eligible under the HRSA COVID-19 Uninsured Program.
Provider Responsibilities and Notifications
It is also important for providers to be aware that Exchange issuers are mandated to inform them about the possibility of claim denials when an enrollee is in the second and third month of their grace period and receiving APTC. This notification, as per 45 CFR 156.270(d)(3), is designed to help providers understand the payment risks associated with providing services during this period.
In conclusion, navigating claims for uninsured individuals, particularly in the context of the CARES Act and COVID diagnosis related services, requires careful attention to health insurance grace periods. Providers should diligently verify insurance status and grace period timelines before submitting claims to the HRSA COVID-19 Uninsured Program to ensure proper processing and reimbursement for their services. Submitting claims only after the grace period concludes and coverage is terminated, or if issuer coverage is reversed, is essential for compliance and successful reimbursement through the HRSA program.
