What You Need to Know About Our ACA Plans

This page serves as a quick links landing page designed to help you navigate our site and find helpful information about how our plans work and our claims policies.

We've selected nine topics we feel are important. Under each topic, we've included a brief description of what the topic is about and links to pages where you'll actually find the information.

Out-of-network liability and balance billing

Check out these pages for information about whether or not a member would have to pay for out-of-network services. Also, we list off any exceptions to out-of-network liability, and whether or not we balance-bill our members in these situations.

Enrollee claims submission

Check out these pages for general information on how a member can submit a claim without their doctor, and a time limit to submit the claim. When you submit a claim, send it to the address listed on the claim form.

Grace periods and claims pending policies during grace periods

This page explains the 90-day grace period for enrollees with premium tax credits. You'll also find other information about how we pay, pend, process and retroactively deny claims during a grace period.

Retroactive denials

This page explains retroactive denials and ways to prevent them.

Enrollee recoupment of overpayments

This information is for members who have overpaid for their coverage. Overpayments are credited automatically, unless you request a refund.

Medical necessity and prior authorization timeframes and enrollee responsibilities

Check out these pages for an explanation of what prior authorization is and why you need it for some of your medical or dental services, or prescription drugs. Also, it explains what could happen if a member doesn't get prior authorization and the time frame for a decision.

Drug exceptions timeframes and enrollee responsibilities

Check out these pages for an explanation of the internal and external exceptions process for members to request drugs their plan doesn't cover. Also, you'll find information about the timeframes for these decisions, how to complete the application and how the review process works.

Information on explanations of benefits, or EOBs

This page explains what an EOB is, when we send them out and how to read and understand them.

Coordination of benefits, or COB

This page explains what COB is and how it helps to coordinate other benefits with your current plan to pay for services.