Checking member eligibility, benefits is crucial under health care reform

For years we’ve stressed the importance of checking member eligibility and benefits every time you provide services. With the implementation of health care reform, checking eligibility and benefits is even more crucial.

One reason is that we expect an influx of individual members. These are people who purchase their health care coverage directly from the Blues or through the individual Marketplace. These members will receive ID cards once they enroll, but their coverage will not become active until they pay their first month’s premium and their effective date occurs.

Here are some important considerations:

• Effective date — In some cases, these individual members will have their ID cards a month or two before their effective dates. If they try to use their cards before their effective dates, they will not have coverage.
• Premium unpaid — If the member does not pay his or her first monthly premium, the coverage will not become effective. If the member pays the first payment but later becomes delinquent, coverage could cease. Keep in mind that there are special regulations regarding members with government-subsidized premiums. We will provide additional information in future issues about how to recognize members who are in delinquency, and recommendations on how to handle billing and payment for them.
• Coverage changes — A member can sign up for coverage but later change that coverage. Individual members can change coverage for any reason during the open enrollment period. For this first year of the Marketplace, the open enrollment period runs from Oct. 1, 2013, through March 31, 2014. After that, members with a qualifying event may still be able to change coverage. So a member may not keep coverage but could still present an ID card for services.

The bottom line is that possession of a Blues ID card does not necessarily mean the member has coverage that is currently in effect. While this has always been the case, you may find more situations in which ID cards are presented for coverage that is not in effect. Be aware that the Blues will not reimburse claims when coverage is not in effect at the time of service.

As a reminder, there are three ways to check eligibility and benefits:

• Online using web-DENIS
• By calling our automated phone system, CAREN
• By calling Provider Inquiry