Grace Periods – Can I get Reinstated?
Grace periods under ACA/Health Care Reform
The grace period 31 day's if you are direct with an Insurance Company & don't get subsidies Specimen Policy Page #39 * Health & Safety Code 1365 a 1 * dmhc.ca.gov guidance *
If you do get subsidies (APTC advance payments of the premium tax credit), the Insurance Company - (QHP Qualified Health Plan issuer) must provide a grace period of three consecutive months (more detail on 3 month grace period) as long as you've previously paid at least one full month's premium during the benefit year. Health Care.Gov * 45 CFR 156.270 (d
Full payment is required to keep coverage in force
If you do get into a grace period situation, please understand that making partial payments on the debt will not serve to extend the coverage period, that is stretch out the grace period or delay cancellation. After your notified about premiums overdue, you must pay the full amount owed before your grace period ends to avoid losing their coverage. Insurance Company memo
Jump down to more detail on Grace Periods
Some payment plans - options are more liberal due to the Coronavirus pandemic.
- Individual Companies – Carriers
- Carriers – Companies Employer Group
- See our special enrollment page - with the pandemic it's a lot easier to just reapply!
- JUMP TO SECTION ON:
- Coronavirus? Open & Special Enrollment?
Sample Reinstatement as a ONE TIME Courtesy
Thank you for contacting xyz Insurance. We value the fact that you have chosen xxx as your daughter’s health plan.
We are responding to the grievance we received on May 23, 2022, on your behalf by xxx regarding the termination of your coverage.
She has requested to reinstate the health plan, without a lapse in coverage.
The request has been approved as a one-time exception.
The plan was cancelled effective May 1, 2022, because you did not pay the premium dues by the due date. Before we can reinstate the health plan, we require the dues be paid to current based on the current billing period.
We will contact you shortly to make this payment or you may wish to contact Customer Service at (888) xxx, to make this payment. If payment is not received as requested, xxx will not be able to reinstate the coverage.
Additionally, there are no provisions in the health plan that allows for reinstatement after termination.
It is important to understand that this decision has been made on an exception basis and, in making this decision, xxx does not waive any of its rights to enforce the provisions of your health plan on this or any other claim.
When we receive a grievance, it is assigned to a Grievance Coordinator who is knowledgeable about the plan’s benefits and coverage.
If you have general questions about the plan benefits, please contact Customer Service at (888)xxx. If you have specific questions about this grievance, please call our Grievance Department at xxx.
Information regarding the DMHC
Information regarding ERISA
Notice informing individuals about Nondiscrimination and Accessibility Requirements
CC: Department of Managed Healthcare
- Pay Online – Clients can go to anthem.com/ca, log into their account and click on the Pay My Bill Online link
- Pay By Mail – Clients can mail their invoice with payment. They must mail in time for us to get it on or before the last day of the grace period.
- Pay By Phone – Clients can call the number on the back of their member ID card to use our free Auto Pay Phone Service. Or, they can call Member Services at (855) 634-3381 to pay by credit card or check.
- Check with each Insurance Companies rules & procedures. If you ask, they are often more liberal than required!
- Individual & Family Health Insurance CA
- Companies – Carriers
- Covered CA – Ways to pay
- Blue Cross – Anthem Individual
- Blue Shield 2022 PPO & Trio
- Health Net 2022 Individual Information & Enroll
- Kaiser Permanente – Enrollment – Pay Premium ONLINE
- LA Care – Medi Cal & Covered CA
- Molina Health Care
- Oscar Health Insurance
- Sharp Health Plan – Employer & Family
- Sutter Health Insurance Individual & Employer Plans 2022
- Western Health Advantage Individual & Small Group
- Companies – Carriers
Consequences of cancellation
Once a member is terminated for non-payment, they cannot be reinstated.
In the past, as an agent, we would get late notices, now we don’t or rarely do. So, read up, email us and let’s see what we can do to keep coverage in force for when you need it and avoid tax penalties, bankruptcy or not getting the medical treatment you need – 10 essential benefits.
Clients need to know that cancellation for not paying premiums can have serious consequences. Here’s what happens if they lose their coverage:
• They will still owe unpaid premiums for the first month of their grace period
• They will still owe providers for any health care services they got during the second and third months of the grace period
• They will have to repay any premium tax credits form 8962 1095 A the government paid on their behalf during the second and third months of the grace period
• They won’t be able to get new coverage for themselves or their dependents until the next open enrollment period, unless a life event triggers a special enrollment period
Cancellation for Non-Pay – won’t be a qualifying event either!!!
If you own a business – a group plan.
Are you having a bad month? Low income this or the next few months? Try Medi-Cal. They use monthly income and annual income, whichever is lower! Medi-Cal will give you coverage that meets all 10 essential benefits, plus CA mandated benefits! If your income goes back up, that gives you a special enrollment period back into Covered CA where we can be your agent, no extra charge, Covered CA pays us to help you or direct with an Insurance Company, get a quote.
Try qualifying for Minimum – Catastrophic coverage?
REQUEST FOR #REVIEW OF CANCELLATION –
CA Department of Managed Health Care
- Cancellation Notice from Kaiser
- DMHC Request Review Cancellation
- See our webpage on Appeals & Grievances
Health Insurance Premiums - ExplainedHealth Insurance Premiums - Explained
Check out Special Enrollment -
Change in Income, Enhanced Silver (Cost Sharing Reductions)? * ARPA * COVID 19?
See if you are lucky and can find a special enrollment reason to re-enroll for coverage
What is the proper way to #cancel Health Insurance?
So that I don’t have to pay extra premiums
I’m not restricted when, if I want to reapply.
Don’t have problems with Advance Premium Subsidies
Just let Covered CA or your Insurance Company know at least 15 days ahead of time. See the menu above for the administrative page – contact information for each Insurance Company. However, take a look at this excerpt of email from Covered CA dated 5.24.2018:
Agents and client can cancel the plan directly in the web site but they need a 15 day window to terminate at the end of the month. If it is less than 15 days of the termination date, they need to call Covered California. Covered CA can terminate it with less than 14 days.
2022 – Note – Covered CA’s website now seems a lot friendlier on this point. Appoint us as your broker, no extra charge and we can take care of it.
We provide cancellation help for our clients, at no additional charge as we are paid by the Insurance Companies when we are appointed as your broker. However, we must have proof of new coverage. We will not cancel a policy for a client, without proof of new coverage. We don’t need any malpractice allegations.
The main point is not to let coverage lapse for non-payment of premium as the Insurance Company might send a 10 day demand letter and send you to collections. Saying you didn’t use the Insurance won’t work. That isn’t what Insurance is. Risk Pooling. Proving that you have other coverage will probably work.
Resources & Links
- Termination of coverage or enrollment for qualified individuals. 45 CFR § 156.270 –
- Termination of Exchange enrollment or coverage. § 155.430
CA Department of Insurance is requesting
all Insurance Companies provide a 60 day grace period
Here’s the notice the DOI sent.
Visit our webpage on Insurance Coverage for COVID 19
#Narrow Network – 3 month Grace Period
DOCTORS, Hospitals & other providers do NOT get reimbursed if a policy gets cancelled, because the insured did not pay their portion of the subsidized premium in the 2 or 3 month of the grace period. 45 CFR 155.430 (b) (2) (ii) (A) & (B) and 156.270 (d) – Federal Regulation 41866
See our page on Balance Billing for information at AB 72 to help resolve the issue of going to a hospital or doctors office that is on the list, but still getting out of network bills.
(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.
(e) Advance payments of the premium tax credit. For the 3-month grace period described in paragraph (d) of this section, a QHP issuer must:
(1) Continue to collect advance payments of the premium tax credit on behalf of the enrollee from the Department of the Treasury.
(2) Return advance payments of the premium tax credit paid on the behalf of such enrollee for the second and third months of the grace period if the enrollee exhausts the grace period as described in paragraph (g) of this section. 156.270
Benefits of #Automatic Premium Payments
What if you’re in a coma in the hospital when the premium is due?
Here’s a Long Story –
Bill Duncan* called in and asked if we could get medical insurance for his Mother who has an adrenal problem and possibly has Addison’s Disease and is on Paxil for Major Depression.
Her prior coverage had lapsed for non-payment of premium as she states that she has memory loss due to her medical conditions. The Insurance Company** so far has told them that they won’t reinstate and said that they would send a grievance form for them to fill out. I found a standard grievance form and emailed it to my friend.
I don’t know how this will come out, but I looked all over the California Case Law section on FindLaw.com and so far have found nothing in the sister’s favor. The closest cases were on Life and Disability Policies that had a special provision at additional cost that will pay your premiums, if you are disabled for say 6 months or more. Under COBRA and other Insurance Laws, Anti-Discrimination, etc. they all allow cancellation for non-payment of premium.
Here’s a letter from an Attorney on a similar issue.
The only medical plan I can find for her at this point is MR. MIP, which is really great as it covers virtually anyone who for medical reasons can’t get Individual coverage, the down side was that they have a waiting list to get in.
So, the moral of the story is, make sure that you have a method to pay your medical premiums so that the Insurance Company can’t cancel you, when you need it the most!
Unfortunately, if you can’t remember to pay your premiums, you will probably have trouble working too. Check out Disability Coverage , if you have a Retirement Plan or Cash Values in Life Insurance you might be able to access that money. If all else fails the Government has various plans available. Healthy Families to cover your children, Medi-Cal if you’ve become poor, Social Security Disability – SSI which will qualify you for Medicare – after 2 years of disability and the Free Clinic.
- *Name changed for privacy
- **Insurance Company named not mentioned as we may be filing a grievance and as near as I can tell, all companies and HMO’s would cancel for non-pay, regardless of the reason.
- Blue Cross form Ways to pay your premium or Email us for the form to have your premiums automatically withdrawn from your checking account or credit card
- Blue Shield
No more reinstatements on late payments 1/1/2010
- Find Member Portal for Individual Health Companies CA
FAQ’s “Automatic Premium Payments – Benefits and Advantages”
1. My credit card was on file with Anthem Blue Cross Platinum PPO for monthly payments of my premium. I do this with all of my insurance plans: house, health, and car. I have never had a problem.
2. After my daughter got sick and I was told her prescription wasn’t covered, that pharmacy wasn’t available, I did some investigation by phone and was told that my insurance was canceled and it cannot be reinstated. I am floored and sick to my stomach. I did nothing wrong.
3. I cannot even find the page for payment where my Visa CC was stored on the website.
1. I guess the big issue here is proof, evidence and establishing that Blue Cross had you set up on Auto Pay. Please email us everything you have to show that you were. Please also send us your user name & password to your BC online account and Covered CA if you have thatWhat about the late notices and cancellations they are mandated to send you?
What payment were withdrawn from your credit card?
3. Send us the user name & password of your BC online account. Also, we can contact BC on your behalf if you authorize us as your agent and we will look for what we can in your favor.
If all else fails, there are temporary plans, but most do not meet minimum essential requirements, thus you pay the fine and do not cover pre-existing conditions. Mr. Mip will though.
If you #lose your Advanced Premium Tax Credits (APTC) be careful,
One Can lose ALL Coverage for just missing ONE month Premium!
Excerpt of email blast from one or our carriers:
We are aware that some of our members lost their subsidy and now owe a full month of premium payment(s). Some were able to supply proof needed by the exchange and had their subsidy reinstated, however there is a month or more gap where the government subsidy lapsed, therefore the member is responsible for the full premium during that time. We sympathize and understand that most of our members cannot afford to pay a full month and are therefore skipping that month and trying to pay the following month.
We are receiving a lot of questions asking:
“If the client does not pay the month(s) without subsidy and they pay the following month with subsidy will they be able to use the insurance?”
Unfortunately, the answer is No, they will not. Members must pay their responsible portion of the premium or the policy will lapse. For example:
Month of May Member’s responsibility after applying the subsidy is $22.50 (member sends in $22.50)
Month of June Member’s responsibility is the full Premium after subsidy lost is $550.00 (member did not pay)
Month of July Member’s responsibility after applying the reinstated Subsidy $22.50 (Member sends in $22.50)
In the example noted above, since the member did not pay for the month of June, the $22.50 will be applied to the June premium of $550.00 leaving a balance of $537.50 owed for month of June, and $22.50 still owed for July which will bring it back up to a balance due of $550.00. If the whole balance is not paid, the member will be suspended and will have no coverage until account is brought to current status.
After 90 days the client will be terminated for non-payment, and, unless they have an SEP – Special Enrollment Period, cannot enroll again until open enrollment starting in November and no coverage till January 2016. Molina will not send the member to collections for the owed amount however; they will still owe that until paid in full.
The member always has the right to file an appeal to the Exchange. They would need to submit a letter or an Appeal Request form to:
Health Insurance Marketplace Attn. Appeals
Department of Health & Human Resources
465 Industrial Blvd, London, KY 40750-0061
The following information MUST be in the uppers corner on EVERY page, If not on a page it will NOT be considered as received: First and last name, SSN# and State.
Successful eligibility appeal results will be communicated to the Issuer via a HICS case.
Thank you for your inquiry and hope this information helps in the future. As always if you have any questions please feel free to give us a call.
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Cancellation for non-payment of premium:
When premiums are not paid, coverage will cancelled due to non-payment following our standard grace period rules (see below). Members will receive a notice when premium is past due. The notice includes the date when the grace period ends and that coverage will terminate unless the member sends the full past due amount before the grace period ends. Reinstatement is not allowed if the policy is cancelled for nonpayment.
The grace period is an additional period of time during which coverage remains in effect and refers to either:
The three month grace period required for individuals receiving Advance Payments of the Premium Tax Credit
For individuals not receiving the APTC it refers to any other applicable grace period (All States except Maine:
31 days; Maine: 30 days).
If the full amount of the premium is not paid by the premium due date, the grace period begins. If the required premium is not paid by the end of the grace period, coverage is terminated. The member is not be eligible to apply for other coverage until the next open enrollment period unless they experience a qualifying event. See below for specific information about the two types of grace periods.
Grace period for members receiving Advanced Premium Tax Credits (APTC)
Members who receive APTC are provided with a three month grace period.
During the first month of the three month grace period, coverage remains in effect.
During the second and third month of the grace period coverage will be suspended and the member(s) will be ineligible for benefits under their health benefit plan unless they pay all premiums due before the end of the grace period. Any outstanding authorizations, approvals for services or certifications for health care services to be provided during or after the second and third month of the grace period are also suspended. We will not provide any benefits or coverage for services, supplies, or prescription drugs obtained while the suspension is in effect even if previously approved, authorized or certified.
The application of the grace period to claims is based on the date of service and not on the date the claim was submitted.
If full premium is not received during the grace period, members:
Will have no coverage for claims incurred after the first month of the three month grace period. They are liable for the full cost of any services they receive after the first month of the three month grace period.
May be required by their health care providers to pay for any health care services they need.
Will be liable to us for the premium payment due for the period through the last day of the first month of the three month grace period.
Will be liable to us for any claims payments made for services incurred after the last day of the first month of the three month grace period.
May be required to repay any premium tax credits the government paid on their behalf during the second and third months of the grace period.
If your client makes timely payment of all premiums due before the end of the grace period, coverage will be reinstated, and claims for covered services received during the grace period will be processed.
Grace period for members not receiving APTC
These members have a grace period of 31 days (in all states except Maine which is 30 days). This means if any premium payment is not paid on or before the date it is due, it may be paid during the 31 (30 in Maine) day grace period. During the grace period, coverage will stay in force. If the full premium payment is not made during the grace period, coverage will be terminated on the last day of the grace period. They will be liable to us for the premium payment due including those for the grace period, as well as for any claims payments made for services incurred after the grace period. Copied from Blue Cross CONFIDENTIAL agent manual Form 03673MUBENMUB 10/25/16 *
See also this jpg from Blue Cross Confidential Manual
Grace Period & Cancellation Procedure
Examples of how a #three-month grace period works
Copies of emails to clarify the rules:
Let’s say your client entered the grace period and owes premiums for two months. Here’s an example of what can happen:
• During the first month in grace period, your client’s health benefits stay in effect. We will honor claims incurred during this period. Your client must still pay any unpaid premiums, copayments, coinsurance and deductible amounts, as set forth by the health plan. • During the second and third months of the grace period, your client’s coverage will be suspended.
No one on the plan will be eligible for benefits, unless the full amount due is paid before the end of the grace period. During this time, we will not pay for any health care services, supplies or prescriptions, even if they were approved before. Now, let’s say your client pays for one of the two overdue months right away. Doing so will not extend the grace period or delay suspension, as the grace period moves into the second month. Your client will be on the hook for any claims during this time while coverage is suspended, unless the account gets paid in full before the grace period ends. Ultimately, if your client doesn’t pay the remaining amount due by the end of the grace period, we will cancel coverage. We also will refund the partial premium payment made in the second month because it doesn’t cover the full premium owed. We will only honor claims incurred in the first month of the grace period.
Premium payment grace period clarification
Regulations require a 90-day grace period for on-exchange members receiving subsidies for their health plan. For off-exchange members not receiving subsidies, the grace period is 30 days. For a member who is on a 90-day grace period and does not pay 100% of their total premium due, the grace period does not start over.
Example: A member owes $600.00 for their premium for March and April. In April, they pay one month’s premium for the month of March. In this scenario, the member is still in their 90-day grace period with 30 days left until they are cancelled. Blue Shield Agent Email 6.7.2016
Here are excerpts various bulletins we’ve received about Grace Periods under Health Care Reform
New Payments (Covered CA) can be made here. Policies cancelled for NO reason or explanation
Learn More ==> CA Health Line 3.22.2016 Learn More ⇒ Molina bulletin
In either case, the grace period starts on the date we mail members the first warning notice that their premium is overdue. The letter tells them when their grace period ends. It warns that they will lose their coverage unless they send us the full past due amount before the grace period ends. It says we won’t be able to reinstate them afterward, if their policy gets canceled for not paying premiums. We also send them one or more reminder letters repeating this information, depending on how long their grace period is.
Grace Period and Review of Cancellation in Sample EOC Evidence of Coverage – Policy
Health Net Cancellation Procedures
References & Links
45 CFR § 156.270 – Termination of coverage or enrollment for qualified individuals.
§ 155.430 * Termination of Exchange enrollment or coverage.
The USPS now has a feature called #informed delivery.
Prove you NEVER got the bill?
I’m not an attorney and I can’t find a citation, but if you have this feature in the future it looks like it would be excellent evidence to backup an assertion that the Insurance company never sent a bill or late notice.
Visit the USPS site for more information. informed delivery.usps.com
View the envelope of all your snail mail before it arrives – save emails to prove a letter was never sent to you?
How to prove you never got a bill?
There is no evidentiary proof of a negative act (i.e. failing to receive a document).
There is a presumption of regularity with the mail US Court of Appeals * Marquette Law Review * PAA * Berkeley Law Review Presumptions * so it would be tough Avvo.com *
The “mailbox rule” provides that depositing a properly addressed letter with prepaid postage with the post office raises a presumption that the letter reached its destination by due course of mail. However, seemingly insurmountable “rebuttable” presumptions like the mailbox rule can in fact be rebutted with the right combination of law, luck, and attention to detail. PAA * WNYLC.com *
Informed Delivery Video’s
FAQ’s & Comments
This is probably hearsay, it would also almost certainly fall under the “business records” exception in California (Evidence Code § 1271), leginfo.legislature.ca.gov 1271. and, consequently, be admissible.
1271. Evidence of a writing made as a record of an act, condition, or event is not made inadmissible by the hearsay rule when offered to prove the act, condition, or event if:
(a) The writing was made in the regular course of a business;
(b) The writing was made at or near the time of the act, condition, or event;
(c) The custodian or other qualified witness testifies to its identity and the mode of its preparation; and
(d) The sources of information and method and time of preparation were such as to indicate its trustworthiness.
1270. As used in this article, “a business” includes every kind of business, governmental activity, profession, occupation, calling, or operation of institutions, whether carried on for profit or not.
***So, I guess a private person, not in business wouldn’t count?
While, of course, it might not show that someone never sent something, it could possibly serve as evidence that something was never delivered.
Generally speaking, the way that’s handled now is someone makes a statement under oath or by affirmation (the whole “I declare under penalty of perjury” thing), and unless the other person can show by certified, registered, or delivery confirmation mail that it was delivered, the lack of receiving is presumed. Sometimes, though, if the person can show that it was mailed as in a certificate of mailing by a law office, it will be presumptively received, but judges don’t usually like that argument.
We’ll have to see how accurate the post office is found to be with this new service!
1. I read with interest parts of your website. I have a problem with my Blue Shield health insurance individual PPO, which was a grandfathered plan from the 80s. I have owned a business and carried my own insurance since that time,
2. but in February I signed up for auto pay on the internet and there but the money was not debited from my checking account. I called Blue Shield last week and they said their system is down and they can’t help me and I might be cancelled.
3. If I get cancelled, can you help me find insurance?
4. Do you know if they can get away with blaming their system for not properly submitting my auto pay?
5. I almost feel like this was purposely done to kick me off their plan.
6. If the cancellation goes through, I guess I would not qualify for a special event for Obama care because of non-payment of premiums.
7. I’ve never been without insurance and quite distressed over this.
8. Thank you for any assist and for your informational website. I hope I will hear from you.
1. Thanks for finding and the interest in our website.
2. Auto pay is usually a good thing. See our page on proving that you had auto pay and that they took the $$$ out.
3. Yes, but it might be difficult, unless we can find a material violation.
4. I doubt they can get away with claiming that their auto pay doesn’t work and allowing a policy to lapse. Do they claim to have informed you of this in writing? If you have the proofs, we can file appeals, make complaints and maybe a class action lawsuit.
5 This is a problem with ACA Obamacare – if you get cancelled you generally can’t get a special enrollment for loss of coverage as that excludes non-payment of premium.
Did you get the bulletin about the changes in easy pay?
8. Do you have an online account with Blue Shield? I suggest you make the payment right now! If nothing else, send a check certified mail. If you appoint us as your agent, I’ll send you the form, we can do our best to get you on auto pay again and to make sure that your February & March payments get made.
There are also temporary plans…
Payroll Deduction IRA for Small Biz # 4587
A payroll deduction individual retirement account (IRA) is an easy way for businesses to give employees an opportunity to save for retirement. The employer sets up the payroll deduction IRA program with a bank, insurance company, or other financial institution, and then the employees choose whether to participate. Employees decide how much they want deducted from their paychecks and deposited into the IRA. They may also have a choice of investments, depending on the IRA provider.
Many people not covered by an employer retirement plan could save through an IRA, but don’t. A payroll deduction IRA at work can simplify the process and encourage employees to get started.
Under Federal law, See Publication 590 A individuals saving in a traditional IRA may be able to receive some tax advantages on the money they contribute, and the earnings on the contributions are tax-deferred. For individuals saving in a Roth IRA, contributions are after-tax and the earnings are tax-free.
Advantages of a payroll deduction IRA:
- Simple for employees to set up an IRA.
- Employees make all of the contributions. There are no employer contributions.
- Many employees find smaller, regular contributions a more manageable way to save.
- Low administrative costs.
- No filings with the government to establish the program or any annual reports.
- You have to register and tell Cal Savers on their website.
- Payroll deduction IRAs with automatic enrollment are considered a qualified plan Cal Savers *
- No minimum number of employees required.
- Program will not be considered an employer retirement plan subject to Federal reporting and fiduciary responsibility requirements as long as the employer keeps its involvement to a minimum.
- May help attract and retain quality employees.
- Learn more - read Payroll Deduction IRA for Small Biz # 4587
Links & Resources
Related, Child Pages & Site Map
“Was the cancellation #legal ? Web Visitor Q & A”
I got a refund check in the mail the other day. I called BCBS and they said it was a refund because I was late on a payment. I never received a cancellation letter. I never received bills from them either so that gave me no indication that my insurance had been cancelled. They said they realized this after they had an audit.
Any suggestions would be appreciated.
The specimen policy on page 39 deals with grace periods. The policy says may terminate, rather than shall. That’s in your favor. Of course, I’m not an attorney and am unauthorized to advise on contract law.
I think you are going to wind up in a he said, she said situation with proving or not proving that late notices and your premium payments were sent or not sent. Were your checks cashed?
What dates does Blue Cross say they sent you late notices? US Mail or Email? What proof do they have they sent them.
According to the policy, you lapse 30 days after the late notice, not 30 days after premium was due.
See page 151 for more information on how to file a grievance. The policy says that you must provide ALL pertinent information and the details and circumstances of your concern or problem.
As an authorized agent, we help our clients with filing appeals, reinstatements, communications problems as a complimentary service as we are paid by the Insurance Companies to consult, enroll and service our clients. Here’s instructions to appoint us in CA.
I just received a notice that my Anthem (non-exchange) policy was terminated because of lack of payment for February.
I filed an appeal based on the fact that I thought that auto-payment had been set up.
Anything else I can do?
Will they reinstate my policy?
What documentation do you have to show that you had cause to think the auto pay was set up? Think of an appeal as a court case in front of an Administrative Law Judge. What evidence do you have? See our appeals page. If Blue Cross says no, do you have enough evidence to take this issue to Department of Managed Health Care?
The Blue Cross manual makes lapsing for non-pay look like a black and white issue of no reinstatements.
What does your Blue Cross Member portal show?
Do you have a copy of the automatic premium payment form that you filled out? Proof that you sent it? Proof Blue Cross rec’d it?
What about the alternate ways to pay premium?
There are always temporary plans.
Do you have an special circumstances to qualify for a special enrollment?
I don’t have any documentation supporting my assertion that I thought I had set up autopay.
I thought I set it up online in the same area where monthly bills are paid.
The tab concerning payments on the Anthem site is not available anymore.Any advise as to whether it is worthwhile to ride out the grievance process or should I move on to other options? One issue with that is I have a number of claims that have now been denied because the termination was effective Feb 1.
Any idea what they look for in an appeal? Is it a mere formality?
There aren’t really any other options. One plus in Health Care Reform is no medical questions, guaranteed issue and no pre-existing conditions clause. The downside is one can only enroll at certain times.
I’m not an attorney, near as I can tell an appeal is like an informal court case. I suggest you prepare your appeal in the same manner. When were you notified of the termination? That might get your claims paid?
I requested the Anthem agent to submit the info for my appeal/grievance in hopes of expediting the process. Based on what you have stated I may have been to simplistic in my grievance. Basically I said I thought I was in autopay and received no notice that the payment for February was past due. My first knowledge of the problem was when I received the termination letter. Hopefully they give me an answer within a couple days (they said that is possible)Termination letter was dated March 6. The denied claims are before that date.
Do you mean the customer service representative or your agent, which doesn’t cost anything extra to have?See beginning of this page for information on how and what is needed to file an appeal.
We are talking about February payment right? If it’s January it looks like you’re SOL as the grace period only applies after you’ve made your first payment. Things are really complicated under Health Care Reform. The policy says you shall be informed that you can apply for reinstatement with a new application, BUT they only take applications at Open Enrollment and Special Enrollment. Then it talks about your right to have the cancellation reviewed.
Have you received confirmation that they are handling your grievance?
On the other hand, since you don’t seem to have any documentation to prove your case, it appears you’re SOL. You might contact an attorney? Maybe there will be a class action lawsuit somewhere. However, Health Care Reform seems to allow cancellations. It’s the only underwriting left for the Insurance Companies…???
Here’s Kaiser Foundation on late notices…
I still don’t understand how the Insurance Companies financial mistake on a contract allows them to bill additional – for alleged past due premiums, that were not billed when they were supposed to be.
(I deal with contracts as a Contractor on a weekly basis and this is not allowed)
Here’s the reference material we’ve found on this topic:
One must read a contract, law, statue, rule or regulation 3 times. Then when you think you understand it, read it again.
Guide to Contract Interpretation
Excerpt of Group Agreement
Due Date and Payment of Premiums
The payment due date for each enrollment unit associated with Group will be reflected on the monthly membership invoice if applicable to Group (if not applicable, then as specified in writing by Health Plan). If Group does not pay Full Premiums by the first of the coverage month, the Premiums may include an additional administrative charge upon renewal. “Full Premiums” means 100 percent of monthly Premiums for all of the coverage issued to each enrolled Member, as set forth under “Calculating Premiums” in this “Premiums” section.
Can the Insurance Company send a Invoice several months late?
Well in short the answer is yes, unless more than six years have passed. The only regulations placing a time limit on collecting a genuine debt is the Limitation Act 1980.
Although you have the right to invoice, where the invoice is over 6 months old we would recommend to include a covering letter apologising for the delay or simply calling your customer beforehand to discuss the matter. This is especially true if the invoice is for a large amount and could cause difficulties at their end when it finally appears!
If they have been prudent then they should have accrued for this bill in their accounts, especially if it is a large amount. However for many businesses a late invoice may come as a shock when they receive the invoice. I do grant, this law is from England. If you have a better citation, let us know. https://www.mycreditcontrollers.co.uk/Articles/how-late-is-an-invoice-still-valid.html
What are my options as far as not #paying for the months I didn’t have coverage?
***Pretty much none. If you don’t pay, you won’t be able to get coverage till next Open Enrollment as you haven’t mentioned anything that would qualify you for special enrollment. Check out our page on temporary plans to tide you over till then.
My payments [subsidy – APTC Advance Premium Tax Credit] changed this year because my income is less than last year.
***Next time try the complementary agent support and have someone experienced like us help you with these problems and hopefully let you know in January. We only get paid if you appoint us. Did Covered CA or Health Net give you an explanation as detailed as this page, without waiting on hold?
I’ve been told by Covered CA I will probably be reinstated but I will have to back pay for the months I didn’t have coverage (Feb., March, April, May, and maybe June).
***As soon as you prove that your payment was $208, you did have coverage. Can Health Net prove they sent you a cancellation Notice in January?
45 CFR 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.
If I don’t have coverage are there any other problems besides the fee [Mandate Penalty 2.5% of Income] at the end of the year for not having health insurance for those months..
***Are you OK with paying bills out of future earnings or losing your home and assets and bankruptcy if you have a large unexpected medical problem?
Scroll down for more FAQ’s or to ask a question.
Resources & Links
If you want to file and appeal – as you think you were mislead and get a new special enrollment period – click here for our appeals page.
See our page on – was the cancellation legal?
12 comments on “Paying Back Premiums to get reinstated?”
i had coverage starting in January.
i had a change in income, applied for new coverage and received special enrollment in May.
January, Feb paid with zero balance,
March premium paid on April 13
and new policy starting may 1, first month premium paid on April 20. April remained unpaid.
i contacted Blue cross to make payment for April and June on June 8th and was informed i was cancelled for non payment as of APril 1st.Reply
Is there and advocate for Pennsylvania that can assist me with my coverage being cancelled for non payment?
i have filed appeals with BLue Cross and been denied for reinstatement.
i have filed appeal with Pennsylvania Department of Insurance and been denied for reinstatement.
i have filed a complaint with Better Business Bureau and have had my case closed unanswered.
i am in the process of filing appeal with the Markeptlace.Reply
Ensure me Kevin.com Kaiser requiring back payments on prior year policy?
I found a form online to request a hearing. The form is called “Request for a State Fair Hearing to Appeal a
Covered California Eligibility Determination”.
Here’s a link to the form:
I called the number on the form. (1-855-795-0634) I was able to submit an appeal over the phone instead of having to send in the hearing request form.
I will let you know how it all turns out.Reply
In my humble opinion with the facts you state
that covered California gave you one amount and HealthNet thanks you know a different amount
and we’re talking about proofs here
I don’t think you’re gonna win
I really feel that you got to do this like a court case and submit your documentation that proves your point
I’m not an attorney I can’t give you legal advice
I just haven’t seen that many appeals come out in the clients favorReply
Be sure to read all the instructions on how to file an appeal in the form you just found
on how to submit proofs that are on the covered California form
how is the judge going to know that you were quoted one price by covered California and HealthNet billed you for another price if you don’t send him the proof?Reply
IMHO this is what you are trying to prove so that you get a special enrollment periodReply
Are you sure it was Department of social services or do you mean Department of managed healthcare or department of insurance I don’t see that department of social services has anything to do with it
I don’t know of any law or precedent to allow you to start July 1 if you have that please post it here because it will teach me something new would be helpful to other site visitors
When you say take it to a judge do you mean go to small claims court superior court or in and made a straight of law judge in the appeal section of covered California or Department of insurance I’m using my iPhone now so I can’t put in all the links that I’d like to but if you search for appeals on this website you can find everything that I have but don’t forget you’ve got to show all the proofs and you’re going to have to show that you were never properly canceled and have proof I’m not an attorney so please doublecheck everything that’s not citedReply
I guess you’re right because Medi-Cal is part of the department of public social services
also if you can show a material violation or error then that would get you new enrollment.
So your policy would be not reinstated it would be a brand-new special moment.
Any be able to pick any plan and then you can appoint a says your age and we can get it going for you and that way we get paid for helping you rather than just is a public service
In the menu above put your mouse over special enrollment and then look for material violationReply
Thank for responding back to me. Today I called CA Department of Social Services and submitted an appeal for being wrongfully cancelled and asked that I be reinstated starting July 1st. Since I will be reinstated July 1st, i will not have to back pay for the months I did not have coverage. The back pay is more than the federal fee for not having health insurance. I will gladly pay the federal fee.
If for some reason, Covered CA and Healthnet can not resolve this issue I will have to present my case to a judge and he will decide.
Thanks again for your time and all the great resources you have provided me.
What if my Covered CA bill has my spouses name, but it’s ONLY me that’s covered?
On Exchange records displays the name of the Responsible Party instead of the main applicant. The Responsible Party is the person who set up the Covered CA application and indicated that they are responsible for the payment and oversight of the account. Before the binder payment is processed, the Responsible Party name will show up on the Individual List Bill (ILB), but the SSN and DOB will show as the main applicant. The main applicant is different from the Responsible Party. This will typically happen when the Responsible Party applies for a dependent or a spouse through On Exchange Covered California plans. All correspondence sent out will be addressed to the Responsible Party, including the initial binder payment letter. Once the binder payment is processed, the main applicant and additional dependents will be visible. Blue Shield Email Dated 1.13.2013
Causing the cancellation of policies by not billing seems to be a common problem with Anthem. Check out the complaint by Roberta of Lyons, CO at https://www.consumeraffairs.com/insurance/anthem.html?page=15. I especially like the way Anthem cashed the check and then claimed they didn’t…
Your citation is from 2006, why bother us on this website?
I have battled Anthem over a wrongful cancellation. I paid my premiums on time, sent certified mail so I know it was received, but Anthem apparently decided not to cash one and claimed that I owe it.
According to Black’s law dictionary, payment is “The performance of a duty, promise, or obligation, or discharge of a debt or liability, by the delivery of money or other value. Also the money or other thing so delivered.” This means that the check doesn’t need to be cashed in order for the payment to be made; it means that the payment (check, money order, etc) only needs to be delivered. This makes sense. Your mortgage company couldn’t repossess your home by refusing to accept your payment.
Further, the Uniform Commercial Code (Article 3) states that if you give someone a payment, and they refuse to accept it, your debt to that person is reduced by the amount of your payment. (paraphrased)
Last but not least is the concept of good faith and fair dealing. In contract law, the implied covenant of good faith and fair dealing is a general presumption that the parties to a contract will deal with each other honestly, fairly, and in good faith, so as to not destroy the right of the other party or parties to receive the benefits of the contract. (Wikipedia). When I sent my payment and Anthem didn’t cash it, Anthem appeared to be acting in bad faith by denying me the benefits of having the insurance I had paid for (see point #1)
Just a few thoughts on what’s happening……..
Please, when citing things, put in a URL – Internet Address
Found your name on website of anthem…..We have lost our coverage due to exceeding grace period time frame…..DEVASTATING….Anthem is going through process of reinstatement application but informed me it does not look good. Is their any hope? My husband and I are 61 years of age. what can we do? We pay $1,980.00 monthly in premiums.
Thank you for our conversation by phone this a.m. Please e-mail me whatever documents that may be able to assist me in getting reinstated with Anthem Healthkeepers Gold Richmond VA under Blue Cross Blue Shield
Do you qualify for any special enrollment periods?
How about a temporary plan? The time periods for coverage have become very limited though.
Didn’t you get a late notice?
Personally, I don’t like submitting appeals and grievances over the phone. You don’t know if the person taking the grievance really knows what they are doing or are looking out for your best interests. I suggest you put everything you have together and file your own grievance. Then if you get denied, you are all ready to give it to your attorney or the appropriate state agency to help you.
So, basically, read everthing I have and follow the links in this section of the website and put together your best argument.