What happens if I’m late with a monthly health insurance premium payment?

Individuals with no coverage | How Premium Tax Credits And Cost-Sharing Reductions Work |

The answer depends on whether or not you are receiving advanced premium tax credits. For people receiving advanced premium tax credits, if a payment due date is missed, insurers must provide a 90-day grace period during which consumers can bring their premium payments up-to-date and avoid having their coverage terminated. However, the grace period only applies if an individual has paid at least one month’s premium. If, by the end of the 90-day grace period, the amount owed for all outstanding premium payments is not paid in full, the insurer can terminate coverage dating back to the end of the first month of non-payment.

In addition, during the first 30 days of the grace period, the insurer must continue to pay claims. However, after the first 30 days of the grace period, the insurer can hold off paying any health care claims for care received during the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers request that you pay out-of-pocket for the full cost of care, or they may not provide care until the premiums are paid up so that they know they will be paid. Alternatively, providers may provide care with your regular cost-sharing; if your coverage is subsequently terminated, they may bill you for the total cost of services you received during the 90-day grace period. If you pay your premiums in full by the end of the 90-day grace period, your coverage will be reinstated and claims during that time will be paid.

People not receiving advanced premium tax credits generally get a much shorter grace period; currently, the general practice is 31 days, but it may vary in each state.

Note, however, that under certain circumstances, your state may require insurers to extend grace periods to policyholders who temporarily cannot afford to pay their premium. This may apply during public emergencies or following natural disasters. Check with your state department of insurance to see if your state requires grace periods in certain circumstances.

(45 C.F.R. §§ 156.270, 155.430(d)(5).)

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