QUESTION

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
ANSWER

The answer depends on whether 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, which means the enrollee may be responsible to cover any health care services they receive during the second and third months if they fail to catch up on the amounts they owe before the end of the grace period. Insurers are supposed to inform health care providers when someone’s claims are being held. This could mean that providers may request that you pay out-of-pocket for care or may not provide care until the premiums are paid up so that they know they will be paid. Alternatively, providers may provide care and if your coverage is subsequently terminated, may bill you for the total cost of services. 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 are expected to get a much shorter grace period; currently, the general practice is 31 days but it may vary in each state.

Not paying your premiums may affect your ability to get future coverage. If you are seeking new coverage from an insurer to whom you owe premiums for prior 12-month coverage, the insurer can request that you pay your past due premiums as a condition of enrolling you into new coverage. This only applies to insurers to whom you owe premiums for prior 12-month coverage (i.e. if you switch to a new insurer, the company cannot condition enrollment on paying premiums you owe to your previous insurer). Insurers can impose this obligation during both open and special enrollment periods. (45 C.F.R. § 156.270;; 45 C.F.R. § 155.430(d)(5); 45 C.F.R. § 147.104; 82 Fed. Reg. 18346, April 18, 2017).

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