I’m behind on my health insurance premiums. How long will they continue to pay my claims?

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This Q&A column addresses questions from real patients about health care costs. Have a question you’d like to see answered? Submit it to [email protected].


I purchased my health insurance through Healthcare.gov last year. I’ve made all of my payments on time, until now. My income was recently cut by about 25% when I lost the part-time job I was working to make ends meet. I’m two weeks late on my health insurance premium, but need to get my medication refilled and schedule a checkup. Will these be covered? How long do I have to get caught up before my policy is canceled?


When life throws a curveball, like your recent job loss, financial chaos can ensue. Losing one-fourth of your income is pretty significant, so your inability to stay on top of your premium is understandable.

An estimated 13% of those who signed up on ACA federal and state marketplaces in 2015 have since lost their insurance due to premium nonpayment, so you’re not alone. Fortunately, there are some safeguards in place to protect you, and options available should your policy actually lapse.

You’re likely entitled to a “grace period.”

Most people who purchased insurance plans on state and federal marketplaces qualified for tax credits, making their insurance more affordable. If you received a premium tax credit to reduce your monthly premiums, you’re in luck: The Affordable Care Act instituted a 90-day grace period for these subsidized plans.

For the first 30 days after your missed payment, your insurance company must pay your claims. For days 31-90 of the grace period, they don’t have to pay the claims but will hold them rather than flat-out denying them.

During the entire 90-day grace period, you are afforded the opportunity to get caught up and have your insurance pick back up once you are current on your premiums. Any claims held during this time will be processed once you’re caught up. If you’re unable to get caught up during this time, your policy will be canceled and any claims submitted after the initial 30 days will be your responsibility entirely.

If you didn’t qualify for a premium tax credit, call your insurer.

If your plan isn’t protected by the ACA 90-day grace period for subsidized plans, your insurer may still offer you some time to catch up. Thirty days tends to be the norm, but grace periods and the specifics of coverage during these times vary widely from insurer to insurer. Your best chance for resolving the issue with minimal disruption is to contact them directly and explain your situation. Even if they aren’t willing to give you additional time to pay, you’ll at least know what you’re up against.

If your policy is canceled, don’t wait to take action.

It sounds like you have recurring prescription costs, and likely the doctor’s visits that often accompany them. If your policy is canceled or you know a cancellation is inevitable, you should immediately begin looking for other coverage options or budgeting to pay out of pocket.

Depending on the extent of your current financial hardships, you could be eligible for Medicaid. Check with your state’s Medicaid office for eligibility specifics. If you’re not eligible, you’ll have to wait until open enrollment begins on Nov. 1, 2015, to shop for a new plan on the marketplace, as nonpayment of premiums disqualifies you from “special enrollment periods.” Also, if you go without health insurance for more than three consecutive months and do not qualify for an exemption, you will be responsible for paying a penalty at tax time.

If forced to go uninsured for the remainder of the year, set aside what you can to pay for your medical expenses and don’t be afraid to use community health centers. You can reduce prescription costs by opting for generics, choosing more affordable therapeutic alternatives when generics aren’t available and applying for assistance through drug manufacturers and nonprofit organizations. Finally, be a savvy health care consumer by comparing prices for medical services as you would if you were shopping for plane tickets or anything else.

If you find yourself holding an unmanageable medical bill, call your provider and negotiate. You’ll often find they’re willing to work with cash-paying customers who are having a difficult time.

Source: Forbes