Marketplace Exchange FAQs

The Marketplace (Exchange) is a new way for consumers to shop for health coverage under the Affordable Care Act. As a provider, the Marketplace may have an impact on your patients and your practice. Therefore, it's important to understand how the Marketplace works, what options are available for your patients, and how it may impact the claims process for your practice.

Download the Marketplace Exchange FAQs

Each insurer participating in the Marketplace must offer the state's standard plan at each metal level (platinum, gold, silver and bronze). The variations between insurers' standard plans will be limited to price, formularies, provider networks, and the availability of out-of-network coverage.

In addition, to the standard plans, insurers may offer up to three additional plans per metal level.


Yes. Each insurer will continue to have its own ID cards. We will include the metal level plan name on the ID card and use the following prefixes:

YJZ - Individual EPO
YJL - Individual POS


For a list of insurers offering coverage on the Marketplace, please visit:

Health Benefit Exchange


No. Most consumers cannot change their coverage unless there is a qualifying event (marriage, divorce, etc.)

  • Only American Indians and Alaskan Natives can change plans on a monthly basis.


Coverage options on the Marketplace include:

  • Individual
  • Two-person
  • Adult plus children
  • Family
  • Child only (on standard plans only)


No. The plan types did not change, but there are new polivies that meet Affordable Care Act (ACA) requirements.

BlueCross BlueShield will pay commerical rates for the Marketplace products unless you have negotiated a unique fee schedule.


Yes. Please follow the same process for submitting claims.


The answer varies based on whether the member is receiving financial assistance (subsidy, tax credit).

It's business as usual for members who are not receiving financial assistance.

  • We will pay claims for 30-day grace period.
  • If the member does not pay, we will retroactively terminate the member.
  • Claims are then adjusted.
  • You will need to bill the member for any funds owed.

There is a new process for members receiving financial assistance.

  • We will pay claims for 30 days of a 90-day grace period. We'll bear that risk.
  • For days 31-90 of the grace period:

                 - HEALTHeNET (wnyhealthenet.org) will be updated to alert you that a patient is in the grace period.
                 - Medical claims will be pended (based on regulations from the New York State Department of Financial Services).
                 - Pharmacy claims will deny (based on regulations from the New York State Department of Financial Services).

  • We will send you a notification for each pended claim.
  • If full payment is not received by Day 91, member is terminated retroactively to the end of the first month of the grace period and the pended claims are denied.
  • You will need to bill the member for any funds owed.





Need Assistance?

phone icon
By Phone:

Call Us

envelope icon
Have a Comment
or Question?
Submit



Tools