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A QHP is a plan that is certified by the Centers for Medicare & Medicaid Services (CMS) and meets certain requirements under the Patient Protection and Affordable Care Act (ACA). QHPs have networks that are unique to ACA plans. Often, these networks have a smaller number of participating providers compared to our traditional networks.
Open Enrollment starts November 1, 2022 for all states, and ends January 15, 2023 for all states — except California and New Jersey. Open Enrollment for California and New Jersey will end on January 31, 2023.
These plans will have an effective date of January 1, 2023 if a member enrolls and makes their first binder payment by December 15, 2022. If a member enrolls and makes the first binder payment between December 16, 2022 and January 31, 2023, their plan will be effective as of February 1, 2023.
We have on-exchange and off-exchange plans available in all new states we’re entering for 2023:
- California (El Dorado, Fresno, Kings, Madera, Placer, Sacramento, Yolo)
- Delaware (Statewide)
- Illinois (Cook, McHenry, Lake)
- New Jersey (Atlantic, Bergen, Burlington, Camden, Cumberland, Essex, Gloucester, Hudson, Hunterdon, Mercer, Middlesex, Morris, Passaic, Salem, Somerset, Sussex, Union, Warren)
We’re also expanding our plans in the following states we previously entered in 2022:
- Arizona (Banner|Aetna) (Added Cochise, Coconino, Yuma)
- Florida (Added Jacksonville, Orlando, Treasure Coast)
- Missouri (Added Cass, Lafayette, Johnson)
- Texas (Added Dallas, Corpus Christi)
*Subject to regulatory approval.
We have on-exchange and off-exchange plans available in all states we entered in 2022:
- Arizona (Banner|Aetna) (Phoenix, Tucson)
- Florida (South Florida, Southwest Florida)
- Georgia (Albany, Atlanta, Savannah)
- Missouri (Kansas City, Springfield, St. Louis)
- Nevada (Reno, Las Vegas)
- North Carolina (Asheville, Charlotte, Eastern NC, Fayetteville, Triad, Triangle)
- Texas (Austin, El Paso, Houston, San Antonio)
- Virginia (Innovation Health® plans in Northern Virginia and Aetna CVS Health plans in Richmond and Roanoke)
After October 1, here’s how you can check your participation status:
Member ID cards will have "QHP" on them. The product name and the plan name are on the right side of the card. There is also a dedicated toll-free number for Member Services.
Regardless of where the member purchased the plan, you will verify benefits and eligibility as you normally do. With our Availity® provider portal, it’s easy to manage many tasks online. You can submit claims, check claim status and patient eligibility, request precertification, submit disputes and appeals, and more.
Don’t have an Availity account ?
- If your practice already uses Availity: Contact your Availity administrator to request a username. If you don’t know who your administrator is, call Availity Client Services at 1-800-282-4528 for help.
- If your practice is new to Availity: Find registration instructions to set up your Availity account.
Use the number ending in “00” for the subscriber’s member ID number. Submitting requests (such as a claim or prior authorization request) for someone other than the subscriber? Replace the “00” with the last two numbers that apply to that person.
Here’s an example:
Subscriber (Joseph Smith) - 320004841700
Dependent 1 (Jane Smith) - 320004841701
Dependent 2 (Daniel Smith) - 320004841702
Yes. That’s because members have no out-of-network benefits with any plan, in any state, except for emergencies. Note: The following list includes examples of specialties that may be considered direct access and referrals may not be required:*
Durable medical equipment**
Gynecology care (obstetrician/gynecologist)
Home health care
Hospital ambulatory surgery**
Mid-level practitioners (for example, physician assistants, nurse practitioners)
Radiology, pathology and lab**
Therapy (physical therapy, occupational therapy, speech therapy)
To find providers in the exchange network, you can use our online provider search.
*You can review our provider manuals and associated materials online to confirm your state’s direct access referral requirements.
ACA individual insurance plans only coordinate with Medicare coverage. If the member is eligible for Medicare and elected Medicare coverage, then Medicare will always be primary.
Individual insurance plans use Government Exclusion (GE) to coordinate with Medicare. GE is a method of determining Aetna payment when Medicare is the primary insurance for the member. Medicare payments are excluded from the total allowed charges. Aetna CVS Health considers the allowance based on the member’s responsibility after Medicare has considered the claim.
We’ll automatically assign most members a PCP except for those in Missouri, New Jersey, North Carolina and Virginia (Aetna CVS Health members in Roanoke and Richmond). Members can also call us to choose their PCP. Then we’ll mail them a new ID card.
There are no out-of-network benefits with any Aetna CVS Health individual plan & family plan, in any state, except for emergencies. If Aetna CVS Health approves something, it would be at the in-network benefit and at a contracted rate (if broad network provider), or LOA negotiated.
Note: MinuteClinic® locations and some labs have a national network. So they are not considered out of network even if they are outside of the service area.
Payment and billing
Yes, the payer ID and claim address are the same for exchange plans. For information on electronic claims submission, see our claims, payment & reimbursement resources.
We encourage electronic claims submission. However, if you prefer to mail a claim, you can use the address below:
- Medical providers in Arizona, California, Florida, Georgia, North Carolina, Nevada:
PO Box 14079
Lexington, KY 40512-4079
- Medical providers in Delaware, Illinois, Missouri, New Jersey, Texas, Virginia:
PO Box 981106
El Paso, TX 79998-1106
That means we’ll continue to pay any claims that occur during the first month of non-payment. However, the grace period is different between members who receive premium subsidies (Advance Premium Tax Credit) and those who don’t:
For on-exchange members who receive premium subsidies: There is a 90-day premium payment grace period. In all states except Texas, at the start of the second month of non-payment, claims will be pended until premium payment is received in full. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 will be denied.
For Texas members: Claims will be processed during the grace period. If the member doesn’t pay their premium and is terminated, claims paid for dates of service in months 2 and 3 of the grace period would be subject to overpayment recovery.
To determine if a member is in a grace period, log in to Availity to check benefits and eligibility. You will see “HIX Grace Period” under Plan/Product if the member is in a grace period.
For on-exchange members who don’t receive premium subsidies or off-exchange members:The grace period requirements vary between 30 and 31 days. If the member doesn’t pay, their termination date will be effective retrospectively on the last day of the prior month that the premium was paid, and any paid claims with dates of service after termination would be subject to overpayment recovery.
For California members: California applies a 30-day grace period, and if the member doesn’t pay termination of coverage is prospective. Claims paid during the grace period are not subject to overpayment recovery.
We'll process the claim according to plan benefits. If the member has assigned benefits, Aetna CVS Health will pay you directly. Members have no out-of-network benefits on any plan, in any state, except for emergencies.
You’ll be reimbursed as outlined in your current contract (as applicable), or in a specific QHP rate schedule, if our network team has arranged one with you (usually for facilities only). For details, refer to your contract agreement/amendment.
Still have questions?
Health plans are offered or underwritten or administered by Aetna Health of California Inc., Coventry Health Plan of Florida, Inc., Aetna Health Inc. (Florida), Aetna Health Inc. (Georgia), Aetna Life Insurance Company, Aetna Health of Utah Inc., Aetna Health Inc. (Pennsylvania), or Aetna Health Inc. (Texas) (Aetna). Aetna and MinuteClinic, LLC (which either operates or provides certain management support services to MinuteClinic branded walk in clinics) are part of the CVS Health® family of companies.
Health benefits and health insurance plans contain exclusions and limitations.