Issued: January 10, 2025
Partners Health Management is sharing guidance to providers for NC Medicaid beneficiaries enrolled in Marketplace coverage through HealthCare.gov. This information was shared by the North Carolina Department of Health and Human Services (NCDHHS) in a Medicaid Bulletin that addresses (1) information about beneficiaries enrolled in NC Medicaid and Affordable Care Act (ACA) coverage; (2) actions a provider or beneficiary can take to file a complaint concerning potential fraudulent enrollment into an ACA plan; and (3) prior authorizations and third-party billing.
What do providers need to know?
Partners is sharing guidance to providers for NC Medicaid beneficiaries enrolled in Marketplace coverage through HealthCare.gov:
- Individuals who qualify for full Medicaid coverage are not eligible for financial help with the cost of their Marketplace plan. (Individuals may not want to keep their Marketplace coverage because it will cost more than coverage through NC Medicaid and it may cause them to be ineligible for Medicaid.)
- To avoid paying the full cost of their Marketplace plan premium and covered services, individuals should cancel their Marketplace coverage as soon as they find out they are approved for Medicaid.
- If beneficiaries are enrolled in NC Medicaid coverage and an ACA Marketplace plan, the federal government may stop paying for part of their Marketplace plan premium (called advance payments of the premium tax credit), and the beneficiary will have to cover the full cost.
- Beneficiaries do not have to pay back premium tax credits for the months they had both Medicaid and Marketplace insurance.
How to cancel ACA Marketplace Coverage
- If a provider has been informed that a NC Medicaid beneficiary wishes to cancel their ACA Marketplace coverage plan, they should instruct the individual to contact the ACA Marketplace Call Center at 1-800-318-2596 (TTY: 1-855-889-4325) or visit healthcare.gov.
- For more information about when and how to cancel a Marketplace plan, visit the Canceling a Marketplace plan when you get Medicaid or CHIP webpage on healthcare.gov.
Fraudulent Enrollment
- In cases where a beneficiary believes they have been fraudulently enrolled into an ACA Marketplace plan by a broker, the beneficiary should:
- Contact the Marketplace at 1-800-318-2596 to file a complaint and ask for an escalation due to fraudulent enrollment into a health plan without their consent or knowledge.
- File a complaint with the North Carolina Department of Insurance (NCDOI) 855-408-1212 on the NCDOI Assistance or File a Complaint
Prior Authorizations and Third-Party Billing
- If an individual has both NC Medicaid and ACA Marketplace coverage, the ACA Marketplace plan must accept prior authorizations provided by NC Medicaid for individuals eligible to receive medical assistance. The ACA Marketplace plan cannot deny coverage on the basis of the Marketplace plan’s prior authorization requirements not being met. (Section 9E.23(d1) of Session Law 2023-134, which amended NCGS § 108A-55.4).
- Acceptance of prior authorization provided by NC Medicaid includes prohibiting the ACA Marketplace plan from:
- Applying additional prior authorizations in instances where NC Medicaid Direct or an NC Medicaid Managed Care health plan has authorized the service.
- Applying additional prior authorization in instances where NC Medicaid Direct or an NC Medicaid Managed Care health plan would not otherwise require prior authorization of the service.
Who can providers contact if they have questions?
- Providers can contact the NC Medicaid Contact Center at 1-888-245-0179 if they have questions.
- Providers may also call Partners Provider Service Line at 1-877-398-4145.