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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 is 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.


Will the plans offered by different insurers be the same since they follow rules established by New York State?

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.

Will each insurer have its own identification card?

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

ZWZ - Individual EPO

What insurance carriers are offering plans on the marketplace?

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

When you enroll in a marketplace plan, can you change your coverage throughout the year?

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

  • Only American Indians and Alaskan Natives are eligible to change plans on a monthly basis.

Are there family plans offered on the marketplace, or just individual?

Yes, family plans are available. Coverage options on the marketplace include:

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

Will there be a change in plan types (platforms - HMO, PPO, EPO, POS)?

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

What fee schedule will be used to reimburse providers for these products?

Blue Shield will pay commercial rates for the marketplace products, unless the provider has negotiated a unique fee schedule.

Will I submit claims for marketplace plans the same as other plans?

Yes. Please follow the same process for submitting claims.

How are claims processed if a member does not pay their premium?

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:

                 - WNYHEALTHeNET ( 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 be denied (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, the 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.