ACA plan resources for providers

A QHP is a plan that the Centers for Medicare & Medicaid Services (CMS) certifies and meets certain requirements under the Patient Protection and Affordable Care Act (ACA). QHPs have networks that are unique to ACA plans. QHP plans can also be referred to as Exchange Plans or Marketplace Plans.

Member ID cards will have “QHP” on the top right of the card. The product name and the plan name are on the right side of the card. There is a dedicated member services toll-free number.

The date your patient’s Innovation Health plan becomes effective depends on when they signed up for their plan. In most states, Open Enrollment runs from November 1 to January 15. Coverage usually starts on the first day of the month following the plan selection. For example, if your patient selects a plan on December 10, their coverage will start on January 1. Your patients may qualify to get coverage outside of the Open Enrollment window if they’ve had a big life change or one coming up, such as a new child or the loss of their health plan.

To check a patient’s eligibility, use our Availity^® online portal.

Log in to Availity

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.

Yes, the payer ID and claim address are the same for exchange plans. For information on electronic claims submission, review our claims, payment and reimbursement resources.

We encourage electronic claims submission. However, if you prefer to mail a claim, you can use the address below:

Medical Providers in Virginia
Innovation Health
PO Box 981106
El Paso, TX 79998-1106

Innovation Health providers: Check participation status.

Regardless of where the member purchased the plan, you will verify benefits, eligibility, and primary care of record 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.

Log in to Availity

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.

Yes. That’s because members do not have out-of-network benefits with any plan, in any state, except for emergencies.

These specialties allow direct access, and may not require referrals:*

• Behavioral health
• Durable medical equipment*
• Gynecology care (obstetrician/gynecologist)
• Home health care
• Hospital ambulatory surgery*
• Hospital outpatient*
• Mid-level practitioners (for example, physician assistants, nurse practitioners)
• Oral surgery
• Preventive care
• Radiology, pathology and lab*
• Therapy (physical therapy, occupational therapy, speech therapy)

To find providers in the exchange network, use our online provider search.

Search Innovation Health providers

*FOR DIRECT ACCESS TO SPECIALISTS: Reference our Provider Manual and related materials online to confirm your state’s direct access referral requirements.

*FOR DURABLE MEDICAL EQUIPMENT, HOSPITAL AMBULATORY SURGERY, HOSPITAL OUTPATIENT AND RADIOLOGY, PATHOLOGY AND LAB: Some services and equipment may require precertification. To confirm benefits, call your provider support team at 1-888-632-3862 (TTY: 711).

We encourage all providers to review our provider manuals and associated materials.

You can use the Provider Data Management (PDM) tool in the Availity^® provider portal to update and maintain your profile data. To learn about the Availity portal, sign up for training, and find resources like our PDM quick reference guide, visit here.

No, the existing claims filing limits will apply. Check out insurance regulations by state for more information on timely filing standards.

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) = 10XXXXXXXX00

Dependent 1 (Jane Smith) = 10XXXXXXXX01

Dependent 2 (Daniel Smith) = 10XXXXXXXX02

ACA individual insurance plans only coordinate with Medicare coverage. If the member is eligible for Medicare and elects 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 Innovation Health payment when Medicare is the primary insurance for the member. We exclude Medicare payments from the total allowed charges. Innovation Health considers the allowance based on the member’s responsibility after Medicare has considered the claim.

We 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 & 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. We do not consider them out of network even if they are outside of the service area.

You can find formulary information at the link below:

2025 Formulary Information

That means we’ll continue to pay any claims from the first month of non-payment. However, the grace period is different for members who receive premium tax credits (Advance Premium Tax Credit) and those who don’t:

For on-exchange members who receive premium tax credits: There is a 90-day premium payment grace period. In all states except Texas, at the start of the second month of non-payment, we hold claims until we receive the full premium payment. If the member doesn’t pay their premium and we terminate coverage, claims for services in months two and three of the grace period are denied.

To determine if a member is in a grace period, log in to Availity^® to check benefits and eligibility. You'll 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 varies between 30 and 31 days. If the member doesn’t pay, their coverage termination date is the last day of the prior month that they did pay. Any paid claims with dates of service after coverage is terminated are subject to overpayment recovery.

We process the out-of-network claims according to plan benefits. If the member has assigned benefits, Innovation Health will pay you directly. Members don’t have out-of-network benefits with any plan, in any state, except for emergencies.

You’ll be reimbursed as:

• Outlined in your current contract (as applicable), or
• Indicated in your specific QHP rate schedule, if our network team has arranged one with you (usually for facilities only)

For details, refer to your contract agreement or amendment.