ACA plan resources for providers

Legal Notices: Health benefits and health insurance plans contain exclusions and limitations.

Innovation Health Affordable Care Act (ACA) plans are now available for coverage starting 2025.

Innovation Health providers: check participation status

General questions
Plan benefits
Payment and billing

General questions

What is a qualified health plan (QHP)?

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.

How can I identify an exchange member?

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.

When do the 2025 Innovation Health individual and family plans first become effective?

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.

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.

Are the payer ID and claim address the same for exchange plans?

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

How can I check my product participation status?

Innovation Health providers: Check participation status.

Will our online eligibility and benefits verification system indicate if a patient is on a state exchange plan and who their PCP is?

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.

Don’t have an Availity account?

If your practice is new to Availity: Find registration instructions to set up your Availity account.

If I need to refer patients for care, do I have to refer patients to other providers within an exchange?

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).

Are there more provider resources available to support me with providing care, managing my practice and working with Innovation Health?

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

How can I maintain my provider profile information?

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.

Plan benefits

Are claims filing timelines different for the Innovation Health individual & family plans?: No, the existing claims filing limits will apply. Check out insurance regulations by state for more information on timely filing standards.
What ID should I use to verify member benefits or submit an inquiry or claim?: 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
How do individual and family insurance plans work with Coordination of Benefits (COB)?: 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.
If a member does not select, or Aetna doesn’t assign them a PCP, how long does it take for a PCP selection to take effect?: 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.
Do members have out-of-network benefits?: 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.
Where can I find the formulary information for Innovation Health individual & family plans?: You can find formulary information at the link below:

2025 Formulary Information

Payment and billing

I’ve heard that some exchange members qualify for a grace period if they don’t pay their premiums. What does that mean?

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.

How will Innovation Health reimburse out-of-network claims?

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.

How will the plan reimburse me as a participating provider of the Innovation Health individual & family plans?

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.

Now that’s innovation

Innovation Health is transforming the health care journey. Through innovative programs, coordinated care, and convenient access, our health plans are personalized to fit our members’ needs. Discover how we are helping members achieve their health ambitions right in their community.

Legal Notices & Privacy Policies

Health plans are offered and/or insured by Innovation Health Plan, Inc. (“Innovation Health”). Innovation Health® is the brand name used for products and services provided by Innovation Health Plan, Inc. Innovation Health Plan, Inc. is an affiliate of Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services to Innovation Health. Aetna, CVS Pharmacy^® 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.

Availity^® is a registered trademark of Availity, LLC.

This material is for information only and is not an offer to contract. An application must be completed to obtain coverage. Rates and benefits vary by location. Providers are independent contractors and are not agents of Innovation Health. Provider participation may change without notice.

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