“A lot of things are out of our control, so at this point we are going to sit tight for a few months and let things develop.”
choices, physicians must closely evalu- ate their existing contracts and any new offers they receive. TMA continues to research the vari-
don’t know if I’m in the exchange or out, and you can’t even tell based on the complexity of these contracts.” And for smaller practices like hers, “it is a huge drain on our resources to try and evalu- ate these contracts.” That, along with the prospect of los- ing money due to the 90-day grace pe- riod, “makes me disinclined to partici- pate” in the exchange, the chair of TMA’s Council on Legislation added. “We [phy- sicians] are trying to take care of people, and in the end, we are left holding the bag and a big bunch of debt. You can’t practice like that.”
As physicians brace for the impact of the new marketplace on their practices, “the bottom line is doctors will have to be vigilant about their contracts and about tracking patients and payments for ex- change plans, and it may be difficult at first,” cautioned TMA Vice President of Medical Economics Lee Spangler.
Decisions ACA requires most individuals to have health insurance by 2014, and states must set up health insurance exchanges — now referred to as marketplaces — as another avenue for purchasing coverage. Gov. Rick Perry chose not to authorize a state-based marketplace, so Texas de- faulted to a federally run program. (See
“Ready, Set, … ?” August 2013 Texas Medicine, pages 49–53.) When it opened Oct. 1, there were about a dozen different insurance com- panies in the Texas marketplace selling roughly 100 different plans across the state, according to a TMA analysis. (See
Norman Chenven, MD
Dan McCoy, MD 38 TEXAS MEDICINE December 2013
“Texans’ Choices of Marketplace Health Insurers,” opposite page.) The market- place could see an influx of more health plans as they become qualified. That means physicians have deci- sions to make, Mr. Spangler says. Ex- change plan participation is voluntary, so physicians must independently de- cide whether to opt in or, in some cases, opt out. Be- cause insurance carriers take differ- ent approaches to forming networks for exchange plans and notifying doc- tors about those
Dawn Buckingham, MD
ous networks offered. In general, insur- ance carriers are forming so-called “nar- row” exchange networks with fewer phy- sicians and providers than those outside the marketplace so they can offer more affordable premiums. Mr. Spangler says some insurers are using existing network contracts with physicians; others are forming new net- works for the exchange plans. When insurers use their existing net- work contracts, physicians may be noti- fied by the insurer, but that is likely to be an exception rather than the rule. That is because many managed care contracts don’t require insurers to provide any no- tification. Physicians will have to inquire about their status for themselves by contacting the insurer. Physicians who don’t want to participate in the exchange plans must opt out. However, not all in- surance contracts allow physicians to opt out of the various health plans they of- fer, in which case the physician has to decide whether to keep or terminate the entire contract.
In still other situations, particularly with new networks, doctors may get notice of new contract offers or amend- ments to existing contracts to opt into a marketplace plan.
While some carriers have created new networks, they may apply to only one type of exchange health plan, Mr. Span- gler adds. That means “doctors could be in-network for one health plan and not another. There’s no guarantee all plans [under a single insurer] will use the same network.” TMA has fielded calls from physicians inquiring about their contract options in exchange plans. TMA advises physicians to call insurers to find out if they are in- cluded in any exchange networks if they are unsure about their current contract terms and if carriers participating in the exchange have not contacted them. Also, payment rates under the various
exchange plans could differ from those under existing contracts. Mr. Spangler pointed out that exchange plans operat- ing within the marketplace are private,
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