commercial plans, not government-run plans, which means “there is no [nation- al or statewide] exchange fee schedule.” Physicians’ individual, privately negoti- ated contracts determine payments, and “joining exchange plans may change doc- tors’ payer mix and practice revenues.” With Medicaid managed care com-
panies now selling commercial health plans in the Texas marketplace, physi- cians also should evaluate their Medic- aid contracts to find out if they agreed to provide services to exchange patients through those contracts and if the man- aged care plans use Medicaid payment rates for their new exchange products. A pair of new laws that TMA helped pass this legislative session will help physicians evaluate exchange contracts. As of September, under Senate Bill 822, TMA’s “silent PPO” legislation, health plans must allow physicians to separate- ly evaluate the various networks and fee schedules they sign up for and to object and opt out if they choose. Under Senate Bill 1221, which took effect in June, in- surers must warn doctors who currently accept Medicaid managed care and Chil- dren’s Health Insurance Program rates that they may be agreeing to those same rates for those managed care plans’ com- mercial exchange products. The law also requires Medicaid managed care plans to obtain a physician’s permission to add new products to the contract.
Contract confusion Both Texas Oncology and ARC, for ex- ample, already participated in most major health plans in Texas before the launch of the exchange. Because not all of those insurers explicitly invited Texas Oncology to join their new mar- ketplace networks, the group was comb- ing through its contracts and contacting carriers to find out how to opt out of the exchange plans. All of ARC’s exist- ing contracts require insurers to renego- tiate with the group before including it in any new products or networks. Some payers never approached the group; oth- ers came back with lower fee schedules, which ARC declined. On the other hand, 27 percent of respondents in the MGMA survey said they are participating in the exchange because their existing contract
Texans’ choices of marketplace health insurers
The insurers listed below were participating in the Texas mar- ketplace as of Oct. 1. Keep in mind that a single insurer may of- fer multiple different health plan products. In terms of contact- ing those insurers to find out whether your practice is included in a marketplace network, you must follow the guidelines of each insurer, as your practice may already have an assigned network contact. Some insurers, for instance, assign representa- tives to each region of the state, and that information is typi- cally available on the insurer’s website.
Texans’ Choices of Marketplace Health Insurers Of the 254 counties in Texas, 76 of them had only one health insurer
• Aetna • Ambetter from Superior Health Plan • Blue Cross and Blue Shield of Texas • Cigna Health and Life Insurance Co. • Community First • Community Health Choice • Firstcare Health Plans • Humana Health Plan of Texas • Humana Insurance Co. • Molina Healthcare of Texas • Scott and White Health Plan • Sendero Health Plans
providing benefits through the marketplace when it opened in October. 111 counties had just two insurers offering coverage.
Legend: 1 insurer to choose from 2 insurers to choose from More than 2
Source:
Healthcare.gov. Information current as of Oct. 1, 2013. December 2013 TEXAS MEDICINE 39
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