terms required them to participate in all of an insurers’ products under so-called “all products” clauses.
Because a number of Dr. Bucking- ham’s contracts include such clauses, the six-physician practice, Eye Physicians of Austin, faces the prospect of renego- tiation in order to opt out of certain ex- change plans. “To me, my hands are tied, and they
are making me jump off of a plank I don’t want to jump off of. And it’s an ex- pensive process, and it interrupts patient care,” she said.
Meanwhile, it remains unclear to what extent Texas exchange plans cover out-of-network benefits. At minimum, federal rules require marketplace plans to cover out-of-network emergency care and to pay the plan’s “usual, custom- ary, and reasonable” rate, the median amount it pays to in-network providers, or Medicare rates for the same service, whichever is greater. Blue Cross and Blue Shield of Texas (BCBSTX) Chief Medical Officer Dan McCoy, MD, says it continues to build exchange networks and began sending physicians contract notices in August 2012 to solicit participation. Aetna says it is notifying all providers about their ability to opt in or out of its exchange networks. It urges doctors “to check be- fore they refer patients, since the net- works for [exchange] products are dif- ferent than the ‘traditional’ networks.” Molina Healthcare is a Medicaid managed care plan now offering a com- mercial health plan on the exchange. In forming that network, Chief Financial Officer John Molina said the insurer
“really tried to build a marketplace net- work based on our existing Medicaid network.” In general, physicians have to opt in, and those who already contract directly with the health plan would sign an amendment to do that, for example. The company is communicating those options to physicians via phone calls, let- ters, and face-to-face visits. Some insurers are holding off: One of the nation’s largest carriers, United- Healthcare, is not participating in a ma- jority of state marketplaces, including Texas. The carrier told Texas Medicine it is in only a dozen exchanges. Only one-
40 TEXAS MEDICINE December 2013
third of those are exchanges for individu- al insurance; the majority are exchanges for small business insurance. “We are simply taking the time to care- fully evaluate and better understand how the exchanges will work to ensure we are best prepared to participate meaningfully in their development and continue to provide the service our cur- rent customers and members have come to expect,” a United representative said. Humana declined Texas Medicine’s in-
terview request. Cigna did not respond. None of the insurers Texas Medicine
spoke to would comment directly on payment rates. The Blues’ Dr. McCoy said its rates
vary by provider, geography, and cost. Molina views its marketplace plan
“more as a Medicaid-like program versus a commercial-like program. It’s fair to say we have tried to structure our pay- ments more along the lines of what we see reflected in the patient population,” Mr. Molina said.
The health plans also reiterated that their networks had to meet specific ad- equacy requirements before joining the marketplace.
The Centers for Medicare & Medicaid
Services (CMS) says it is enforcing those standards, and insurers are required “to maintain a network that is sufficient in number and types of providers to ensure that all services will be accessible with- out unreasonable delay.” Texas Depart- ment of Insurance officials say that in Texas, CMS also relies on state network adequacy standards in reviewing health plans’ exchange applications. Any plans sold in Texas, in or out of the exchange, must follow state insurance regulations.
90-day notice
As for the 90-day grace period, “from a pragmatic perspective, for someone try- ing to run a business, holy mackerel!” Dr. Chenven said. “It’s hard to figure how that cannot be a problem, so I have to be cautious as I dip my toe in the water.” The grace period is triggered once a patient with subsidized marketplace coverage misses a premium payment. Instead of immediately terminating the policy, health plans must give the patient 90 days to catch up. Federal rules allow
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