health plans to pay, hold, deny, or later recoup payment of claims for services incurred in the second or third month of that window if patients are delinquent on their premium payments. However, insurers must pay physicians for services provided to a patient in the first 30 days of the grace period, and insurers still must comply with Texas law requiring prompt payment of claims submitted at any point in the grace period. Federal regulations require exchange plans to notify affected physicians “as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider.” This includes whether the enrollee is in the second or third month of the grace period and the names of all individuals covered by the policy. The notice also must tell doctors the health plan may ultimately deny payment. CMS officials did not directly respond
to Texas Medicine’s inquiries on whether or how they would hold health plans accountable for appropriately notifying and paying physicians during the 90- day window. CMS said that during the last two months of the grace period, in- dividuals can still receive care, but they are asked to either bring their insurance premiums up to date or pay providers directly. Patients whose health coverage lapses after the grace period could face a tax penalty for not maintaining their health insurance coverage.
The rules mean “doctors will have to check eligibility regularly and through- out treatment” when it comes to ex- change plans, Mr. Spangler emphasized. TMA officials were concerned about
insurers’ ability to timely update eligibil- ity records even before the rocky launch of the marketplace. TMA is working with carriers to ensure they notify physicians of patients in the grace period as soon as possible. It also remains unclear whether physicians can use standard electronic eligibility verifications to find out if pa- tients are in exchange plans or in the grace period, or whether doctors must make separate inquiries via phone or in- surers’ websites. Because Texas is in a federally run
marketplace, participating health plans also rely on the government to a large
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