extent to receive records on new en- rollees. At press time, that process was the subject of bipartisan congressional scrutiny due to what the Obama admin- istration acknowledged were serious technical problems. Health plans also must look to the federal government to receive the subsidy payments for eligible patients.
Health plan practices vary Physicians, meanwhile, should expect differences in how insurers will provide the grace period notifications and in how they will identify patients with mar- ketplace coverage. At the TMA 2013 Fall Conference in October, the Council on Socioeconomics asked carriers to stan- dardize those processes.
The Blues and Molina, for example,
told Texas Medicine they will use elec- tronic eligibility verification systems, such as web portals and Availity, to no- tify doctors of patients in the grace pe- riod. Doctors also can call their customer
service centers. Aetna said its “current eligibility process” will tell doctors if a patient is delinquent. Blues representatives told TMA that Blues patients’ insurance cards will dis- play certain colored letters to differen- tiate exchange versus non-exchange coverage. Aetna insurance cards will say “QHP” to indicate patients are in an ex- change plan, and Molina also plans to identify exchange plan members. To avoid the risk of nonpayment, the Blues and Aetna also encourage physi- cians to check exchange patients’ eligi- bility and benefits before treatment. “That’s true for products on and off
the exchange. It’s also true for any ser- vice physicians perform in their prac- tices,” the Blues’ Dr. McCoy said. “These risks existed before [the marketplace], and with all the changes going on right now, it’s very important for practices to be proactive.” Specifically, the Blues plan will no- tify physicians when a member is in the
grace period and the date through which the premiums are paid. “We are going to do everything we can
to help make this a good experience for doctors participating in the network,” Dr. McCoy said, adding that he is “confident” the insurer’s tools will provide the most up-to-date information available. Rather than holding or denying claims filed during the grace period, the Texas Blues will pay doctors, he says.
“We have a very good track record of working with our members to make sure they get their premiums paid.” If that doesn’t happen within 90 days, however, BCBSTX will cancel the patient’s mem- bership consistent with ACA guidelines and seek recovery of payment for ser- vices in the second and third month of the grace period. The insurer will notify doctors of those recoupments through an explanation-of-benefits (EOB) notice if patients don’t follow through in paying their premiums. Similarly, Aetna said “any claims sub- mitted for a service date after 30 days of delinquency by a patient will result in an EOB to the provider saying the claim is being pended because the member is in a delinquent status.” At press time, the federal government
Hey, Doc: TMA answers your patients’ marketplace questions
“Hey, Doc,” TMA’s multimedia patient education campaign about the Affordable Care Act (ACA) health insurance market- place, provides your patients with no-nonsense answers to their top questions about the law. Since Oct. 1, people who brave the computer glitches can buy insurance from the marketplace to comply with ACA’s “individual mandate,” which requires every- one to be covered next year. TMA’s “Hey, Doc” will continue to provide pertinent, objec-
tive, and timely content each week on video, on the Internet, and in the news media. To keep up with the program or to refer your patients, go to
www.texmed.org/heydoc/. There you will also find resources for your practice, including handouts for your patients, and the latest information TMA has gathered on the marketplace networks.
42 TEXAS MEDICINE December 2013
and insurers had not said how many pa- tients signed up for insurance through the Texas marketplace and how many were eligible for subsidies and therefore the grace period. Earlier this year, the Texas Health and Human Services Com- mission estimated that up to 2.4 million Texans — roughly 40 percent of the state’s uninsured population — could be eligible for exchange subsidies. Molina acknowledged that as a Med- icaid managed care plan branching out into the exchange, a large portion of its members are likely to be subsidy eligible and subject to the grace period. But Mr. Molina does not expect it to be a big is- sue “because we feel the vast majority of patients will be Medicaid eligible.” Texas Oncology’s Mr. Henderson said,
“I don’t think there’s one single thing that will fix it all: network adequacy, being able to count on premiums being paid. 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.”
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68