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ACA exchange plans: questions and answers for Texas physicians
Confused by all you’ve heard about the Affordable Care Act marketplace insurance plans? Do you know whether you’re in — or out — of the narrow networks? How will you tell if a patient is on an exchange plan? What happens to you if patients don’t make their premium payments? What, if anything, can you do about all of this? TMA answers these and other tough marketplace exchange questions.
Q: Where can I find a fee schedule for the exchange plans? A: There is not necessarily a different fee schedule for the exchange product. And there is no single fee schedule as with Medicare. The health plans insurance compa- nies offer on the exchange are state commercial insurance products. Many, if not all, of the exchange plans may use contracts currently in force and their associated fee schedules. You should contact the health plans you contract with to determine which of your contracts may be used for patients on the exchange. Exchange plans are state-regulated insurance products marketed on the federal
exchange (also known as the “marketplace”). This means state insurance laws apply. The Texas prompt pay law requires an insurance company to include a provision in physician contracts that states:
1. The physician may request a description and copy of the coding guidelines, in- cluding any underlying bundling, recoding, or other payment process and fee schedules applicable to specific procedures;
2. The insurer or the insurer’s agent will provide the coding guidelines and fee schedules no later than the 30th day after the date the insurer receives the re- quest; and
3. The contract may be terminated by the physician on or before the 30th day after the date the physician receives information requested without penalty or discrimi- nation in participation in other health care products or plans. (Texas Insurance Code §1301.136)
Q: How will I know which of my patients are on an exchange plan? A: At this time, health plans are not required to identify which of your patients are on an exchange plan. Some companies may choose to identify those plans. For example, patients that Blue Cross and Blue Shield of Texas cover in an ex- change plan will present insurance identification cards marked with either “BCA” (Blue Choice PPO Network) or “BAV” (Blue Advantage HMO Network). Aetna will identify its exchange product on the patient identification card with “QHP.” Humana HMO identification cards will be marked with “HMOx.”
TMA suggests you contact the health plan if you are not certain if a patient is on an exchange plan.
Q: What do I do about the 90-day grace period? I’m worried I won’t be paid by the insurance company if the patient has not paid the premium. A. The Affordable Care Act gives pa- tients who receive a federal subsidy in health insurance exchange plans three months to pay their premiums. For the first 30 days of patients’ coverage, the insurers are required to pay claims under the federal regulations and accept the government advance tax credit as pay- ment of the premium. However, for the last 60 days of the grace period, there is no such mandate. If the insured person does not pay his or her premiums within the grace period, the law does not re- quire the insurer to cover any services the physician provided during months two and three. Insurers in the last two months (of
the three-month grace period) may pend or pay for services provided to their in- sured persons (physicians’ patients). The Texas prompt pay law may even require payment for some portion of the last two months of the grace period. If an insurer pays in the last two months, then, if the insured person (patient) does not pay past-due premiums, the insurer may re- cover from the physician any payments made to the practice. The patient must then pay for all past services out of his or her own funds.
Q. Will physicians have to refund pay- ments to an insurer if a patient who bought coverage from that insurer in
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