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nationally enrolled in and selected a marketplace plan, al- though the figures do not specify whether those enrollees paid their premiums. Texans account for about 6 percent of that group, with just 207,546 enrollees out of the Lone Star State’s roughly 6 million uninsured population. At the TMA 2014 Winter Conference in February, CMS Con- sortium Administrator James Randolph Farris, MD, who for- merly oversaw Texas, acknowledged the “difficulties” in the initial rollout. But he said the agency ramped up outreach and education efforts and expected a “big jump” in enrollments in Texas in the coming months. Texas Health and Human Services Executive Commissioner


Kyle Janek, MD, also expects Medicaid enrollments to spike. That is, once his agency overcomes what he called the “day- to-day headaches” caused by the federal government’s poorly tested system for transferring files to the states on Medicaid- eligible patients who enroll through the exchange. Meanwhile, Texas physicians are not alone in the market-


place confusion marked by severe technical issues, moving deadlines, and ongoing regulatory changes. More than 80 percent of physicians say they don’t have enough informa- tion on ACA to serve as a reliable source to their patients or understand the impact on their practice and comply with its requirements, according to a poll of 1,265 physicians across the country by QuantiaMD, a physician social media outlet. TMA is standing in that gap by deploying various educa- tional campaigns to help physicians and patients understand their rights and obligations in the confusing marketplace en- vironment. Go online to find TMA’s detailed “ACA Exchange Plans: Questions and Answers for Physicians” at www.texmed


.org/ExchangeQA and its “Hey, Doc” campaign for patients at www.texmed.org/heydoc. Despite the added burdens, physicians say they are doing their best to muddle through and ensure these newly insured patients get the best care.


TMA opposes CMS rule


In the latest twist, the federal government in December in- troduced an interim rule to smooth widely reported problems with incorrect health plan network listings and concerns about patients’ inability to keep their current doctors in the smaller marketplace networks. Federal officials acknowledge in the rule that patients shop- ping in the exchange could be misled by “evolving provider networks [that] may result in some directories containing outdated information.” They also clarify that under existing mar- ketplace rules, health plans “must make current provider directories available to the exchange for pub- lication online” and ensure the di- rectories “contain the most current listings of in-network providers so that consumers are relying upon accurate information to make en- rollment decisions.”


To avoid disruptions in care, the same interim rule “strongly encourages” health plans to treat any out-of-network physician as in-network if the plan incorrectly lists that physician in its directory.


“In other words,” states an opposition letter TMA filed, “a physician’s out-of-network status may change without the physician’s knowledge or consent, based solely on a [plan’s] failure to maintain an accurate provider directory.” Effectively, the policy would require physicians to abide by terms of a con- tract they haven’t agreed to and actually may have rejected or terminated. But it provides doctors with no recourse to dispute incorrect designations and no accountability for health plans that don’t do their part to maintain accurate directories, the association wrote. TMA shares CMS’ concerns over possible disruptions in care. But “only [the marketplace plans] have the access, ability, and obligation to ensure that provider directories are accurate and up-to-date, and [they] must be held accountable for such misrepresentations,” not physicians, TMA’s letter states. “TMA strongly opposes the financing of [marketplace] coverage on the backs of physicians” and instead recommends that health plans:


• Fully pay incorrectly listed physicians and calculate the pa- tient’s financial responsibility based on the out-of-network physician’s billed charge; and


• Allow out-of-network physicians to continue to provide care to patients when discontinuing care could cause harm, and fully pay based on the out-of-network physician’s billed charge. Patients would be responsible for no more than they would have paid had the physician been in-network.


In mid-February, TMA was reviewing newly released fed- eral guidance that, under certain circumstances, would allow patients who had enrolled in a marketplace plan to switch to one that included their preferred physician. Austin Regional Clinic (ARC) Founder and Chief Executive Officer Norman Chenven, MD, says plans overall “have done a poor job of listing providers available, and it hasn’t been easy for patients or providers.” The clinic has received a number of calls from confused patients who discover their doctors are not in the plan they chose, he says. Marketplace network directories ARC partici- pates in still list doctors who retired or moved away five years ago. And specialist availability “is very spotty for some of the


“At the end of the day, all we want is to be able to provide care.”


April 2014 TEXAS MEDICINE 21


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