The Texas Department of Insurance didn’t respond to Texas
Medicine inquiries about health plan conduct since the launch of the marketplace.
A guessing game CMS also says it fixed most of the technical and data glitches
that delayed and complicated patients’ enrollment in exchange plans through
healthcare.gov. The problems prompted the federal government and health plans to push off the original deadlines set for patients to enroll in marketplace plans and pay the necessary premiums to activate their coverage. Health plans acknowledge the issues on their end, too, and say they are working with the federal government to resolve problems like missing files and discrepancies between the marketplace database and health plan eligibility information. Physicians are bearing the brunt. TMA continues to field calls from practices that report wait times of up to two hours when they call health plans to verify patients’ eligibility status and coverage in exchange plans, re- ceiving little to no information once they get through. Such headaches could be alleviated if health plans did their part to help practices better identify patients with exchange coverage, says Austin internist Tony R. Aventa, MD, a member of TMA’s Council on Socioeconomics.
At the TMA Winter Conference, the council renewed its call for health plans to standardize their marketplace identification and eligibility verification processes. The American Medical Association, in collaboration with the Medical Group Man- agement Association, created an exchange checklist to help practices address exchange plan problems. (See “Marketplace Checklist,” below.) As far as Dr. Aventa knows, he participates in just one mar-
ketplace network. Several patients already visited him with what he says looked like a valid insurance ID card for coverage with that particular carrier. It wasn’t until Dr. Aventa tried to get care preauthorized that he discovered the patients were on a marketplace plan that denied his care requests. “The patient is left expecting to be cared for, and we’re not able to get anything done. So it’s very important for physicians to be able to identify these patients,” he said. It’s especially relevant now that the clock is ticking on the 90-day grace period. “Physicians are the ones who are going to be on the hook,
and we need to be able to identify which patients to be dili- gent about and educate patients about what the potential con- sequences are,” Dr. Aventa said. “At the end of the day, all we [physicians] want is to be able to provide care. It shouldn’t be about us trying to decide if in the future a patient is going to
MARKETPLACE CHECKLIST
The American Medical Association advocates for legislative and regulatory relief from the many “grow- ing pains” with the marketplace implementation that interfere in physicians’ ability to run their practices and care for patients, President Ardis Hoven, MD, told members at the TMA 2014 Winter Conference. To cope with problems that could arise with new
exchange health plans, physicians can use the check- list created by AMA and the Medical Group Manage- ment Association. For more information, visit AMA’s Affordable Care Act resource page,
www.ama-assn
.org/go/aca. Consult TMA’s “ACA Exchange Plans: Questions and Answers for Physicians” (
www.texmed.org/Ex
changeQA) for specifics on the marketplace rules and Texas-specific information on plans and state regulations. And point patients to TMA’s “Hey, Doc” campaign (
www.texmed.org/heydoc) for answers to marketplace questions.
• Double-check whether your practice’s physicians are participating in ACA exchange products by checking your contracts or calling your current health plans. (See “Marketplace Q&A,” page 24.)
• Determine your practice’s ability to accept new patients.
• Train staff who speak with callers and patients. • As with other insurance, check patient eligibility, coinsurance, deductibles, and copays for each visit.
• Be prepared to discuss out-of-pocket expenses and the cost of care with each patient.
• Know the “essential health benefits” in your state. (See “Ready, Set …?” August 2013 Texas Medicine, pages 49–54, or visit
www.texmed.org/Essential Benefits.)
April 2014 TEXAS MEDICINE 23
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