Affordable Care Act Exchange Plans Questions and Answers for Texas Physicians Where can I find a fee schedule for the exchange plans? 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 companies 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, including 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 not later than the 30th day after the date the insurer receives the request; 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 discrimination in participation in other health care products or plans. (Emphasis added.) 1 How will I know which of my patients are on an exchange plan? At this time, there is no requirement for health plans 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 exchange 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, as shown below. TMA suggests you contact the health plan if you are not certain a patient is on an exchange plan. 1. Texas Insurance Code 1301.136
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. The Affordable Care Act gives patients 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 payment 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 require the insurer to cover any services the physician provided during months two and three. Insurers in the last two months (of the threemonth grace period) may pend or pay for services provided to their insured 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 recover 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. Will physicians have to refund payments to an insurer if a patient who bought coverage from that insurer in the Affordable Care Act marketplace doesn t pay his or her premiums? Yes, possibly. Here is what the government said in the March 27, 2012, Federal Register, when adopting the regulation: We note that QHP [qualified health plan] issuers may still decide to pay claims for services rendered during that time period in accordance with company policy or State laws, but the option to pend claims exists. If the individual settles all outstanding premium payments by the end of the grace period, then the pended claims would be paid as appropriate. If not, the claims for the second and third months could be denied. The grace period under this final rule represents an extended time for enrollees to catch up on premium payments before coverage is terminated. (Emphasis added.) Here are examples the government provided to explain its regulation. Assumptions for a monthly premium: premium for January and February coverage. Example No. 1: Patient misses coverage. Patient realizes mistake and April coverage, satisfying all obligations for premium payments through the end of March.
with normal practices (that is, for nongrace periods). April. Example No. 2: on April 30 for March, April, and May coverage. and third months of the grace period), but: a denied claim. in April and May until patient pays outstanding premiums. Example No. 3: payment due April 30 for May coverage. March 31. Insurer can deny claims for services rendered during April and May. Physician could then seek payment directly from the patient for any services provided during that time. As you can see, coverage is available for the first 30 days of the grace period, and the insurer may not recoup. Termination of coverage begins on the 31st day. After that time (day 31 forward), the insurer can retroactively terminate coverage and recoup payments to the physician. Remember that state law applies to exchange plans. Texas prompt pay law says insurers must pay you within 30 days following receipt of a clean claim. Thus, you may receive some payments within the grace period. For insurance companies, Texas prompt pay law permits recovery of overpayments and audits with the ability to recover paid amounts termination may cause an overpayment or audit recovery by the insurance company. Will physicians know if an insured patient is delinquent in paying the premium? Practices will be able to discover which patients are in the nonpayment grace period. Federal regulation requires insurers to give notice to treating physicians of individuals who are in the grace period. Different insurers will meet the obligation in different ways. Some may tell physicians when the medical office calls to verify coverage. Practices often call insurers the day before scheduled visits of current patients to verify whether the patient still has the insurance coverage on file with the practice. Other offices may verify coverage when the patient checks in. At verification of coverage is when physicians likely will be notified. Some insurers will provide this information electronically. Can I withhold services from or directly bill for services for a patient who has not paid the premium? Can I refuse to see any exchange plan patients? The obligations to withhold from collections and accept certain people as patients generally stem from the contract between the insurer and physician. The grace period regulation is a limitation on cancellation of insurance coverage. It is not a regulation of physician business practices generally. Absent an agreement, there is no limitation on how a physician interacts with his or her patients as it may regard collections. Also, if you have no contract in place, you are free to choose the patients you serve, except in emergencies. This is in line with American Medical Association ethics opinions, which state: Opinion 9.06 Free Choice Free choice of physicians is the right of every individual. One may select and change at will one s physicians, or one may choose a medical care plan such as that provided by a closed panel or group practice or health maintenance or service organization. The individual s freedom to select a preferred system of health care and free competition among physicians and alternative systems of care are
prerequisites of ethical practice and optimal patient care. In choosing to subscribe to a health maintenance or service organization or in choosing or accepting treatment in a particular hospital, the patient is thereby accepting limitations upon free choice of medical services. The need of an individual for emergency treatment in cases of accident or sudden illness may, as a practical matter, preclude free choice of a physician, particularly where there is loss of consciousness. Although the concept of free choice assures that an individual can generally choose a physician, likewise a physician may decline to accept that individual as a patient. In selecting the physician of choice, the patient may sometimes be obliged to pay for medical services which might otherwise be paid by a third party. (VI) If you have a contract with an insurer to provide services to those covered under the insurance plan, you may not withhold services from or directly bill the patient during the grace period. In addition to the federal regulation that anticipates patients will be treated as fully covered until the grace period expires, many insurance company contracts have nondiscrimination clauses that prevent the withholding of services. Here is an example of a nondiscrimination clause: Physician and Insurance Company agree that Enrollees expect physicians listed in the Company s directories to accept new patients. Physician shall provide services to Enrollees on the same basis as other patients. Physician shall accept Insurance Company Enrollees as patients. This example imposes an obligation that affects duties under the patient-physician relationship. In regard to the grace period, it is possible to interpret the phrase to accept patients on the same basis as other patients as meaning that care cannot be withheld when the patient is considered covered by the insurer. Indeed, the example above expressly permits the insurer to list the physician as accepting new patients. The last sentence of the example gives the physician no flexibility in accepting patients. He or she must accept all enrollees as patients, even if the patients are in exchange plans or if the physician previously terminated the relationships. Thus, a professional relationship that was terminated because of a patient s unwillingness to follow medical advice could be created once again. The contract also should be examined for any stated patient minimums, and the physician should ensure that his or her practice has the ability to handle the caseload. Still other provisions in contracts regulate when a physician may collect payment from patients. Some insurers prohibit collection of patient responsibility until the insurer has processed the claim and sent out the explanation of benefits. Physicians should review contracts and the physician manuals to determine the collection parameters to which the practice has agreed to be bound. Close scrutiny of the physician s obligations is a must. If I receive notice that patients are within the grace period, may I pay their premiums so they have coverage while I provide services? That may be a risky practice and can t necessarily be recommended. The Centers for Medicare & Medicaid Services (CMS) posted an addendum to its frequently asked questions regarding the Affordable Care Act on this very question. CMS states: The Department of Health and Human Services (HHS) has broad authority to regulate the Federal and State Marketplaces (e.g., section 1321[a] of the Affordable Care Act). It has been suggested that hospitals, other health care providers, and other commercial entities may be considering supporting premium payments and cost sharing obligations with respect to qualified health plans purchased by patients in the Marketplaces. HHS has significant concerns with this practice because it could skew the insurance risk pool and create an unlevel field in the Marketplaces. HHS discourages such third party payments. HHS intends to monitor this practice and to take appropriate action, if necessary.
So, the federal government is instructing insurers to refuse these payments, and warning physicians and providers that the act of paying the patient responsibility could elicit regulatory scrutiny. TMA also has an ethics opinion on the topic. That opinion holds that paying the premium is an ethical practice only if the physician does not directly or indirectly receive a benefit. The opinion states: PAYING FOR INSURANCE PREMIUMS. It is ethical for a physician to pay a patient s insurance premiums provided the physician does not receive a direct or indirect benefit. Thus, a physician should not charge or bill the patient or his insurance company for the physician s services to that patient. Such payments should only be made in compliance with state and federal law and where true hardship exists. If I am contracted with an insurer, does that mean I am participating in that insurer s Affordable Care Act exchange plans? Not necessarily. Just because a physician may have a contract with an insurer does not mean that physician is included in the network of plans that insurer offers. In Texas, 12 insurers are offering plans on the federal insurance exchange, or marketplace. The federal insurance exchange is composed of stateregulated insurance products offered by insurers. These are commercial insurance products, and your contract with insurers will dictate participation in insurers networks. Typically physicians agree to participate in insurer networks through a contract provision known as an all products clause. Here is a typical example of an all products clause : Medical practice agrees to participate in the plans and other health products as described in this Agreement. Company reserves the right to introduce, modify, and designate medical practice s participation in plans and products during the term of the Agreement. Note that the physician has agreed to participate in all plans as designated by the insurance company. Just as important, note that the company has not agreed to designate the physician as participating in all plans. Thus, depending on your contract, you may not be able to reliably answer patient questions about your participation in federal insurance exchange networks without further research. A physician must ask the insurer whether he or she is in the plans offered on the exchange. Another method of verification is to go to the insurer websites and search for the physician through the carrier s provider finder tools. Patients also can perform this search. Some insurers have created special exchange networks and invited only a limited number of physicians into those networks. Other insurers may tier or offer exclusive access based on their ratings systems, essentially creating an exclusive high performers tier out of its normal network. There is no prohibition of these methods of designation or exclusion. Careful review of contract terms and fee schedules is a must in this new environment. Which insurance companies are offering exchange products in Texas? 10193.12-13