American College of Physicians: Internal Medicine — Doctors for Adults ®

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Practice Tips: What your practice needs to know about health insurance exchanges

From the October ACP Internist, copyright 2013 by the American College of Physicians

Health insurance marketplaces, or exchanges, will offer more people coverage than before. With many primary care practices already bursting at the seams, it seems hard to imagine how to handle the influx of new patients. Many individuals will find it intimidating to choose a plan and will have questions, which physicians’ office staff will invariably receive. Here’s what office staff needs to know to help these patients.

Open enrollment for health insurance exchange plans begins Oct. 1, and the exchanges will begin operating on Jan. 1, 2014. Individuals who are not covered by government- or employer-sponsored insurance will be able to buy coverage through the exchanges that is more affordable than they would have been able to find on their own. Certain small businesses will also be able to purchase plans through the exchanges.

Insurers that qualify to participate will set up new products for the exchanges. The new plans are tiered, based on premium, copay, deductible and co-insurance. The tiers range from “platinum” (with higher premiums but lower cost-share) to “bronze” (with lower premiums but higher cost-share). Qualified plans should have already notified physician offices about their exchange products, so keep an eye out for this communication from insurers.

It will be important to look closely at insurance cards and verify patients’ eligibility before rendering services. Copays and deductibles will vary depending on the plan purchased, as well as by state. There may be more enrollment in high-deductible plans, requiring vigilance from office staff to identify and collect from these patients.

Individuals are required to pay a premium to their selected plan, and the insurer is required to pay the clinician during the first 30 days of enrollment. However, if a patient does not continue to pay the premium, the insurer is not required to reimburse for services provided during the 31st through 90th days of enrollment, putting the onus on the practice to collect them. Therefore, it is important that the practice verify eligibility and clearly notify patients in writing of their payment responsibility in the event of disenrollment from their plan due to nonpayment of premiums.

The exchanges may reimburse physicians at a lower rate than other payers. At the same time, the range of services covered will be broader. For example, more preventive care and screenings will be covered, which may result in an increase in such services. Some preventive services may not have a copay, so again, it will be important to verify benefits before providing service. It is not known yet how this will play out in practice.

Enrollment is not a simple process, and helping patients enroll could be time-consuming for physician practices. A better option is referring patients to enrollment resources that will be available in your state. The primary way to sign up will be using an online system. Although traditional insurance brokers will also be able to enroll people, they will charge a fee for doing so. “Navigators” will also be available in the community to help individuals enroll. More information on how to access these “navigators” will be forthcoming and ACP will provide additional information when it is available.

For more information about health insurance exchanges, ACP has developed a resource.

Margo Williams is senior associate for practice management in ACP’s Center for Practice Support, a division of ACP that encompasses the College’s primary resources for medical practices.

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