Some Texas physicians have notified TMA they have received letters from Blue Cross and Blue Shield of Texas (BCBSTX) notifying them that a patient is in the second or third month of the Affordable Care Act (ACA) 90-day grace period. The grace period is triggered once a patient with subsidized marketplace coverage misses a premium payment. Instead of immediately terminating the policy, health plans must give the patient 90 days to catch up.
Federal rules allow health plans to pay, hold, deny, or later recoup payment of claims for services incurred in the second or third month of that window if patients are delinquent on their premium payments. However, insurers must pay physicians for services provided to a patient in the first 30 days of the grace period, and insurers still must comply with Texas law requiring prompt payment of claims submitted at any point in the grace period.
Federal regulations require exchange plans to notify affected physicians "as soon as is practicable when an enrollee enters the grace period." This includes whether the enrollee is in the second or third month of the grace period and the names of all individuals covered by the policy. The notice also must tell doctors the health plan may ultimately deny payment.
Grace period notification is also available when verifying patient benefits, both online and over the phone.
Physicians who have signed a BCBSTX contract have agreed to limit the reasons for which they may terminate the patient-physician relationship. The payer's February 2014 Blue Review newsletter includes a provision that states:
"Your agreement with BCBSTX requires the provision of services to members and prohibits advance payment for such covered services except for member’s required cost sharing, if any. You may notify your patients that they will be responsible for payment for the full cost of provided services, up to billed charges, if their health care coverage terminates at the end of the grace period. You can encourage your patients to make their premium payments to avoid termination of their health insurance policies. In addition, the terms of your BCBSTX agreement prevent you from refusing to provide services to a BCBSTX member, irrespective of where they purchased their coverage."
TMA President Austin King, MD, iterates physicians' ethical responsibilities to the patient despite payment problems.
"Unlike insurance companies, we can't ethically tell patients that suddenly we cannot care for them since they did not pay their premium. In fact, if the patient has a complex condition such as cancer, heart problems, or many other serious conditions then we may have to care for that patient for many months until their condition stabilizes and only then can we think about discontinuing care," Dr. King said.
TMA encourages physicians to educate themselves about the ACA exchange plans. TMA has the following helpful resources on its website:
TMA, AMA, and more than 80 state medical societies and specialty organizations have asked the Centers for Medicare & Medicaid Services (CMS) to revisit its policy that allows plans to pend and deny claims for months two and three of the 90-day grace period. The groups say insurers who offer health plans on the ACA exchanges should provide immediate notice when patients enter the first month of the 90-day grace period.
In addition, the Texas Delegation to the American Medical Association took a resolution to the AMA House of Delegates, which convened in Chicago this month, asking the AMA to work to prevent recoupment if an ACA marketplace insurer has not notified the physician a patient is in the last 60 days of the grace period for not paying his or her premiums.
Action, June 16, 2014