Marketplace Means Decisions for Doctors

The opening of the health insurance marketplaces under the Affordable Care Act (ACA) on Jan. 1 means you must be vigilant in your dealings with the health insurance companies. Or you could face major problems. For example, do your existing contracts with insurers mean you're already included in an exchange network? And, it's possible you'll have to refund payments to an insurer if a patient who bought coverage in the ACA marketplace doesn't pay his or her premiums.

 "The bottom line is doctors will have to be vigilant about their contracts and about tracking patients and payments for exchange plans, and it may be difficult at first," TMA Vice President of Medical Economics Lee Spangler says in a story to be published in the December issue of Texas Medicine. Because of the urgency of this issue, we're bringing it to you three weeks early. It's posted on the TMA website. We also have a PDF version for you to print if you’d like.

Here are some highlights of the story:  

  • Participating in an exchange plan is voluntary, so you must decide whether to opt in or, in some cases, opt out. Because insurance carriers take different approaches to forming networks for exchange plans and notifying doctors about those choices, you must closely evaluate your existing contracts and any new offers you receive.  
  • When insurers use their existing network contracts, you may be notified by the insurer, but that is likely to be an exception rather than the rule. While some carriers have created new networks, they may apply to only one type of exchange health plan, thus, Mr. Spangler says, "doctors could be in-network for one health plan and not another. There's no guarantee all plans [under a single insurer] will use the same network." 
  • Payment rates under the various exchange plans could differ from those under existing contracts.  
  • With Medicaid managed care companies now selling commercial health plans in the Texas marketplace, you also should evaluate your Medicaid contracts to find out if you agreed to provide services to exchange patients through those contracts and if the managed care plans use Medicaid payment rates for their new exchange products. 
  • Federal regulations give patients in health insurance exchange plans three months to pay their premiums and allow health plans to deny or later recoup payments from doctors for services provided to patients who end up delinquent. 

 These are the insurance companies participating in the Texas marketplace as of Oct. 1:  

  • Aetna 
  • Ambetter from Superior Health Plan 
  • Blue Cross and Blue Shield of Texas 
  • Cigna Health and Life Insurance Co. 
  • Community First 
  • Community Health Choice 
  • Firstcare Health Plans 
  • Humana Health Plan of Texas 
  • Humana Insurance Co. 
  • Molina Healthcare of Texas 
  • Scott and White Health Plan 
  • Sendero Health Plans   

Hey, Doc: TMA Answers Your Patients' Marketplace Questions
"Hey, Doc," TMA's multimedia patient education campaign about the Affordable Care Act (ACA) health insurance marketplace, provides your patients with no-nonsense answers to their top questions about the law. Since Oct. 1, people who brave the computer glitches can buy insurance from the marketplace to comply with ACA's "individual mandate," which requires everyone to be covered next year.  

TMA's "Hey, Doc" will continue to provide pertinent, objective, and timely content each week on video, on the Internet, and in the news media. 

To keep up with the program or to refer your patients, go to There you will also find resources for your practice, including handouts for your patients, and the latest information TMA has gathered on the marketplace networks.   


Action Special Report, Nov. 6, 2013

Last Updated On

April 05, 2016

Originally Published On

November 06, 2013