Uncertainties Linger as Physicians Prepare for Round Two of the ACA Marketplace

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Tex Med. 2015;111(1):59-63.

By Amy Lynn Sorrel
Associate Editor 

Round two of the Affordable Care Act (ACA) health insurance marketplace launched with far less fanfare than last year's botched rollout. But even as physician practices do their part to adjust and help care for these newly insured, some of the same uncertainties linger. And with potentially new twists ahead, Texas Medical Association officials once again remind physicians to be mindful in their business practices surrounding exchange plans. 

For its part, the Centers for Medicare & Medicaid Services (CMS) says it ramped up outreach efforts and largely smoothed out the technical problems from last year that complicated not only patients' enrollment through healthcare.gov, but also physicians' ability to track their coverage. Thanks in part to TMA's advocacy, health plans also have begun to improve their eligibility verification and notification processes to help physicians care for this population and mitigate doctors' risk under the 90-day grace period. The federal rule subjects their payments to recoupment if patients with subsidized coverage fail to pay their premiums for 90 days. (See "What's the 90-Day Grace Period?")

Still, the prevalence of high-deductible plans and "narrow" networks that limit the doctors and hospitals patients can use contribute to persistent concerns over access to care. Meanwhile, inconsistencies in health plan practices continue to make it difficult for physicians to identify exchange patients in the first place, which could be complicated by the addition of new carriers and new health plans to the Texas marketplace this year. An overall lack of health care literacy also puts more pressure on physicians to educate newly insured patients unfamiliar with how insurance works. 

With more than 200 marketplace patients so far, Physicians at Sugar Creek now has processes in place to regularly check their eligibility and benefits, says Sugarland family physician Lindsay Botsford, MD, the practice's medical director. 

"Theoretically, we are treating these patients a little bit differently and verify their insurance every 30 days, versus every year. But it's all still relatively new, so we haven't had too many [recoupments]," she said. "Even more of a concern, the overall access picture remains a big problem." 

Dr. Botsford says a lack of specialist availability, coupled with high-cost plans, is starting to affect patients' health care decisions, as well as their pocketbooks. 

Some of her patients chose to defer ultrasounds or other testing because of copays and deductibles that run into the thousands. She had trouble referring other patients for procedures like colonoscopies and cardiac stress tests because some specialists in her area are reluctant to accept exchange plans, fearing they'll be on the hook for an expensive procedure if subsidized patients can't afford to – or don’t — pay their premiums on time. 

"People who bought exchange plans are finding they don't have as much access as they need, and doctors are questioning whether [patients] can afford their coverage when their out-of-pocket costs remain so great," Dr. Botsford said.

So Far, So … Better

When it opened on Nov. 15, 2014, there were 14 insurance companies in the Texas exchange, up from 12 last year, according to a TMA analysis. (See "2015 Participating Marketplace Insurers in Texas.") Because some contracts may require doctors to participate in all of an insurer's products, TMA officials recommend physicians check their existing insurance contracts and call their health plans to confirm inclusion in exchange plans. 

More carrier participation and an expected surge in enrollments also mean physicians could see another influx of newly insured patients. Patients with existing marketplace coverage, on the other hand, can switch plans during open enrollment, something physicians should pay attention to, as well, TMA officials caution. Open enrollment runs until Feb. 15. 

Austin Regional Clinic (ARC) was "stunned" when 35,000 patients newly insured in the marketplace poured in, said founder and Chief Executive Officer Norman Chenven, MD. "Now it's pretty routine, but initially it was tough because a lot of people literally did not have any care for 10 to 15 years. A new visit wasn't just a new visit, but a scroll with 40 problems on it." 

ARC also had to adjust to a web of differing administrative requirements that could grow with four new carriers in the Texas marketplace this year. "At first, not all the plans were well organized to handle [the volume] of preauthorizations. So the first three to six months was more of an administrative hassle. Then it became more of a clinical burden. But it's gone quiet now," he said.  

Dr. Chenven takes that as a sign carriers have adapted, too. The fact that UnitedHealthcare decided to join the Texas marketplace this year "also suggests things are going well, generally speaking, because they decided to hold out [in 2014] to let everyone else experiment."

After a year delay, this is also the first year small businesses can shop for insurance on the Small Business Health Options Program.

All Quiet on the Recoupment Front?

Still, like many physicians, Dr. Chenven remains concerned the 90-day grace period creates some "built-in risk" in the system, "and I'm not really ready to declare victory just yet." 

That risk remains significant because most people who enrolled in exchange coverage last year — 85 percent nationwide and 79 percent in Texas — qualified for subsidies, according to federal figures. Only patients with subsidized plans qualify for the 90-day grace period.

The physicians Texas Medicine spoke to reported few recoupments, thus far. 

But an October Health Affairs study suggests, "the larger ramifications of the grace-period policy, if any, will likely not be evident for several months, because some people who enrolled in a health plan during the first open enrollment period may have not had their coverage become effective until April or even May." And in November, CMS revised its numbers for how many patients had paid their premiums from 7.3 million down to 6.7 million out of 8 million total enrollees.

The U.S. Supreme Court agreed to review a case challenging the legality of the subsidies in states that did not set up their own exchanges. 

Aetna officials add despite technical improvements at the federal level, "many more are needed" to help insurers "reconcile data appropriately between their [federal] systems and the systems managed by health plans, resulting in data inconsistencies which produce consumer confusion and frustration." 

TMA Director of Payment Advocacy Genevieve Davis says Texas exchange plans, for the most part, have begun to update the phone and electronic eligibility verification systems physicians can use to check patients' status in the grace period. Federal rules require plans to notify doctors "as soon as practicable" of the possibility for denied claims when an enrollee is in the second and third months of the grace period, although there is no specified timeframe for providing the notice.  

Blue Cross and Blue Shield of Texas (BCBSTX) says it is providing the information in real time, and its preauthorization letters also encourage physicians to confirm whether patients are in the grace period. In addition to online eligibility verification checks, Humana is sending notification letters after receiving a claim, and United is sending letters when patients are delinquent in paying their second and third month's premiums. 

But Ms. Davis says not all physician practices are consistently or timely receiving these or other types of eligibility notices. As patients renew their exchange plans, it remains unclear when any reported changes in their subsidy eligibility will take effect and affect claims, she adds. 

TMA created a sample letter practices can use to inform patients who fall into the grace period of the risks of losing their coverage. This and other tools TMA created to help physicians and their patients deal with the marketplace confusion are available in TMA's online marketplace resource center and at www.texmed.org/heydoc.  

Austin internist Tony Aventa, MD, received a few warning letters from carriers that fortunately did not materialize into refund requests. But he says the burden would be much lighter if plans consistently identified these patients in the first place. "It's really challenging to get information at the time of service when we don't have anything that identifies them." 

Not all insurance identification cards differentiate exchange plans from non-exchange plans: Aetna and Humana have said they will use "QHP" and "HMOx," respectively. United cards will say "Texas Health Insurance Exchange." Citing patient privacy reasons, BCBSTX says nothing on its cards signify marketplace coverage. 

Plans also appear to vary in their payment practices during the grace period: BCBSTX and Humana, for example, indicate they are paying claims during that time, but if subsidized patients end up delinquent, the plans will recoup any payments made. Aetna says it may hold claims filed during the grace period.

TMA continues to call on insurers to standardize their marketplace identification and eligibility verification processes and provide real-time grace period notifications. Some states have enacted these and other requirements that, for example, bar insurers from recouping payment if they fail to provide such notification, according to Health Affairs. 

TMA also worked with the Texas Department of Insurance (TDI) to ensure plans pay claims on time for all patients with marketplace coverage. Carriers selling plans in or outside the marketplace must adhere to Texas prompt pay laws, a key enforcement mechanism requiring commercial insurers to pay penalties on clean claims they fail to pay in a timely manner, says TMA Vice President for Medical Economics Lee Spangler

TDI published a set of Frequently Asked Questions for Health Carriers specifically addressing the federal grace period and clarifying Texas prompt pay laws "do not allow [insurers] to pend claims as suggested under federal rules." 

Access Uncertainties Linger

The marketplace also has heightened concerns over the use of narrow networks and high-cost plans that TMA President Austin King, MD, says amount to little more than "catastrophic coverage that doesn't do much good when it comes to regular, outpatient treatment." 

He also notices a lack of health literacy among the newly insured, and his practice often bears the responsibility of educating patients who don't understand their coverage. Only 20 percent of those surveyed by the American Institutes for Research knew their cost-sharing amount for an in-network doctor visit.   

Nor do patients understand that their doctors may not be included in the skinny networks proliferating in the exchange, adds Dr. King. The Abilene otolaryngologist chose to participate in some marketplace plans as a referral specialist. 

A study released by the American Heart Association, however, reveals wide variation in availability of in-network cardiologists, neurologists, and radiologists. It also found inconsistencies in difficult-to-navigate health plan directories — something CMS says it has improved by requiring plans to provide Healthcare.gov with direct links to up-to-date physician directories patients can use without navigating insurers' entire websites.   

TMA has tracked similar difficulties and shortages of pathologists and infectious disease specialists in some Texas exchange networks. The association is working with the health plans and TDI to resolve the problems. 

Health plans might be responding: Dr. Chenven says what was once a commonplace problem for ARC's primary care physicians to find an in-network specialist is now "a rarity." 

CMS says it raised its network adequacy standards for 2015, but Mr. Spangler says the changes mostly address indigent care. Meanwhile, the National Association of Insurance Commissioners is revising its model regulations for network adequacy, with input from TMA and TDI. 

Exchange plans must comply with state and federal network adequacy standards, but those rules offer some flexibility in how insurers design their networks. Insurers maintain the limited networks are key to affordability. 

"High-value networks help keep premiums affordable and enhance the quality of care by rewarding providers for delivering better health outcomes that lower overall medical costs," Aetna officials said, adding "in order to support a strong marketplace that supports consumer choice, it's vital that CMS allows carriers to create innovative and cost-effective plans."

Aetna also says these "high-value networks have increased choice in the (national) individual market by approximately 30 percent from 2013 to 2014, primarily due to new plans based on more affordable provider networks."

A TMA analysis shows patient choice might be improving in Texas: Last year, patients in 26 percent of counties could choose from three or more plans on the exchange. This year, that number is up to 39 percent.

But research suggests most of those options are high-deductible plans. 

A November Health Pocket study found average deductibles for bronze and silver plans — deemed more affordable because of their lower premiums — ranged from $3,000 for an individual to $10,000 for a family. That's well beyond the Internal Revenue Service's 2015 definition of a high deductible plan: $1,300 for individuals and $2,600 for families.

CMS and health plans say patients still have a range of options. BCBSTX officials point to data showing "the uninsured, more so than their peers, consider the premium to be the most important variable in selecting a health plan," adding that some of its new 2015 benefit packages will include lower copays. 

In Texas, however, overall marketplace premiums are up 2 percent on average, according to The Wall Street Journal. And about half of low- and middle-income adults insured privately both in and out of the marketplace still find their deductibles difficult to afford, according to the Commonwealth Fund

"Cost-sharing in health plans is affecting people's medical decisions in ways that should be of concern to policymakers and the medical community," authors cautioned. 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.


What's the 90-day Grace Period?

It's a federal rule that subjects physician payments to recoupment if patients with subsidized coverage fail to pay their premiums for 90 days.

Patients must have paid at least their first month's premium to be eligible for the 90-day grace period. Failure to make a premium payment after that triggers the grace period. Health plans must give the patient 90 days to catch up. 

Insurers must pay physicians for services provided in the first 30 days of the grace period. If patients end up delinquent after 90 days, federal rules allow health plans to pay, hold, deny, or later recoup claim payments for services incurred in the second or third month of that window. But TMA officials and the Texas Department of Insurance (TDI) say health plans must comply with Texas' prompt pay law for claims submitted at any point in the grace period. Access TDI’s prompt pay guidelines at www.tdi.texas.gov/hprovider/ppguidelines.html. For additional prompt pay resources, visit the TMA website, www.texmed.org/promptpay.

Federal regulations require exchange plans to notify affected physicians "as soon as is practicable when an enrollee enters the grace period, since the risk and burden are greatest on the provider." Notification includes where the enrollee is in the grace period and the names of everyone covered by the policy. The notice must tell doctors the health plan may ultimately deny payment. But federal rules don't specify when or how insurers have to send the notification.  


2015 Participating Marketplace Insurers in Texas

Blue Cross and Blue Shield of Texas
Firstcare Health Plans
Assurant Health
Scott and White Health Plan
Cigna Healthcare
Ambetter from Superior Health Plan
Community Health Choice
Molina Marketplace
Valley Baptist Health Plan
Community First 

January 2015 Texas Medicine Contents
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Last Updated On

May 13, 2016

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