HHS: Subsidies Cover 76% Of Premiums For Private Health Plans

According to new data released by HHS, Americans who enrolled in private health plans through the federal exchange qualified for tax credits that covered about 76% of their monthly premium payment. In addition, 87% of Americans who purchased coverage through the exchange were eligible for subsidies. Experts say it’s critical that Americans know about the subsidies; surveys have shown that many uninsured individuals who did not sign up for coverage said they could not afford it and many said that they did not even know about the subsidies. However, it is important to know that many of the exchange plans have high deductibles, coinsurance, and co-pays when individuals actually seek treatment.

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Docs Fear ACA Plans Will Leave Them with Unpaid Bills

Doctor groups fear that their members will not get paid because of the 90-day grace period for government subsidized health plans and urge physicians to check patients’ insurance status before every visit. If an enrollee in a subsidized plan falls behind on their premium payments, insurers are responsible for covering their medical bills for 30 days. However, for the next 60 days, insurers can withhold paying the claims, and even deny them if the patient does not catch up on his/her premiums. Ultimately, this means that doctors don’t get paid for their services. If the insurer ends up canceling the plan after 90 days, doctors can bill patients, but there is no guarantee they will get paid.

The American Medical Association and other physician groups have asked the Obama administration to “spell out” how and when insurers must notify physicians when their patients fall behind on paying their premiums. Some argue that notifications will only lead to physicians denying services to patients, but physician groups disagree, stating that most physicians would not turn away patients, especially those with life-threatening conditions.

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8 Things to Know About the ACA in 2014

If you’re having a difficult time making sense of what the new health law means, don’t worry! We have the answers to your most common questions:

  1. You have until March 31 to sign up for insurance or pay the penalty.  The penalty will either be $95 or 1 percent of your income based on your income tax return (whichever is greater in 2014).  However, there are some exceptions-like if your plan was one of the thousands that was canceled last year in the big healthcare.gov fiasco.
  2. If you have insurance through a large employer, you are most likely unaffected although your employer is technically allowed to change the plan.  The new law has also made changes to workplace insurance; most plans ban lifetime coverage limits and guarantee that an adult child (children up age 26) can stay on his or her parents’ insurance plan.  Some smaller employers are even asking employees to get insurance through the exchanges.
  3. Some existing plans, sometimes called “grandfathered plans,” can still charge co-pays for preventive services even though the health law requires it to be free. However, if you have one of these plans and your employer makes changes that raise your out-of-pocket costs, that plan would lose its “grandfathered” status and the ACA’s protections would need to be applied.
  4. Insurance companies can no longer deny you coverage or charge you more for a pre-existing condition!  They also cannot limit the coverage of your essential health benefits which include prescription drugs and hospitalizations. Also, you cannot get dropped by your insurer for getting sick.
  5. Most people are now eligible for preventive services such as breast cancer screenings and cholesterol tests without any out-of-pocket costs.
  6. 25 states and the District of Columbia have expanded Medicaid.  Anyone who makes less than $16,000 for an individual and $32,500 for a family of four receives full coverage. If you make more, you still qualify for a subsidy through the insurance marketplaces which are available to those people making $11,490-$45,960 per year.
  7. Beginning in 2015, all employers with 50 or more full-time employees must provide health coverage or face penalties.  There is also a tax credit to help cover costs for those who have less than 50 full-time employees (however, if you don’t provide insurance for your employees and have less than 50, you will not face any penalties).
  8. Yes, the Healthcare.gov website had its fair share of issues in 2013.  However, officials say more than 2.2 million people have successfully enrolled in new health plans after the website revamping!

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Insurance Exchanges Matter for those with Coverage through their Employers

Connecticut’s health insurance exchange is intended to extend coverage to the uninsured, small businesses, and individuals buying their own plans.  But, Kevin Counihan, CEO of Connecticut’s exchange, Access Health, recently stated that the exchange could serve others, too.  According to Counihan, changes in the health insurance market could mean that the exchanges may soon become relevant to those individuals who get coverage through their employers, calling it the “401K-ing of health insurance.”  Similarly to companies transitioning from offering pensions with benefits to giving employees a fixed amount of money to invest for retirement, companies may approach health benefits by giving employees a fixed amount of money and then allowing them to buy what they want on the exchange.

In order for this change to take place, health insurance exchanges, both private and publicly run, must exist and allow customers to comparison-shop.  However, individuals will need to be well educated about all their options so that they can make the best decisions.  Connecticut’s exchange, Access Health, is currently developing an All-Payer Claims Database, a tool meant to help consumers learn about health insurance costs and quality.

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HMS Exclusive: What Happens if a Privately Insured Individual Doesn’t Pay His/Her Premium Under the ACA?

We’ve been hearing a lot about the insurance exchange and the enrollment process.  But, there has been very little discussion regarding insurance premiums and the privately insured, specifically, the consequences of a privately insured individual who is unable to pay his/her premium on time.  Of course, this isn’t an important matter for people insured through their employer since most employers tend to pay premiums on time (or it’s automatically deducted from employees’ paychecks).   So, what happens when an individual buys insurance through the exchange but then does not pay the premium?

According to experts, insurance companies have “contract language” with hospitals and physicians which allows for a 90 day grace period for a patient who has an exchange plan and then suddenly stops paying his or her premium.  For the first 30 days, the insurer is required to continue to pay claims but in the last 60 days, payment can be withheld.  What does that mean? If a patient fails to pay the premium, they’ll lose coverage at the end of 90 days and physicians will not get paid!

This will significantly impact doctors and hospitals so it is extremely crucial that providers have a plan in place to prevent nonpayment.

HMS recommends your practice does the following to help ensure you get paid for your services:

  • Accept major credit cards
  • Collect all applicable copays and applicable deductibles at the time of service
  • Have strict financial policies in place that clearly outline practice expectations with regards to patient responsibilities. These should be signed by patients acknowledging that they understand the policy and all obligations related to it
  • Payment plan options
  • A collection agency relationship
  • Financial hardship policies

HMS emphasizes that you communicate with your patients the importance of them understanding their policy/contract so that they can be prepared to meet their responsibilities (i.e. co-pays, deductibles, premium dude dates, and the terms of which they can be terminated).

If you have questions and/or concerns, please contact HMS at (203) 294-6659.

Tiptastic Tuesday: How to Prepare for Healthcare Industry Changes

As we all know, the healthcare industry is going through some major changes.  The implementation of the Affordable Care Act, practices moving to Electronic Medical Records, and the transition from ICD-9 to ICD-10 will impact all providers in the upcoming months.

It is extremely crucial that providers stay abreast of these changes, especially since many patients will be changing their healthcare plans- whether it’s changes to their current plans or changes through the ACA exchange.  For providers, we recommend your front desk agent be proactive about checking patients’ information so that proper information is received each time, preventing delays and any cash flow issues.

Here are a few tips to ensure your staff is checking the correct patient information:


  1. Appointment reminder calls and new patient calls:  please remind patients to bring current insurance cards and copays with them to their visit.
  2. If a patient is checking in and has updated information for you, please make sure that they complete a new patient information form and be sure to make a copy of their insurance card.
  3. Make applicable changes to your practice management system so that everything is up to date.
  4. With the upcoming changes, you could see higher copays and more deductible plans.  Please make sure to check each patient’s co-pay and ask if it is a deductible plan so that you accurately note their account.
  5. Make sure your patients understand your practice’s financial policy regarding patient balances.  We recommend drafting a document about your policy and having each patient sign it.
  6. Always double check to be sure that the patient’s name is registered to your practice management system.  Check the spelling of their name on the insurance card!  This is especially important for Medicare and Medicaid patients; if a name does not match, it could result in a denial.
  7. Get into the habit of repeating the address and insurance you have on file for each patient.  Sometimes, patients receive new insurance cards and forget to let providers know.

We hope these tips help you have a smoother transition with the upcoming changes!  Stay tuned to our blog and our newsletters for more tips on how to successfully integrate these changes into your practice.  If you have any questions about this information, please don’t hesitate to call us at (203) 294-6659.