Providers, Insurers Partnering To Launch Narrow-Network Plans

Across the country, providers and insurers are partnering to launch narrow-network plans. In some cases, these healthcare systems and insurers will offer the narrow-network plans on state exchanges with monthly premiums in line with other exchange options. According to experts, the ACA is driving the shift toward these narrow-network products. Because the health law standardizes health plan benefits and sets caps on out-of-pocket costs, providers and insurers use the networks as a “differentiator.” Experts say it will take “unique and appealing plan benefits and participating providers to attract consumers who are accustomed to broader choices of hospitals and doctors.”

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Uncertain Future for CT’s Safety-Net Hospitals

Although the ACA provides coverage for legal immigrants, it does not allow illegal immigrants to buy coverage through the new insurance marketplace.  Illegal immigrants also cannot apply for Medicaid, even if they are poor.  For many safety-net hospitals-hospitals that provide emergency care to everyone regardless of income, insurance, and legal status, this means they must treat these vulnerable populations at their own expense (as mandated by federal law).  Hospitals lose millions of dollars in federal and state subsidies to pay for this care but the bigger issue at hand is figuring out how safety-net hospitals will fare as the health care reform unfolds.

Connecticut hospitals spent $233.6 million in uncompensated care in 2012 and another $868.3 million to cover Medicaid and Medicare reimbursement shortfalls.  With health reform in full effect in 2014, it is expected that the budget gaps will only increase as the health law reduces government subsidies under the assumption that everyone will be covered by Medicaid or private insurance. Due to these budget cuts, hospitals will be forced to layoff employees and cut back on new hires, patient services, research and technology while still paying for uncompensated care.

Connecticut has five hospitals which all function as safety-net hospitals.  Despite the challenges ahead, hospital spokespeople state that they will find a way to continue serving the poor and uninsured, noting that preventative services are the key to effective health reform.

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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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6 Tips for Picking the Right Health Insurance

If you’re still confused about picking the right health insurance, don’t worry! Here are some quick and easy tips to consider when picking an insurer:

  1. Look at options both on and off the exchange.
  2. Get the summary of benefits and coverage form (SBC) which lists information about the different health insurers.
  3. Look at the price, not just the price of the premium but also other out-of-pocket expenses like co-pays.
  4. Look at provider networks to see if your doctor is covered, especially if you need out of network benefits (from providers like psychologists and chiropractors, for example).
  5. Check to see if your medications will be covered and if they will, what the cost will be.
  6. If you are still confused about choosing the right provider, consult with an insurance broker.

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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.

Insurers Send Thousands of Cancellation Letters to Customers

Insurers around the country are sending hundreds of thousands of cancellation letters to consumers who buy their own coverage, forcing some to buy more expensive policies. About 14 million people aren’t offered insurance through their employers, therefore having to buy their own insurance.   Insurers say that many of the policies sold after March 2010 don’t meet the Affordable Care Act’s requirements which start on January 1, 2014.  The new policies that meet the ACA’s requirements, will offer consumers better coverage and 10 “essential” benefits which include prescription drugs, mental health treatment, and maternity care.

The notices have upset some customers who thought they would be able to keep their plans if they liked them.  Florida Blue is canceling 300,000 policies, Kaiser Permanente in California is canceling 160,000 and Independence Blue Cross, the major insurer in Philadelphia, is terminating 45 percent of its plans.

Consumer advocates believe insurers may be doing this to rid their systems of policy holders they no longer want but insurers deny the allegation, stating they expect these policy holders to re-enroll in new plans that may actually offer more coverage.  But, consumers worry that this better coverage may come at a high cost.

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Michigan’s Unique Medicaid Expansion Program

Did you know that there’s a government shutdown?  Of course you do.  Democrats and Republicans can’t seem to agree on a spending plan, especially when it comes to the Affordable Care Act. Some states have chosen to expand Medicaid, and about 26 states have chosen not to.  Michigan, considered a largely Republican state, has chosen to expand its Medicaid coverage to 133 percent of the federal poverty level. In a combined effort by both sides, lawmakers conjured up a unique program to satisfy both Republicans and Democrats. Their program includes incentives for enrollees to improve their health, and also will require them to pay certain premiums and co-pays or move to private insurance after four years in the program.  Perhaps Michigan can service as a model for other more conservative states facing similar issues.

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