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Reform Update: Exchange enrollees confused over when their coverage starts


By Sabriya Rice
Posted: March 3, 2014 - 4:15 pm ET
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Some physicians and other healthcare providers are experiencing new challenges associated with enrollees of the new health plans sold on the Obamacare insurance exchanges. Management groups working with providers are offering suggestions on how to be prepared, as HHS expects another enrollment surge ahead of the March 31 open enrollment deadline.

One of the key issues is misunderstanding about enrollment versus actually being covered. It's confusing for both patients and providers, experts say.

“Just because a patient is enrolled doesn't mean they are covered,” said Anders Gilberg, senior vice president of government affairs for the Englewood, Colo.-based Medical Group Management Association. For example, patients who paid their premium and were enrolled on Feb. 20 would not be covered until April 1, he said. So when new patients walk into a doctor's office saying they are “enrolled,” the physician still may need to confirm the effective date of the patient's coverage.

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"This is causing a lot of headaches,” Gilberg said. Medical office managers now find themselves interacting with the health plans on frustratingly long phone calls as they try to confirm patients' coverage.

There also has been concern about which plans physician practices are signed up for as participating providers. Many insurers have multiple provider networks to offer more competitively priced plans, said Adam Powell, president of Payer & Provider, a Boston-based healthcare consulting firm. To keep premiums down, insurers have changed their network designs, often excluding physicians who demand higher rates.

Powell said it's a lot more likely patients will think a doctor is in their network when they're not, particularly for plans on the exchanges. It's not enough for a medical office to know it has a contract with that insurer. “The physician needs to be aware of which networks they are members of and which they are not, because a health plan may have multiple networks.” For providers who have had contracts with an insurer for a long time, he urged them to double-check whether the contract includes the insurer's new exchange plans.

In collaboration with the American Medical Association, the MGMA provides its members with a checklist for handling the new insurance exchange business. The checklist suggests that providers educate office staff so they are prepared to speak with patients upfront about payment policies, cost-sharing and other financial information.

Powell noted that the Affordable Care Act has accelerated the shift to high-deductible plans and that physicians have to be prepared for patients who are shopping around for lower prices because they are shouldering more costs out-of-pocket. “Patients have more cost exposure now than they had in the past,” he said. “Insured patients that have little savings may have trouble paying their deductible, and may be more interested in comparison shopping.”

Health plans seek patient data to assess exchange risk pools

The Wall Street Journal reports that health plans, including those operated by health systems such as Great Neck, N.Y.-based North Shore-LIJ Health System, are asking new insurance exchange enrollees to give them information on their health status so they can more accurately assess the exchange risk pool and set premiums for 2015. The insurers say they also want to steer the new enrollees toward lower-cost drugs and services, and arrange primary-care appointments for people who previously did not have a regular physician.

Obama proposes $14.6B new funding for healthcare training

On Tuesday, President Barack Obama is expected to propose $14.6 billion in new funding for healthcare training as part of his 2015 budget plan. That includes more than $5 billion over 10 years to train 13,000 doctors to serve in high-need areas. The president's budget also is expected to propose nearly $4 billion over six years to expand the National Health Service Corps to 15,000 providers. In addition, Obama is expected to seek more than $5 billion in increased payments to providers who serve Medicaid patients.

Follow Sabriya Rice on Twitter: @MHsrice


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