Written by Steve Selbst, CEO, Healthcents Inc. and co-authored by Susan Charkin, President, Healthcents Inc. and Regina Vasquez, Senior VP, Healthcents Inc.
Last October, the national health insurance exchanges were launched. There has been quite a bit of press each day since about the pros and cons of the new health insurance exchanges, the previous problems with the federally run website, “grandfathered” individual insurance policies that are being cancelled because these policies did not meet the minimum coverage requirements established in the Affordable Care Act and the cost of premiums for those who enroll but do not qualify for federal subsidies.
However, there is very little written about the effects of Health Insurance Exchanges on medical practices and how to navigate the health insurances exchanges to maximize reimbursements. The purpose of this article is to help medical practices learn about ways to better manage health insurance exchange patient reimbursements.
First, it is important to have a basic understanding of the structure of the health exchanges. That is, what is consistent across all exchanges (federally run and state run) and what is unique and, therefore, inconsistent. As of the time of this writing, there were 16 states that have implemented state run exchanges. The remaining 36 exchanges (including Washington D.C.) are either run by the federal government or in a partnership with the federal government. See figure 1, below:
Regardless of who runs the exchanges, the state or the federal government, there are some very clear consistencies. Here are the key elements of the state exchanges that are consistent. There are other common elements, but the following are key operational elements which have downstream effects on the delivery and reimbursement for care. We have highlighted the items that are key to understanding the exchange plans from a provider perspective. Key features that are common across all exchanges and all plans are:
- Each state offers the exact same plans, both in features and structure. There are catastrophic, bronze, silver, gold and platinum plans offered in each state exchange.
- Each of these plans, regardless of the payers who participate, have the same percentage of payer coverage. Catastrophic will provide for 60% coverage, Bronze <60%, Silver 70%, Gold 80% and Platinum 90%.
- Each plan requires that doctor visits, prescription drugs, hospitalization, maternity and newborn care, and preventative care be a part of the exchange plan.
However, there are many inconsistencies at this time. Inconsistencies include:
- Which payers choose to participate in a particular state exchange
- The premiums established by each payer
- The benefit plans (Catastrophic through Platinum) that the payers choose to offer
- The products established for the exchange plans
- The physician reimbursement associated with exchange plans
As of this writing in August, 2014, many of the enrollment difficulties at the federal website have been resolved. However, it is estimated that 5 million (or more) people purportedly had their current insurance policies terminated effective 1/1/2014. The resolution of this issue could affect the physician reimbursement outcomes as those individuals look for new plans on the exchanges, possibly at lower reimbursement rates, in some cases, than standard PPO Plans. The current trend in healthcare exchange enrollment indicates that the vast majority of individuals currently enrolled in state exchange plans qualify for expanded Medicaid coverage, and are accessing policies with reimbursement rates equal or close to state Medicaid rates. This could potentially have a significant downside impact on a practice’s revenue and margins.
There are a range of questions about the exchanges as it relates to physician reimbursements, and here we will take a pragmatic view of each.
Here are some of the common questions that physicians are asking:
- How do I know if I have an option to contract with a payer’s exchange product or opt out of an exchange product?
- How can I validate if my practice is already in an exchange product?
- What are my exchange product reimbursement rates and do they differ from my current contracted rates?
- With enrollment problems, why would we assume that there will be accurate systems and business processes in place to track premium payments for exchange-based policies/plans, benefit eligibility and deductible amounts paid to date?
- Can I collect from the insurance company if a patient in an exchange plan misses premium payment(s) or has terminated or changed their plan choice in the exchange?
How do you know if you have an option to contract with a payer’s exchange product and how do I validate participation?
The answer varies from payer to payer and from state to state. First, whether you participate in a state run exchange or a federally run state exchange, you can go to healthcare.gov and figure out the plans that are in place in your state. Simply go to the healthcare.gov web site and follow the questions about coverage for a family to get to the options available. If you are in a state run exchange, this site is now integrated to your state’s website and will transition you during your answers to the qualifying questions. Below is a partial result of navigating healthcare.gov for a selected county in the state of North Dakota to find plans for a family including, “You, your spouse and children”. You immediately get the results for all payers and plans that are a part of the exchange, along with the estimated premium payments based on the query: