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Wednesday Feb 12, 2014

Verifying Coverage Key for Patients Insured Via Marketplace

Implementation of the Patient Protection and Affordable Care Act (ACA) has created several challenges in our offices and to patient work flow. For instance, does your practice have a system in place to verify patients' insurance coverage at each appointment? If not, you may need to update your office's check-in procedures.

Under rules issued by CMS, certain consumers now have a 90-day grace period to pay outstanding insurance premiums before insurers can drop their coverage. The CMS rule requires insurers to pay outstanding physician charges during the first 30 days of this grace period. However, if a consumer fails to make a payment to the insurer within the 90-day period and his or her coverage is dropped, insurers will not be required to pay for claims incurred during the last 60 days of the grace period.

That means physicians could be left to work directly with patients to collect payment for services provided during those final 60 days.

The rule, which took effect Jan. 1, applies only to consumers who purchase subsidized coverage through the ACA's health insurance marketplace. The Academy has developed an FAQ to address questions family physicians may have about the new rule.

As of Jan. 24, roughly 3 million people had enrolled(www.hhs.gov) in private insurance through federal and state marketplaces since October. People making between 100 and 400 percent of the federal poverty level(aspe.hhs.gov) can qualify for the premium tax credit health insurance subsidy. The Congressional Budget Office has estimated(aspe.hhs.gov) that 7 million people will enroll through the marketplaces before the March 31 deadline, and 86 percent of those, or 6 million, would qualify for assistance.

Although those 6 million patients represent only 2 percent of the U.S. population, the new rule presents a challenge for those of us who care for this group of patients. Again, it will important to verify eligibility for patients who have coverage through an exchange plan at every visit.

It's not yet clear how the new rule affects physicians in states with prompt pay laws. Physicians should consult with their chapters about laws and regulations in their states.

Robert Wergin, M.D., is President-elect of the AAFP.

Posted at 12:26PM Feb 12, 2014 by Robert Wergin, M.D.

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