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The bulk of the Affordable Care Act's coverage provisions went into effect on January 1, 2014, including tax credits for Marketplace-based coverage, Medicaid expansion, and insurance industry reforms such as prohibitions on pre-existing condition coverage limits. For physicians and patients, the expansion of coverage presents an opportunity to improve patients' access to care and nurture the doctor-patient relationship. The ACA may also create new challenges, as some insurance plans offer limited provider networks that may disrupt continuity of care, create tight prescription drug formularies, and require high cost-sharing responsibilities that may place a financial burden on patients. This document will provide practical advice to physicians and their patients and what they can do to ensure access to patient-centered care in the reformed health system. ACP has created resources for physicians and their patients to help them learn about the ACA's coverage provisions, how to sign up for coverage and where to get enrollment help. The ACA enrollment resources can be found here.
Have questions or comments about ACA health insurance marketplaces and enrollment? Contact ACP staff at email@example.com to share your thoughts.
Some Marketplace-based insurers have formed limited networks of providers in an effort to curb costs. A McKinsey & Co. report found that in 2016, 48% of individual market hospital networks across all metal tiers were tiered, narrow or ultra-narrow. Network breadth is declining in some areas and the percentage of consumers who only have access to narrow network plans has increased three-fold since 2015.
The ACA network rules are in place to ensure that:
For plan year 2017, the provider network adequacy of plans sold through the federally-run marketplace will be evaluated using a reasonable access standard and will give special attention to a network's access to hospital systems, mental health providers, oncology providers, and primary care providers. If CMS determines that a plan's network does not provide sufficient access, the agency will alert the plan, evaluate the health carrier's response, and decide whether the plan can be certified. CMS will also work with state officials and provider ongoing monitoring of QHP network access.
State insurance regulators are largely responsible for enforcing the ACA's insurance regulations. If physicians are concerned that a health plan is not meeting network adequacy standards, they should contact their state's insurance regulator to file a concern.
There have been reports that health insurers may be including physicians in their marketplace-based plan networks by using all-products clauses to designate a physician as participating in the plan without their knowledge.
To help promote continuity of care in cases where a provider is terminated without cause, federal marketplace-based network insurers are required to allow an enrollee who is in active course of treatment to continue treatment until completion or 90 days, whichever is shorter, at in-network rates. Some states require plans (often managed care plans) to temporarily continue care provided by a health care provider that does not participate in the plan's network. A list of relevant state laws can be accessed here.
Despite these policy improvements concerns about limited provider networks remain. Physicians and their patients should be aware that the ACA requires that non-grandfathered plans (i.e. most plans created after March 23, 2010) cover hospital emergency care and that plans provide coverage of emergency services without prior authorization and cannot charge higher cost-sharing for out-of-network emergency services.
ACP has issued recommendations on how to improve provider networks. The College's work can be found here.
If a Marketplace-based health plan denies to pay a patient's claim for a service they've already received, the patient can request an internal review with the health plan, but must do so within 6 months of receiving notice that the claim was denied. If the patient disagrees with the health plan's internal review decision, they can have the claim reviewed by an independent third party. An expedited external review may be granted depending on the immediacy of the patient's medical need. A representative - such as a physician or other health care professional - may be appointed by the patient to act on their behalf during the external review process. Health insurers are required to abide by the decision of the external reviewer. More information on this process can be found here.
State appeal review processes may vary, so patients should check with their local Department of Insurance or other related regulator regarding their appeals rights.
Patients may also appeal eligibility decisions made by the Marketplace and associated plans, including a Marketplace's decision on eligibility for premium or cost-sharing assistance. More information on that process can be found here and here.
Patients can seek help with an appeal through the following resources:
The law caps cost-sharing and mandates minimum benefits for most health plans. Shopping for, and enrolling in, health insurance is less complicated. Insurers are prohibited from denying or renewing health coverage based on a patient's pre-existing condition or health status. Annual and lifetime dollar limits on essential health benefit coverage are banned (plans that existed before March 23, 2010 may be subject to annual dollar limits) and plans can no longer drop enrollees from coverage when they get sick.
Despite these positive changes, the new system will undoubtedly pose challenges to physicians and other health care providers. Many of the currently uninsured and newly insured may not understand health coverage concepts like deductibles and coinsurance, leading to cost-sharing collection problems. Reflecting trends in existing employer-sponsored health plans, many Marketplace plans will have significant deductibles and other cost sharing requirements.
However, physicians can smooth the transition by educating themselves about the law's coverage provisions and directing patients to Navigators and other consumer-assistance resources. If possible, physicians should tell their patients at the time of service what their cost-sharing obligation will be. It's also a good idea to contact the patient's insurer and verify that they're enrolled in coverage. Physician practices should be aware that patients receiving premium tax credits who do not pay their monthly insurance premiums will enter a 90-day grace period after which their coverage will be terminated. During months two and three of the grace period, insurers may pend claims for services provided during that period; if the patient's coverage is terminated, the insurer is not obligated to pay claims for services provided during the final 2 months of the grace period. Insurers are required to notify providers that the patient has entered the grace period and that claims may go unpaid for services provided during final 60 days.
Patients need to be aware of their cost sharing responsibility and make necessary financial arrangements, such as setting aside money to pay deductibles.
Patient advocacy and provider organizations have raised concerns that health insurance plans may be crafting their benefit packages in a way that would discourage sick people from enrolling, such as through the creation of tiered prescriptions drug formularies that would force chronically ill patients to pay steep co-payments for necessary medications. Advocates for HIV/AIDS patients have filed complaints against a number of Florida health plans arguing that prescription drug benefits have been structured in a manner that discriminates against vulnerable patients. When shopping for the right Marketplace-based plan, patients should consider the plan's drug coverage adequacy and cost and whether or not the plan uses drug tiers, quantity limits, formularies, step therapy or other mechanisms.
Regulations state that health benefits cannot be crafted or implemented in a way that discriminates based on a person's age, expected length of life, present or predicted disability, degree of medical dependency, quality of life, or other health conditions. Formulary drug lists must be easily available and accessible to plan enrollees and prospective enrollees, current, accurate and include a complete list of all covered drugs. Lists must also disclose any tiering structure or restrictions on the way the drugs can be obtained. Individual and small group health plans are now required to cover an essential health benefits (EHB) package that includes services in categories such as hospitalizations, outpatient care, and maternity care. Prescription drug coverage is among the EHB categories. Specifically, to meet EHB requirements, plans must cover:
The 2016 regulation encourages plans to provide a one-time refill of existing prescriptions, even if the drug is not on the plan's formulary, during the first 30 days of coverage.
Health plans are required to have in place an exceptions process to ensure that enrollees have access to clinically-appropriate drugs that are prescribed by a provider but are not included on the plan's drug list.
Patients should contact their plan for specific guidance on accessing non-covered drugs. The general Marketplace-recommended process is as follows: