Practice Management & Allied Staff News & Materials
Insurance Marketplace (Insurance Exchanges) and Your Provider Contracts
November 6th, 2013
The Affordable Care Act (ACA) mandates that all individuals obtain insurance effective January 1, 2014. Many individuals and families who currently do not have insurance will be purchasing their coverage through insurance marketplaces created under the ACA. Previously referred to as exchanges, these insurance marketplaces, whether state-operated or federally-operated, will be a single, online source where consumers may obtain information about their health coverage options in an easy, side-by-side comparison of private insurance plans and coverage options. The number of payers participating in the marketplaces varies by state. Visit the Kaiser Family Foundation’s interactive map at http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#map to check your state’s decision regarding insurance marketplaces.
As patients insured through your state marketplaces present to your practice, keep in mind that your current managed care contracts may automatically make you a participating provider within the plan offered through the marketplace. This may be due to an “all products clause” written into the provider contract. “All product clauses” typically state that if the provider is interested in participating in any particular product offered by the plan, the provider must participate in all of the health plan products as a condition of participation. There are only 10 states that prohibit “all products clauses” from being written into provider contracts. In the remaining 40 states, while sporadically practiced, plans have the freedom to incorporate such clauses into their contracts. Given the infancy of insurance marketplaces, it is likely that those payers that did not previously incorporate such clauses into the contract language, may do so to assure beneficiary access to healthcare providers.
Additionally, while you may be contracted with a plan, what the plan covers and what they reimburse in and out of the exchange may differ. Plans offered through the exchange may reimburse according to a different fee schedule and offer only what is required under the ACA in order to keep premiums lower within the exchange.
On the contrary, while some marketplaces may “force” providers to participate resulting from these all-product clauses, some marketplaces are offering limited provider networks in attempts to keep premiums low. In such states, providers and hospitals may find themselves being released of their provider contracts without cause.
Finally, policies purchased through the marketplace carry a 90-day grace period for beneficiaries to pay their premiums before the policy lapses or terminates. Regardless if you are a participating or non-participating physician, please keep this in mind as you verify benefits for patients insured through the marketplace. They may be deemed covered at the time of service; however, payment may be delayed or even denied depending upon when or if the beneficiary pays their premium. While this is a risk with any plan, as most provide a 60-day grace period, the additional grace period may prove more burdensome, particularly if your practice treats a large number of patients insured through the marketplace.
The Centers for Medicare and Medicaid Services offers the two publications which can be found at: