Providers' bur­den

Grace pe­riod on pre­mi­ums lets in­sur­ers sus­pend claims pay­ments

Modern Healthcare - - THE WEEK IN HEALTHCARE - Jonathan Block

Provider groups are protest­ing a CMS rule in­ter­pret­ing the health­care re­form law that gives con­sumers a grace pe­riod for un­paid health in­sur­ance pre­mi­ums will put them at sig­nif­i­cant risk of de­liv­er­ing ser­vices for which they won’t get paid.

The Pa­tient Pro­tec­tion and Af­ford­able Care Act and the CMS rule give con­sumers a 90day grace pe­riod if they don’t pay their pre­mi­ums be­fore their in­surer can drop their cov­er­age. The rule ap­plies to peo­ple in all states who ob­tain sub­si­dized cov­er­age through the new in­sur­ance ex­changes. That likely will con­sti­tute 80% of in­sur­ance sub­scribers on the ex­changes, said Jennifer Kowal­ski, vice pres­i­dent of the health re­form prac­tice at con­sult­ing firm Avalere Health.

Un­der the rule in­ter­pret­ing the law, in­sur­ers of­fer­ing plans on the ex­changes must pro­vide a three-month grace pe­riod to in­di­vid­u­als who have en­rolled and who have stopped pay­ing their pre­mi­ums. In the first 30 days, the in­surer must con­tinue to pay in­curred claims. But for sub­scribers who ul­ti­mately fail to pay pre­mi­ums within the 90 days and whose cov­er­age is ter­mi­nated, pay­ers are not re­quired to pay for claims in­curred dur­ing the last 60 days of the 90-day pe­riod.

That has provider groups such as the Amer­i­can Hos­pi­tal As­so­ci­a­tion, the Fed­er­a­tion of Amer­i­can Hos­pi­tals, the MGMA-ACMPE, the Mis­souri Hos­pi­tal As­so­ci­a­tion and the Mis­souri State Med­i­cal As­so­ci­a­tion steam­ing.

“This process un­duly bur­dens physi­cians, hos­pi­tals and other health­care providers who must then col­lect pay­ment from the

“Physi­cians, hos­pi­tals and other health­care providers can­not rea­son­ably be ex­pected to know or pre­dict if an en­rollee’s pre­mi­ums are paid or will be paid be­fore the end grace of the pe­riod.”

MHA CEO Herb Kuhn and Mis­souri State Med­i­cal As­so­ci­a­tion Ex­ec­u­tive Vice Pres­i­dent Thomas Hol­loway wrote in an Aug. 12 let­ter to CMS Ad­min­is­tra­tor Mar­i­lyn Taven­ner

pa­tient, and puts them at an un­fair and sig­nif­i­cant risk for pro­vid­ing un­com­pen­sated care to pa­tients,” MHA CEO Herb Kuhn and Mis­souri State Med­i­cal As­so­ci­a­tion Ex­ec­u­tive Vice Pres­i­dent Thomas Hol­loway wrote in an Aug. 12 let­ter to CMS Ad­min­is­tra­tor Mar­i­lyn Taven­ner.

“Physi­cians, hos­pi­tals and other health­care providers can­not rea­son­ably be ex­pected to know or pre­dict if an en­rollee’s pre­mi­ums are paid or will be paid be­fore the end of the grace pe­riod,” the let­ter con­tin­ued. “If the cur­rent rules can­not be amended or in­ter­preted in a more eq­ui­table man­ner, we fear there will be a wide­spread re­luc­tance among physi­cians and other providers to par­tic­i­pate in ex­change plans.”

Cur­rently, de­pend­ing on the state, con­sumers who do not pay their pre­mi­ums can be dropped by their in­surer, though some states al­low a 30-day grace pe­riod. If the sub­scriber is dropped for non­pay­ment, providers must col­lect di­rectly from pa­tients, Kowal­ski said.

But up un­til now, con­sumers in the in­di­vid­ual in­sur­ance mar­ket have had a strong in­cen­tive to stay up to date on their pre­mi­ums, be­cause if they let their cov­er­age lapse they might not be able to ob­tain new cov­er­age, par­tic­u­larly if they have pre-ex­ist­ing med­i­cal con­di­tions. Un­der the Af­ford­able Care Act, how­ever, in­sur­ers have to ac­cept all ap­pli­cants re­gard­less of pre-ex­ist­ing con­di­tions. So peo­ple know they can sign up again with­out penalty dur­ing the next open en­roll­ment pe­riod.

The ACA did not ad­dress whether health plans or providers should foot the bill for claims re­ceived dur­ing the 90-day pe­riod for which a car­rier re­ceived no pre­mi­ums. The CMS ad­dressed this in a rule pub­lished in March of last year.

The MGMA-ACMPE also has weighed in. In a July 3 let­ter to Taven­ner, MGMAACMPE Pres­i­dent and CEO Dr. Su­san Tur­ney ob­jected to a part of the pro­vi­sion re­gard­ing in­surer no­ti­fi­ca­tion to providers of the 90day grace pe­riod. As the reg­u­la­tion is cur­rently writ­ten, health plans in ex­changes “should

no­tify all po­ten­tially af­fected providers as soon as prac­ti­ca­ble when an en­rollee en­ters the grace pe­riod, since the risk and bur­den are great­est on the provider.”

Tur­ney ar­gued that providers should be no­ti­fied as soon as the 90-day grace pe­riod be­gins or else “it will be too late for physi­cians to en­gage pa­tients and make in­formed de­ci­sions prior to fur­nish­ing po­ten­tially un­cov­ered ser­vices.” She rec­om­mended that is­suers be re­quired to no­tify providers within the first 15 days of the grace pe­riod, or else be held fi­nan­cially re­spon­si­ble for any ser­vices in­curred in the last 60 days of the pe­riod.

Kowal­ski said that dur­ing those last 60 days of the un­paid pe­riod, in­sur­ers sim­ply won’t process any claims for the in­sur­ance sub­scriber. If the sub­scriber fails to pay within the 90 days, the in­surer will deny the claim. That will leave the provider with the un­paid bill, re­quir­ing the provider to seek pay­ment di­rectly from the pa­tient.

On Aug. 15, the heads of the AHA, FAH, and As­so­ci­a­tion of Amer­i­can Med­i­cal Col­leges wrote a let­ter to Taven­ner urg­ing the CMS to re­vise its rule to re­quire in­sur­ers to pay claims dur­ing the full three-month grace pe­riod. They ar­gued that the rule un­fairly shifts the bur­den for pro­tect­ing low-in­come pa­tients from in­sur­ers to providers. “The re­al­ity is that it will be ex­tremely dif­fi­cult to col­lect pay­ment from low-in­come pa­tients who al­ready are hav­ing trou­ble pay­ing their (plan) pre­mi­ums,” they wrote.

An ear­lier ver­sion of the CMS rule man­dated that in­sur­ers pro­vide a grace pe­riod of at least three months. But in a vic­tory for pay­ers, the fi­nal rule changed that to re­quir­ing in­sur­ers to pay claims only dur­ing the first 30 days and to sus­pend claims for ser­vices pro­vided dur­ing the sec­ond and third months.

In a 2011 let­ter to the CMS, Amer­ica’s Health In­sur­ance Plans, the lob­by­ing group for in­sur­ers, wrote that “re­quir­ing health plans to pay claims for en­rollees who do not pay pre­mi­ums in­creases pre­mi­ums for all en­rollees, ef­fec­tively re­quir­ing pre­mium-pay­ing en­rollees to sub­si­dize cov­er­age of in­di­vid­u­als who failed to pay their pre­mi­ums.”

Be­sides fret­ting about not get­ting paid, the Mis­souri providers’ re­cent let­ter warned that un­scrupu­lous con­sumers could use the 90day grace pe­riod to take ad­van­tage of providers and get free health­care. “We also are very con­cerned that some dis­rep­utable in­di­vid­u­als will learn they can ma­nip­u­late the sys­tem and win a full year’s in­sur­ance cov­er­age on only nine months of pre­mi­ums,” the MHA and Mis­souri State Med­i­cal As­so­ci­a­tion wrote.

The CMS did not re­spond to a re­quest for comment.

Newspapers in English

Newspapers from USA

© PressReader. All rights reserved.