Over the past 2 or 3 years of fielding questions on eligibility for ACA exchange members, I’ve learned a few lessons that I want to pass along. While I’ve definitely seen a change in the level of education about ACA plans, there are issues that continue to arise consistently. I’m hoping the lessons I’ve learned below will help with a little of the confusion.
This has come up a lot lately and it always seems to surprise providers when it happens, the scenario is usually something like this:
The member paid their premiums for a few months and then stopped. The next month the payer puts the member into a 90 day “grace period” status awaiting the premium payment. Technically they still have coverage but at this point there’s a good possibility they won’t very soon. The person goes to the hospital or physician for services, the provider checks eligibility,and the eligibility response indicates the member is currently eligible. 2 months later, the payer terminates the member and back dates it two months. The provider’s claim gets pended and then rejected and they blame their eligibility vendor for giving them bad information.
Just to recap,in most states the Affordable Care Act only requires the payer to pay claims for the first month of the grace period. This only applies to members that are receiving a federal subsidy/tax credit. If the member doesn’t pay their premiums, the insurance company isn’t going to pay for services incurred during the 2nd or 3rd month of the grace period.
I can’t tell you how many conversations I’ve had with providers that are angry because their claim got denied due to a retroactive termination. Unfortunately this type of risk is part of participating in the program.
If you’re lucky enough to have a copy of their card, the plan type is usually indicated there. Some eligibility vendors can help with this by adding flags to their responses to help identify these members. Some payers have made the decision to not identify these members but there are ways to tell with the larger payers. The group name or plan name can sometimes indicate the type of plan, Look for words like ACA, HIX, and Exchange in the group name. Also the metal names (silver, gold, etc) will sometimes be in the group name.
Determining on exchange vs off exchange can be a little more tricky.
Most payers have different plan names for on vs off exchange plans plus the network name may be different. I think many of the BCBS plans have different prefixes for on vs off plans.
Knowing if the patient purchased their plan plan on or off the exchange can help you determine if the member is in a network that you have a contract with. Along those same lines, it will help you accurately calculate expected reimbursement.
Some payers are better than others at identifying whether or not a person is in their grace period. If you’re still calling for eligibility, you’ll need to specifically ask that question. If you’re verifying eligibility electronically through a vendor or on the payers website, check the eligibility response for a “premium paid thru date”. I saw a payer website yesterday list it as “Deliquent as of”. If the patient is in their grace period, there’s a possibility you won’t get paid by the insurance company. The “paid thru date” doesn’t necessarily mean the member will be terminated on that date, but it’s good indication that there’s an issue.
Insurance companies aren’t particularly sympathetic when it comes to paying claims for someone that doesn’t have coverage anymore. This is true for ACA plans as well as commercial plans. It doesn’t hurt to appeal but don’t expect UHC or Aetna to rush to cut you a check. The best way to cover yourself is to make sure the patient signs something acknowledging their responsibility to pay if insurance doesn’t.
Once a patient enters the 2nd or 3rd month of their grace period, their claims will be held pending receipt of their payment. Your should be receiving notifications of these claims from your insurance companies. I’ve talked to several providers that have processes in place to proactively reach out to patients in their grace period. This probably isn’t practical for everyone but for hospitals with thousands of dollars at risk, this might be something to consider. I’m not talking about stalking them for payment or pressuring them to send their plan a check. A notice that their claims are pending waiting on their payment may help some patients prioritize their premium payments a little higher.
I’m sure I’m preaching to the choir on most of theses lessons but I still run into people that are completely oblivious on how the ACA works. I’ve included some links to additional reading on ACA plans below. I’m curious to know your challenges with the ACA plans. Please leave me a comment below on the biggest challenge your organization has faced with the Affordable Care Act.
CMS is in the process of migrating submitters from their HETS legacy eligibility system to their new “Redesign” system. Providers and clearinghouses are being moved to this new system in groups and the first group is moved last week. The HETS system is primarily accessed by clearinghouses but I think there are some health systems that are accessing it directly.
There are a few things to be aware of regarding this migration:
If you would like to read the full release summary with all the changes, click the link below:
Also see the new full HETS companion guide if you’re interested in the business logic they use for responses.
I’m hoping that this system migration will be uneventful and straightforward but you can never tell with CMS. This move gets them closer to being able to truly sunset the common working file eligibility queries, which is long overdue. I won’t be surprised if CMS sends out an announcement Q1 2017 regarding shutting off the CWF queries.
Here are a few interesting goodies I’ve run across the past week or two. Have a great day!
I ran across a few interesting tidbits this week that I thought I would share.
I didn’t know that Aetna was moving to digital ID cards this quickly. Have any of you received any of these digital cards? If so is it causing you to change your workflow at all?
They posted this blurb in their provider bulletin this month:
If an Aetna patient shows you a digital or printed copy of their ID card, you should accept it. Old member ID cards could cost you and your patients’ time and money. We’ve got you covered. When you reference a digital ID the information is up to date. That’s why we’ve given you and our members the ability to access digital member IDs.
If a member doesn’t have a copy of their ID card, you should submit an eligibility and benefits inquiry using their name and date of birth. You should complete an eligibility and benefits inquiry for every patient at every visit. You’ll get a response with everything you need to know about your patient.
Learn more Check out our new reference tool and tutorial.
Change Healthcare (formerly Emdeon) has posted this notice numerous times and I thought it was worth passing along.
The Dept of Veterans Affairs (VA) has observed a high volume of EDI transactions rejected due to invalid member ids. The Department of Veterans Affairs (VA) would like to remind providers that new Veteran Health Identification Cards were issued to every veteran enrolled in VA health care, which includes the Veterans Choice Program. Each member ID card contains a new Member Identification (ID) Number and Plan ID. The veteran’s Social Security number (SSN) is no longer printed on health identification cards. Please also note that all inquiries for a veteran should be sent to payer ID for VAFEE and only spouses and dependents of Veterans should be sent to VAHAC or the member eligibility will not be found.
At the present time, providers must continue to use the Veteran’s SSN as the member ID when submitting EDI transactions to VA Fee Basis Programs. Per the payer’s instructions, Emdeon will reject EDI transactions that do not contain the veteran’s SSN as the member id. Providers should also ignore the Plan ID number printed on ID cards and continue to submit real-time transactions to Emdeon Payer ID VAFEE or 00231 for VA Fee Basis Program.
In the future, providers will be able to use the new veterans’ member ids when submitting EDI transactions, but an ETA has not yet been provided. The payer will provide more information on this matter as it becomes available and will publish updates on the VA ListServ Community Newsletter and Purchased Care website. http://www.va.gov/PURCHASEDCARE/programs/veterans/nonvacare/index.asp
The new cards have a 10 digit ID instead of the SSN so make sure you ask for the SSN when seeing these patients.
UHC has officially announced that their getting rid of their ACA business in all but 4 markets next year. I haven’t see the list of the states that will remain but I’ll post it when it’s released. It will be interesting to see who follows in their foot steps.
This might be a power move by BCBS to move the contract negotiations along. Dropping 44 HCA hospitals would be a huge deal.