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Monday, January 6, 2014


Hassles and red tape from the new health insurance marketplace rang in the New Year. Most concerning are new Affordable Care Act (ACA) requirements that could deny or delay your payments, such as the 90-day grace period and lack of identification on patients’ insurance cards clearly indicating they are participating in the marketplace.
  • As many of you know, the 90-day grace period is triggered once a patient with subsidized marketplace coverage misses a premium payment. Instead of immediately terminating the policy, health plans must give the patient 90 days to catch up. Federal rules allow health plans to pay, hold, deny, or later recoup payment of claims for services incurred in the second or third month of that window if patients are delinquent on their premium payments. However, insurers must pay physicians for services provided to a patient in the first 30 days of the grace period, and insurers still must comply with Texas law requiring prompt payment of claims submitted at any point in the grace period. 
TMA talked to the Centers of Medicaid and Medicare Services (CMS) about the faulty law. CMS acknowledged it’s problematic but didn’t take steps to fix it. Recognizing this is not an acceptable solution, TMA reached out to Texas carriers directly to ensure you get paid. The good news is that Blue Cross and Blue Shield of Texas (BCBSTX) stepped up to the plate.
BCBSTX recognized the fault in the current law, and rather than hold or deny claims filed during the grace period, BCBSTX will pay physicians. TMA is calling on other insurers to follow suit.
  • TMA also is talking with the carriers about clearly identifying patients in the health insurance marketplace on their ID cards. For specific information on what carriers are doing, check out ACA Exchange Plans: Questions and Answers for Texas Physicians on the TMA website. We will continue to update this page as changes arise. 
TMA is listening and taking action to fix ACA requirements affecting your practice. Please feel free to call me or my staff any time to report problems.

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