Written by Healthcare Billing and Management Association // May 2015
Two prominent complaints by patients since the ACA became effective have been inaccurate provider directories and higher than expected out-of-pocket costs (premiums, copays and deductibles) for the plans sold on the Health Insurance Exchanges.
In early May, federal health officials announced that beginning in 2016, they will require Qualified Health Plans (QHPs) sold on the Exchange to update and correct their provider directories at least once a month. Furthermore, plans sold on the Exchanges for the 2016 Plan Year, will be required to provide an out-of-pocket cost calculator so individuals can have a better sense of anticipated out-of-pocket expenses when selecting one plan compared to another.
Inaccurate or outdated provider/health professional directories are not unique to the Exchange market, they exist for Medicare Advantage and Medicaid Managed Care plans as well. To address Medicare directories, federal rules will require insurers to update their Medicare directories each month, “with specific notations to highlight those providers who are closed or not accepting new patients.”
Accurate provider/health professional directories are important because after premium cost, the single most important factor in a consumer choosing one plan over another is the provider network. Is “my” hospital or “my” physician in the plan’s network is the typical question asked by most consumers when trying to determine whether a Health Plans network is “adequate”.
Equally important, if a patient has coverage for a service but cannot get access to that service due to inaccurate provider/health professional information, the patient faces unnecessary and avoidable burdens when trying to obtain that service. Moreover, going outside the insurer network typically imposes additional costs on the consumer that he or she might not have expected because they believed the provider/health professional to be in-network.
The new Qualified Health Plan requirements are consistent with earlier efforts by the Obama administration to mandate that insurers publish information on:
- Health Professionals who are accepting new patients,
- Physician specialty and medical group affiliation; and,
- Up-to-date contact information
Insurers must also provide the data in a format that facilitates the creation of a consumers‟ check to help consumers identify health plans their doctors participate in. Failure to comply will be met with financial penalties.
The calculator mandated under this new policy will take into account the QHPs premiums, subsidies, co-payments, deductibles and other out-of-pocket costs, as well as a person’s age and medical needs (including expected medical procedures such as childbirth).
Federal officials said that they might link HealthCare.gov to an out-of-pocket cost calculator later this year.
This article was originally published by Healthcare Billing and Management Association. To view the original article, click here.
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