The final rules for the formation and procedures related to health exchanges are rolling in. Doing research into laws gives me a head ache.
Are you ready to start reviewing contracts presented by Qualified Health Programs (QHPS)? Do you even have a clue what a health exchange is going to look or act like?
There remains latitude in how the plans can be presented, advertised and contracted with health care providers. A final ruling that will present a challenge to providers of health care involves the 90 day grace period the insured receive associated with non-payment of health insurance premiums.
Under the final ruling QHP’s are required to pay for services provided up to 30 days after the commencement of a non-payment. To protect the interests of the QHP’s and of the insured services provided in the 31st -90th day could be held and marked as pending. If the insured fails to bring his account to full status by the 90th day of the grace period his policy may be terminated. At that point all pending claims can be denied.
This scenario only applies to those individual insured who received advance payment of the premium tax credit. It should also be noted that QHP’s are given the option to not pay for services provided between the 30th-90th day of non-payment. If they are moved by the largeness of their heart they can pay all 90 days of claims. Raise your hands if you think this is going to happen.
This ruling leaves providers open to potential debt and fees associated with collecting those debts.
It also raises questions in my mind.
When a provider is notified that all payments are pending, can a provider require cash payment in advance prior to providing services? What about elective procedures? Can the provider decline to provide non-essential services? I don’t have the answer to these questions.
If you have any advice or expertise it would be appreciated.
Below is a quotation from the federal register of 5/27/2012.
You can also follow this link and look for page 18394
“Comment: Several commenters requested clarification regarding how the grace period for non-payment of premiums would work for individuals receiving advance payments of the premium tax credit and whether these policies differ for those who are not. Response: We clarify in §155.430(b)(2)(ii)(A) and (B) of this final rule that the grace periods for nonpayment of premiums are not the same for individuals receiving advance payments of the premium tax credit and other enrollees. The 90-day grace period for non-payment of premiums for individuals receiving advance payments of the premium tax credit is addressed in §156.270(d). In §155.430(d)(5) of the final rule, we clarify that the last day of coverage for individuals not receiving advance payments of the premium tax credit should be consistent with existing State laws regarding grace periods for non-payment.”