New individual and small group or metallic plans have a number of important changes due to regulations brought on by the Affordable Care Act (ACA). Here you can learn more about the changes for these ACA-compliant plans.
Many of our new, ACA-compliant individual and small group plans encourage members to select a primary care provider (PCP) when they enroll in the plan. Members pay a lower copay when they visit their designated PCP. Members pay a higher copay if they don’t select a PCP or if they visit a different Premera provider or group. The split copay amounts are listed on the member’s ID card. Providers need to confirm a member’s eligibility and benefits in advance of the patient’s visit to determine the correct copay.
How to verify a member’s PCP:
Types of PCPs:
We developed new tiering standards for our contracted hospitals, facilities and providers. The standards include the addition of a new tier (Tier 4), effective Jan. 1, 2014. Tier 4 includes two new networks that support our new 2014 plans: The new networks are: Heritage Signature and Heritage Prime.
Here are some key things to note about the Heritage Signature and Heritage Prime networks:
Tips for Tier Assignment and the Member’s Network
A new provision under the Affordable Care Act requires plans to give members who receive the Advance Premium Tax Credit subsidy a three-month grace period to pay for their coverage. They cannot be terminated for non-payment during this period and are eligible to receive services as Premera members.
Here’s how it works:
Three-month grace period timeline example for members eligible for the Advance Premium Tax Credit:
Under the Affordable Care Act, everyone has access to health insurance regardless of health status. To create a system in which payers are compensated for the risk associated with the members they cover (known as risk-adjusted payments), complete and accurate diagnosis coding is necessary to capture the risk profile of each patient. Learn more about Commercial Risk Adjustment.
With accurate diagnosis coding, disruption will be minimal for medical practices. However, if diagnosis coding is inaccurate, it's more likely that we will request medical records due to the U.S. Department of Health and Human Services' (HHS) documentation requirements to support insurers' risk score submission.
Getting Your Practice Ready
Improving coding processes now and implementing checks will help to ensure your practice is ready. It will also help your transition to ICD-10 in 2015.
Here are some things you can do today to prepare:
Health Plan Basics
Healthcare Reform and Your Practice
Washington New Individual and Small Group Plans: What You Need to Know (webinar)