DOI guidance helps physicians when patients are late making premium payments

by Marilyn Rissmiller, CMS Senior Director, Health Care Financing

Earlier this year the Colorado Division of Insurance (DOI) issued proposed regulations concerning grace periods for policyholders receiving federal advance premium tax credits (APTC) per the Affordable Care Act (ACA). The purpose of the regulation is to establish the requirements for grace periods when a policyholder is delinquent in the payment of monthly premiums for health benefit plans offered on the state’s health insurance exchange (Connect for Health Colorado).

By issuing this regulation the DOI had an opportunity to provide additional clarity to the 90-day grace period that was not addressed in ACA. However, the rule fell short. Neither the ACA nor the proposed regulation provided carriers with specific direction about the type and notification timing of critical information sent to providers regarding a patient’s eligibility status.

Physicians, and the provider community as a whole, expressed concerns regarding the potential financial burden they face when they do not receive timely notification about when a patient enters the second and third month of the grace period. This uncertainty could become a disincentive for physicians to participate in the health plans offered through Connect for Health Colorado.

Colorado Medical Society (CMS) has supported the insurance exchange because of the expanded access to coverage it offers to patients. We thought that the proposed regulation offered a means to mitigate these concerns. CMS and 10 other organizations submitted detailed comments regarding when the notice should be provided and what information needed to be included. CMS Past-president Jan Kief, MD, also testified at the public hearing in May.

While Insurance Commissioner Marguerite Salazar concluded that the DOI does not have the authority under current statute to incorporate the changes requested, she did issue an August bulletin to carriers that provides additional direction. Specifically, we are pleased to report that many of the CMS’ suggestions were accepted concerning what information is reported about a patient’s eligibility status within the 90-day grace period and when physicians are alerted. The bulletin also clarifies the relationship between the grace period and the existing statute on eligibility verification.

The bulletin, B-4.77, will go a long way to ensuring that physicians and others receive consistent and timely information from carriers concerning their patients’ eligibility status. CMS has developed a fact sheet that can be found on the CMS website, along with a copy of the bulletin. The major points are outlined on the next page. The key to these protections lies in the physician practice’s hands. It is important to check the patient’s eligibility status prior to services being provided so that financial arrangements can be made in advance of potential problems later related to unpaid patient premiums.

Categories: Communications, Colorado Medicine, Practice Management, Coding and Billing