Health Insurance Exchange implementation: A primer

October 1st, 2013 - Scott Kraft
Categories:   Insurance  

Health insurance policies issued as part of the state and federal health insurance exchanges under the Affordable Care Act (ACA) will take effect Jan. 1, 2014. That means that, starting on that date, patients may present to your office for insurance coverage under the plans. Here are the things you need to know to be prepared for handling these policies.

First, certain elements of implementation have been delayed for a year, notably the employer mandate. That shouldn’t have a huge impact on your operations, as most employers affected by the mandate already offer coverage. The individual mandate requiring people to obtain insurance through the exchange or pay a tax penalty will take effect as scheduled.

Second, most of the coverage offered by the exchanges will be offered by the same insurance companies that you’re used to dealing with now.

Exchange set-ups

The ACA allowed for three different types of exchanges.

In a state-based exchange, the state sets up, operates and regulates its own health insurance exchange.

In a partnership exchange, the federal government facilitates the exchange, but the state operates certain functions, such as public outreach, consumer assistance and plan management. These functions may vary based on the state.

A federal exchange will operate in all states that opt not to set up their own exchange or participate in a partnership.

According to a Kaiser Family Foundation report in June, these states or territories have opted to set up their own exchanges: California, Colorado, Connecticut, the District of Columbia, Hawaii, Idaho, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New Mexico, New York, Oregon, Rhode Island, Washington and Vermont.

These states have opted for a partnership exchange: Arkansas, Delaware, Illinois, Iowa, Michigan, New Hampshire and West Virginia.

All other states will use the federal exchange. Seven states – Kansas, Maine, Montana, Nebraska, Ohio, South Dakota and Virginia – will conduct some plan management within the federal exchange.

Timeline and plan types

Individuals may begin to select coverage under the ACA beginning on Oct. 1, 2013. They’ll choose from either the state or federal exchange depending on the state. The coverage takes effect on Jan. 1, 2014.

Individual applicants may not be rejected for coverage based on pre-existing conditions or other factors, nor will rates be determined by illness history. Plans are allowed to charge older applicants no more than three times the rates of younger applicants and to assess a surcharge of up to 50 percent for smokers.

Plans come in four types – bronze, silver, gold and platinum. This is a key distinction for you to understand, as it directly affects how you will get and seek payment from the plan and patient.

Here are some key details about the plan types:

Bronze plans: Bronze plans are intended to cover 60 percent of the incurred costs of the insured. These plans will likely be popular for relatively healthy, younger applicants. For medical practices and facilities, however, these plan holders will likely have larger deductibles and coinsurance costs, creating a collections risk for the practice.

Silver plans: These plans will cover 70 percent of the incurred costs. As a result, these plans may have slightly lower coinsurance costs and deductibles and may offer an improved drug benefit from the bronze plan. Exchange participants are required to offer silver plans.

Gold plans: The gold plan covers an estimated 80 percent of the incurred costs. These plans are a little closer to replicating typical, decent employer coverage and may exempt office visits from the deductible and offer lower coinsurance. Exchange participants are required to offer gold plans.

Platinum plans: The platinum plan covers an estimated 90 percent of the incurred costs, meaning lower coinsurance and deductible costs. Because exchanges are not required to offer platinum plans, they may not be widely available. For example, Oregon’s exchange, offered through Cover Oregon, does not show any platinum plans available from any participating insurers.

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association