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Changes to ACA ‘grace period’ needed, Society says in letter to CMS

The Wisconsin Medical Society on Tuesday asked the Centers for Medicare & Medicaid Services (CMS) to reconsider the “grace period” provision for enrollees in the Health Insurance Marketplace (also known as health insurance exchanges) through the Affordable Care Act (ACA). In a letter to Mandy Cohen, MD, senior advisor to CMS Administrator Marilyn Tavenner, Society CEO Rick Abrams expressed concern that physicians and hospitals will decline to participate in qualified exchange health plans.

The provision gives certain Marketplace beneficiaries a three-month period during which their coverage cannot be terminated for failure to pay premiums and requires insurers in the Marketplace to pay all claims during the first 30 days of the grace period. Insurers also are allowed to pend and deny claims during the remaining 60 days if coverage ultimately is terminated. Under more traditional employer-sponsored health plans, insurers still are liable for paying physicians even if premium payments are not paid on time.

“This process unduly burdens physicians, hospitals and other health care providers with a double whammy,” the letter said. “First, they provide the care. Then, they bear the burden of having to collect private payment from the patient for care rendered during the final 60 days of the grace period if the patient fails to pay his/her premium, or shoulder the unfair and significant risk for providing uncompensated care. This dual burden simply is not fair.”

In its original proposal, CMS required insurers to pay all appropriate claims during the entire grace period – which the Society supported. That provision was amended in the final rule, which also requires insurers to notify physicians and other health care providers “as soon as practicable” after a patient enters the grace period.

“We strongly urge you to make the notification process accessible whenever a provider needs to inquire, and to make it consistent with the current ‘real-time’ standards for electronic HIPAA verification transactions (X12N 270/271), which generally require health plans to transmit eligibility information within 20 seconds,” the letter said.

The Society and the Wisconsin Hospital Association also voiced its concerns about the grace period in a letter to Tavenner in August. Read more in this Medigram article.

Back to October 3, 2013 Medigram