Tuesday, December 31, 2013

Resources to Help Consumers and Providers with Insurance Coverage Questions

Many individuals have new insurance coverage beginning Jan. 1

Starting Jan. 1 millions of Americans will have new health insurance coverage through the Health Insurance Marketplaces, Medicaid or the Children’s Health Insurance Program, all part of the implementation of the Patient Protection and Affordable Care Act.

Hospitals have worked through coverage issues with patients and insurers for many years and have plans in place to assist patients with enrollment issues. This year, hospital Certified Application Counselors have been engaged in helping consumers navigate the enrollment process and have been preparing to help individuals sort out coverage problems that may arise at the beginning of 2014.

However, given the extended dates for enrollment and premium payments, which vary by state and insurance carrier, hospitals and other care providers in January may not be able to easily verify coverage at the point of service. Moreover, patients may not fully understand their care options and financial responsibilities under their new health plans.

To assist patients and providers, the Centers for Medicare & Medicaid Services (CMS) has posted additional resources that can help address questions related to coverage, network providers, premium payment, copayments, cost sharing and other issues. In addition, consumers who signed up for coverage through HealthCare.gov can find information related to their health plan by logging into their HealthCare.gov account or by contacting the Health Insurance Marketplace call center at 1-800-318- 2596. Please share this number with your staff and patients.

It also is important for your hospital to consider developing or updating detailed contact sheets for the insurance carriers in your local market to help ensure prompt resolution to patient questions. You also may consider asking insurance carriers for detailed information on the network composition of their various benefit plans so that you can help inform patients of their in- network versus out-of-network options.

Below are links to a number of CMS factsheets available to assist consumers and providers with plan specific information.

As always, we encourage you to work with the patient’s insurance issuer to ensure that patients understand their coverage, care options and financial responsibility, and to ensure that quality care is provided promptly to those in need.

If you encounter significant coverage-related issues in the coming weeks that are not addressed by the information above or other resources, please let us know at: coverage@aha.org.


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