Washington has become the first state to enact legislation that requires health insurers to notify physicians when patients enrolled in exchanges under the Affordable Care Act (ACA) enter the grace period, and other states may not be far behind.
Legislation passed last month will require a health plan, upon request by a physician, to provide information regarding an exchange enrollee's eligibility status “in real-time.” The law also requires that health plans in the exchange notify physicians and other health care providers that “an enrollee is in the grace period within three business days after submittal of a claim or status request for services provided.”
While insurers must inform physicians of a patient’s grace period status under the ACA, there is no substantive requirement around when this communication must take place. The AMA and other medical groups have urged the Centers for Medicare & Medicaid Services to require this notification when responding to an eligibility verification request.
The new Washington law remedies this uncertainty by requiring insurers to provide “detailed and binding information in a timely manner to physicians regarding a patient’s grace period status,” according to a letter the AMA sent the Washington state senate in support of the bill. Insurers are required to notify physicians when patients are in the grace period within three business days after a claim or status request has been submitted.
“This is a big win for physicians and patients in our state,” said Dale Reisner, MD, president of the Washington State Medical Association. “It goes a long way to ensure continuity of care by eliminating questions about the grace period status of patients.”
A similar bill was introduced in the Connecticut legislature last month, requiring insurers to clearly communicate to physicians the actions it plans to take when a person is in the grace period, such as place a hold on payments, pay the claim, or pay the claim and seek to recoup payment if the patient continues to miss premium payments. The AMA sent a letter of support for this bill as well. Both pieces of legislation were based on an AMA model bill.
At the latest meeting of the National Association of Insurance Commissioners, which took place this week, AMA Board Member Stephen R. Permut, MD, spoke to the ACA Medical Professional Liability Working Group on the grace period issue.
“The grace period needs greater clarity and transparency,” Dr. Permut said. “The federal notification requirement about the grace period is vague at best. We believe that as soon as a patient enters the grace period, the physician should be able to find out …. Physicians need this information to minimize risk, to plan effectively and to help educate patients.”
More information about the grace period and resources for physicians can be found on the ACA grace period Web page.
