Monday, November 25th, 2013
There is a litany of national news service articles this week, covering the full political spectrum, highlighted concerns expressed by physicians in New York State regarding unfair treatment by health insurance companies offering coverage in New York’s Health Insurance Exchange.
Articles appeared in:
· US News & World Report and
· Kaiser Health News highlighting the challenges patients may face in New York’s Health Insurance
Exchange as a result of a number of concerns identified through the preliminary results ofMSSNY
survey gauging physician experiences with health insurance companies offering coverage through
New York’s Health Insurance Exchange.
The problems with health insurers identified in the MSSNY survey include failure to communicate whether a physician is part of an Exchange plan, failure to provide information regarding reimbursement for providing needed patient care and, in many cases, offering fees that, generally speaking, are significantly below existing commercial coverage. MSSNY continues to regularly communicate with top staff at the New York Exchange to convey these concerns. Last week’s MSSNY’s Advocacy Matters program featured top staff of the New York Health Insurance Exchange describing the roll-out of the Exchange in New York, including responding to many physicians’ questions. To watch a recording of this webinar, click here.
We also continue to urge physicians to complete the survey so that it is more representative of physician experiences statewide. If you have not already done so, we urge you to please complete the survey here.
We Need to Hear from You
MSSNY has contacted the NYS Department of Health regarding complaints of some physicians that they are listed as a participating physician in a health plan exchange network, but were not provided any written notice by the health plan that gave prior notification of such participation requirement, or the terms and conditions of such participation, including but not limited to, the fee schedule applicable to the exchange product. The NYS Department of Health has asked MSSNY to provide specific examples of physicians who believe that the health plan failed to provide prior written notice of participation in the exchange product. If a physician is interested in having the DOH investigate the specifics, the doctor should send an email to Regina McNally, VP of Socio-Medical Economics at firstname.lastname@example.org The email should identify the plan name and identify whether or not they have any contract with the specific insurer.
Sam L. Unterricht, MD
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Thursday, November 14th, 2013
CONTRACTS IN THE NEW HEALTH CARE WORLD
Question: I received an amendment to my payor participation agreement related to increased payments under the Affordable Care Act. Any reason not to sign?
Answer: Maybe. We have seen some amendments to participation agreements of late that have been presented to medical practices to implement enhanced primary care payments under the Affordable Care Act. While the payments may be easy to accept, be careful of the trade-off. Be especially concerned if the amendment includes language that provides the payor with new rights to audit your practice or new grounds for termination, and consult experienced health care counsel before signing.
The days of signing so-called “standard” managed care agreements and amendments should be behind you. This holds true for other agreements, as well, e.g., data sharing agreements, EHR agreements, business associate agreements, employment agreements, leases, etc. Today, most physicians have complex relationships with multiple parties, each governed by a written agreement that may implicate any number of statutes or regulations and which may limit your ability to freely contract with other parties. Bottom line: it is more important than ever to read and understand the fine print.
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Thursday, November 14th, 2013
AMA submits recommendations to Senate Finance and House Ways & Means Committees on repealing the SGR
On Oct. 30, the Senate Finance Committee and the House Ways and Means Committee released a bipartisan, bicameral discussion draft proposal that “would permanently repeal the SGR update mechanism, reform the fee-for-service (FFS) payment system through greater focus on value over volume, and encourage participation in alternative payment models.” The AMA submitted recommendations to the committees on Nov.11, to build upon and strengthen the draft proposal to best achieve the shared goal of developing a new, more stable Medicare payment and delivery system that supports high-quality care. The AMA will continue its advocacy efforts with the committees and all members of Congress to shape and advance legislation this year to eliminate the SGR.
AMA, state and specialty societies urge CMS to intervene in Medicare Advantage terminations
The AMA and 81 state and specialty societies sent a letter on Nov. 8, urging CMS to take immediate action to ensure that beneficiaries participating in Medicare Advantage (MA) plans have accurate and reliable information to make health insurance elections during the 2014 Open Enrollment period, and to address a lack of MA sponsor transparency on network adequacy. The AMA, state medical associations, and national medical specialty societies have been contacted by hundreds of physicians who have been terminated from 2014 MA plan networks in certain markets. The terminations are “without cause” and have been timed in a manner that undermines the accuracy and reliability of the information Medicare beneficiaries rely upon to make important decisions about their 2014 health insurance coverage. The timing and process used to communicate the terminations and modifications to the networks are inconsistent with CMS guidance and regulations. The AMA, state and specialty societies urged CMS to act to ensure that the program is transparent and equitable.
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Wednesday, November 13th, 2013
Question - A few doctors have been calling asking if they are going to be required to accept any of the new insurances that are coming out as a result of the Affordable Care Act (ACA) - it seems that some patients are asking them.
Answer – To address this concern, please refer to the document Certified Plans by County and Boroughs. Physicians should look at the plans that will be serving patients in their area or region. Next, the physician should review the document called Health Plan Provider Network. Once the physician has located the plan(s) serving the area patients, the physician should click on the URL for the physician directory of the plan to see if he/she is listed as a network.
If the physician is listed as a network physician, then yes, the physician would be expected to accept the patient and the plan’s benefits. If the physician is not listed on the plan’s directory, the physician would want to know if the plan allows for Out-of –Network (OON) benefits. If the plan allows OON benefits, it would then be a business decision between the doctor and patient as to whether or not to proceed with care and treatment or to refer the patient back to the plan for an in-network physician.
Note, we have heard from NYS DOH Exchange/marketplace that people who purchase insurance through the exchange should have `HX’ on their identification cards.
Question – why would a physician be listed as a network provider if they never signed up, especially for some of the newer insurance products
Answer – it is possible that the insurer sent a letter to the physician(s) to give them an opportunity to opt in to participate in the exchange. Or, more likely, the insurer sent a letter to the doctor and saying because they were participants in the commercial product they would automatically be a participant in the exchange product, and if the doctor did not want to participate, the doctor had to opt out within X number of days. Of course, if the doctor did not read the letter, the doctor would be deemed to agree to participate by failing to opt out.
Or, the insurer just automatically enrolled the physician in the exchange product. If it did, this might not be illegal if the underlying participation agreement includes some type of an “all products clause” that states if a physician is a participant and the health plan develops a new product, the health plan may require the physician to participate in the new product.
We do not know which plans used an opt-in method and/or which plans used an opt-out method. Or, which plans merely required physicians to participate through an all-products type of requirement. Therefore, physicians need to review the exchange network directories.
Question – if a doctor sees that he is listed in a particular plan can he now opt out or is he locked in and if so, for how long?
Answer - the physician has to look to the terms of the contract.
Question - if the doctor is locked in, what happens if he refuses to see new patients?
Answer - If there is an existing contract, that contract could be put at risk/jeopardy.
Question – what about a fee schedule- how does the doctor bill and know how much he will be paid?
Answer - As far as the fee schedule is concerned, he/she will need to contact the plan to see what the exchange fee schedule will be if it is not the same as the existing fee schedule.
The following plans have products with out of network benefits in the following counties:
HealthNow d/b/a Blue Cross Blue Shield of Western NY in Erie and Niagara counties
Independent Health in all counties they provide coverage
CDPHP in all counties they provide coverage
Excellus in all counties they provide coverage
Excellus d/b/a Univera in all counties they provide coverage
HealthNow dba Blue Shield of Northeastern New York in all counties they provide coverage
Independent Health in all counties they provide coverage
United d/b/a Oxford in all counties they provide coverage
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Tuesday, November 5th, 2013
With regard to managed health care plan terminations, non-renewals, or network reductions, physicians should file an appeal. This action should be taken even if the plan indicates that no appeal is needed or available. In doing so the physician should obtain letters of support from patients impacted from any and all different product lines.
Separately, while the appeal is underway, the physician should advise the patients to shop and if possible seek enrollment with any other managed care plan the physician might still have a contract with.
Specific to the Medicare population, the physician should advise these patients of Medicare’s open enrollment period that closes on . During the Medicare Open Enrollment Period, ALL people with Medicare can change their Medicare health plan and prescription drug coverage for 2014. Information on 2014 plans will be available beginning in October. People with Medicare can call 1-800-MEDICARE or visit www.medicare.gov for plan information. These patients also have the ability to change their Medicare coverage back to the traditional fee-for-service Medicare plan, if they so choose.
For Your Patients: Medicare Advantage Defaults to Traditional Medicare
Please be mindful of two things –
1) Medicare patients are not eligible to purchase insurance through the NYS of Health Exchange.
2) If these disadvantaged Medicare patients do not select another Medicare Advantage plan during the open enrollment period (October through
), their coverage will default to traditional FFS Medicare. However, if they don’t purchase a Medigap/Supplemental to Medicare plan and don’t have retiree coverage through a former employer and don’t purchase a Medicare Part D product for their prescription drugs, this population will have a great deal more out of pocket expenses to deal with in 2014.
For information regarding Health Insurance Information, Counseling and Assistance, your patients can go the following NYS Medicare website: http://www.aging.ny.gov/healthbenefits
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Wednesday, October 30th, 2013
Medicare Advantage Outreach and Education Bulletin
Empire BlueCross BlueShield
We want you to know about changes to our individual Medicare Advantage HMO and LPPO plan service areas. These changes will take effect Jan. 1, 2014. Some plan service areas will be eliminated or reduced.
These service area changes do not impact your participation in the Medicare Advantage network.* Employer or union sponsored Medicare Advantage plan members are not affected by these changes. Empire Medicare Advantage member ID cards contain a CMS identifier in the lower right corner of the card. The number will be five characters (XXXXX) followed by three characters (XXX). The member is in an employer or union sponsored plan when the last three digits Start with an eight (8XX).
Empire will continue to offer Medicare Advantage HMO plans in Albany, Bronx, Kings, Nassau, New York, Putnam, Queens, Richmond, Rockland, Saratoga, Schenectady, Suffolk and Westchester counties. Empire will continue to offer Medicare Advantage LPPO plans in Albany, Bronx, Fulton, Kings, Nassau, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie and Suffolk counties. Specific plan changes by county are detailed below.
We will no longer offer Empire MediBlue Select HMO plans in Dutchess, Nassau, Orange, Sullivan and Ulster counties. We will reduce the service area of Empire MediBlue Essential HMO plans in Albany, Dutchess, New York, Orange, Putnam, Schenectady and Sullivan counties.
We will reduce the service area of Empire MediBlue Freedom I LPPO plans in Columbia, Delaware, Greene, Montgomery, Warren and Washington counties. We will reduce the service area of Empire MediBlue Freedom II LPPO plans in Clinton, Columbia, Essex, Fulton, Montgomery, Rensselaer, Suffolk, Sullivan, Ulster, Warren and Washington counties. We will reduce the service area of Empire MediBlue Freedom III LPPO plans in Albany, Greene, King, Rensselaer, Saratoga, Schenectady, Schoharie, Warren and Washington counties.
As of Oct. 1, 2013, Empire will not market Medicare Supplement plans. Members that currently participate in one of Empire’s Medicare Supplemental plans will be able to retain their coverage.
Prior to Oct. 2, 2013, Medicare Advantage members affected by these changes will receive a letter from us that explains their Medicare coverage options. Members will continue to have coverage through their current plans until December 31, 2013. It’s important to note that members may have a different network of providers and/or different benefit structure when switching from previous plans.
We are working with Centers for Medicare & Medicaid Services (CMS) to help ensure our members understand options for continuing their Medicare health insurance coverage.
We understand our members may contact their doctors’ offices with questions about their plan when they receive this notification. Our customer service representatives are available to assist them with their concerns. Members may call the customer service telephone number in the
letter they receive from us or they may contact our customer service through the number provided on the back of their member ID cards.
We are always evaluating our Medicare Advantage products to ensure that they meet our members’ needs for access, cost and quality.
If you have any questions, please contact your provider network manager.
* Providers who may receive termination notices for reasons other than service area reductions/eliminations are not impacted by this Notice.
Services provided by Empire HealthChoice HMO, Inc. and/or Empire HealthChoice Assurance, Inc., licensees of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield plans. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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Wednesday, October 23rd, 2013
Over the last several weeks, MSSNY has been urging physicians to share with us concerns they may see regarding the health plans being offered in New York’s Health Insurance Exchange, which began enrolling New Yorkers on October 1 through its website . In response, MSSNY has received comments from some physicians regarding possibly unfair provisions contained in contracts offered to them to participate in some insurers’ Exchange products. MSSNY staff has been in near-daily contact with various New York State agency officials to share these concerns, and ask that they be addressed. Earlier this week we sent out a survey to physicians with the goal to better quantify the extent of the concerns that have been identified by physicians. If you have not already done so, we urge you please complete the survey here.
As a reminder, physicians are also encouraged to go to mssny.org to view a presentation given by Donna Frescatore to physicians in August regarding implementation of the Exchange and what physicians need to know. Implementation of the Exchange will also be the focus of MSSNY’s MSSNY Advocacy Matters program. Exchange Staff will make a presentation and answer your questions.
MSSNY will continue to closely monitor implementation to assure that employers and consumers are getting what they pay for, and physicians are treated fairly by insurers providing coverage in the Exchange.
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Friday, October 11th, 2013
Access to Jurisdiction K Local Coverage Determinations during the Federal Government Shutdown
The Centers for Medicare & Medicaid Services (CMS) Coverage Database will not be updated on its usual weekly basis during the federal government shutdown. In the event that the shutdown continues through the Jurisdiction (JK) transition dates of October 18 and October 25, 2013, the JK local coverage determinations (LCDs) will be effective on the transition dates even if they are not viewable as “Active” LCDs for their respective effective dates. These LCDs are currently listed on the “Future” LCD index for the JK states and will continue to be available from that index.
For access to the JK LCDs, use this link: JK LCDs. This will take you to the Index for Maine Part A. The LCDs listed here are the same for all JK states, Part A and Part B.
For access to the JK home health and hospice (HH&H) specific LCDs, use this link: HHH LCDs Effective October 18, 2013.
These links can also be found on the Jurisdiction K Transition Information Web site at http://www.ngsmedicare.com/wps/portal/ngsmedicare/jktransition.
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Tuesday, October 1st, 2013
As of late afternoon on Monday, September 30, it appears increasingly likely that Congress will miss the deadline for passing a Continuing Resolution (CR) in time to fund federal agencies and programs in the new fiscal year, which begins on October 1. Deliberations continue, and it is anticipated that at least a short-term CR will be enacted in the next few days. In the meantime, however, many government programs will be forced to stop operating after midnight tonight if Congress fails to reach agreement.
Attached is a memorandum released last week by the Department of Health and Human Services that outlines the department’s contingency staffing and operating plans in the event that the government is forced to shut down.
Activities authorized by law, including those that do not rely on annual appropriations, and those that involve the safety of human life and protection of property will largely be unaffected. Following are some of the specific HHS activities that will continue in the event of a federal government shut-down:
Among the activities that will not continue:
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Friday, September 27th, 2013
The White House announced Washington Post (9/26, Harrison) reports that the Obama Administration is delaying “yet another piece of the health care overhaul,” this time “pushing back online enrollment for small business owners on the new federal health insurance exchange.” With this latest delay, “small business owners will not be able to purchase coverage online until ” on the SHOP exchanges. Instead, “for the first month, they will have to mail or fax their information to government officials to enroll.”that it was pushing a piece of the Affordable Care Act’s SHOP exchanges, news that was carried by many major papers and websites, which portrayed it as the latest in a series of delays for the beleaguered law. The
The New York Times (9/27, Shear, Subscription Publication) reports coverage for employees enrolling through their business by will still begin . Officials said the small business start date was “less important” than the individual market because businesses remain eligible to enroll all year. Republicans complained the Administration accepted delays for businesses while refusing Republican demands to delay the requirement that individuals get insurance.
The Wall Street Journal (9/27, Radnofsky, Subscription Publication) also reports skepticism that individual online marketplaces will be ready on time, although the Administration stated it expected to meet its deadlines. Miscalculation problems with the exchange-supporting software has also continued into this week, and the software that determines eligibility for enrolling customers was making inaccurate decisions. The individual plans are expected to cover seven million people, five million more than the small business plans. According to Peters, “We have made significant progress in recent days and weeks and are now completing our final end-to-end testing, which is designed specifically to identify remaining issues before open enrollment and correct them.”
Bloomberg News (9/26, Dorning, Wayne) reports the Administration has cautioned that glitches are “expected” in such a “complex system of websites and call centers.”
Reuters (9/26, Morgan) reports Hispanics remain approximately 33% of 47 million uninsured Americans, but Hispanic community representatives have expressed concern that the Spanish-language program will be unavailable until , or possibly as late as the 28. Spanish speakers can enroll through a call center or enrollment navigators until then. These glitches are occurring within a substantially-sized new information technology (IT) infrastructure needed to process applications and determine subsidies, but HHS Secretary Kathleen Sebelius stated in an interview with MSNBC, “As promised, people will be able to see what’s in the marketplace, how to look at coverage, ask questions about whether or not this is good for their employees, find out about the tax credit then beginning , do the online enrollment.”
CNN (9/26, Pagliery) reports business owners exploring the Small Business Health Options Program (SHOP) can still look at health plan overviews, but not details like accurate premium costs. Some individuals and organizations question the delay’s significance, believing few businesses intend to use the SHOP exchanges and are more likely to utilize brokers instead. USA Today(9/27, Jackson) also covers the story.
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