Healthcare Law Blog

Does the Shutdown “Shut Down” Health Care?

The ongoing partial federal government shutdown that began on October 1, 2013, was initiated in an effort to defund the Affordable Care Act (“ACA”). Now, it seems that the shutdown is affecting everything but the ACA. More >

UPS Denies Insurance Coverage of Spouses and Cites ACA as Reason

The United Parcel Service (“UPS”) recently made a big statement when they decided to drop 15,000 working spouses eligible for health coverage through their own employers from the UPS plan in 2014. The shipping conglomerate explained the change in a memo to its workers and repeatedly cited the Affordable Care Act (“ACA”) as the reason for the new policy. Rising medical costs “combined with the costs associated with the Affordable Care Act, have made it increasingly difficult to continue providing the same level of health care benefits to our employees at an affordable cost,” the memo stated. The new policy will not affect union workers, as their health benefits are already spelled out in labor contracts, but will apply to about a quarter of the UPS U.S. workforce. More >

The ACA Loophole Of Which Providers Should Be Aware, Part II

Earlier this week, we discussed the three-month grace period afforded to enrollees of qualified health plans (“QHPs”). To recap that article, the ACA requires that QHPs pay claims for the first thirty days of the grace period during which premium payment remains unpaid, but issuers may pend claims for the final sixty days of the grace period. If the balance remains unpaid, the issuer may deny any claims submitted within the final sixty days. More >

The ACA Loophole Of Which Providers Should Be Aware

Providers contracting with state health insurance exchanges may find themselves shortchanged for services provided due to a little-known loophole in the Affordable Care Act (“ACA”).

Under the ACA, an individual who fails to pay his or her insurance premiums has a three-month grace period before the policy is cancelled. Insurers, however, are only responsible for paying claims during the first month of that grace period. The ACA will allow exchange plan, also known as “qualified health plan” (“QHP”), issuers to pend claims submitted by providers during the last two months of a federally subsidized patient’s three-month grace period for premium payment delinquency. If the patient is terminated at the end of the three months, the QHP is free to deny all claims submitted for that patient within the final two months.

Here’s what providers can expect during the three-month grace period:

First month of delinquency:

• Claims are paid normally. The QHP treats this month as paid even if the enrollee is eventually terminated for non-payment.
• Providers are not notified of the patient’s delinquency.

Second and third months of delinquency:

• The QHP has the option to pend claims for services performed until the enrollee pays his or her outstanding premium balance.
• Providers submitting claims during these two months are notified of the potential that claims submitted for services performed for the enrollee may be denied.
• If the enrollee pays off the premium balance, providers’ claims are paid at that time.

Terminated after three months of delinquency:

• The QHP has the option to deny all claims for services performed in the second and third months of delinquency.

Note that the timing of an enrollee’s grace period is based upon the date when a service was rendered, not the date of claim submission. In fact, a patient may enroll in a different QHP during the next open enrollment period regardless of whether they have paid off an outstanding premium balance with their previous insurer.

Providers have the option to seek payment from the patient for denied claims, but a patient who is unable to pay their insurance premium is also unlikely able to pay a provider’s bill. Further, the legal action necessary to recover payment is a costly endeavor for any provider. Check back on Thursday for more information on this topic.

Services may be performed by others.

This article does not constitute legal advice.

New IRS Guidance for Charitable Hospitals

The Patient Protection and Affordable Care Act added section 501(r) to the Internal Revenue Code, which imposes new requirements on 501(c)(3) organizations (nonprofit hospitals) that operate one or more hospital facilities. Under section 501(r), each hospital facility operated by a 501(c)(3) organization must meet four general requirements on a facility-by-facility basis in order for the nonprofit hospital to maintain its tax exempt status: More >

Beyond Making the Rounds: Hospitalists & Quality of Care under the ACA, cont.

On Tuesday, I discussed how hospitalists play a vital role in meeting the ACA's  quality of care standards for the inpatient setting. Now, let's take a look at how PCPs must also work to meet these same standards. More >

Beyond Making the Rounds: Hospitalists & Quality of Care under the ACA

By now, everyone knows the Affordable Care Act’s (“ACA”) motto is “increase quality, decrease costs.” As providers transition from the fee for service payment model to new payment systems that are tied to quality, one subset of providers will play a pivotal role in bringing health care into a new era: hospitalists. More >

Proposed Payment Changes for Medicare Home Health Agencies

The Centers for Medicare and Medicaid (“CMS”) recently released a proposed rule involving 2014 payment changes for the Home Health Prospective Payment System. The rule projects that the changes could reduce Medicare payments to home health agencies by 1.5 percent. CMS estimates that 3.5 million beneficiaries currently receive home health services, costing Medicare approximately $18.2 billion in 2012, so a 1.5 percent reduction would be significant ($290 million, to be exact). More >

Squeezing Blood from a Turnip: Health Care Reform & Kentucky’s Physician Shortage

Deloitte Consulting, a technology firm helping to establish the new Kentucky Health Benefit Exchange mandated by the Affordable Care Act (“ACA”), recently completed a review that paints quite a grim outlook for the future state of health care in the Commonwealth. According to the review, Kentucky needs 3,790 additional physicians (including primary care doctors and specialists), 612 more dentists, 5,635 more registered nurses, 296 more physician assistants, and 269 more optometrists to meet current demand. The numbers are stunning on their own, but in light of health care reform and Medicaid expansion, they are downright staggering. More >

Employer Mandate Enforcement Delayed Until 2015

On Tuesday, the Obama Administration announced that enforcement of the employer mandate provision of the Affordable Care Act (“ACA”) would be delayed until 2015, a year from its intended January 2014 start. The mandate requires that businesses with 50 or more full-time equivalent employees provide affordable health insurance for those employees or pay penalties. The administration has been under substantial pressure to delay the mandate, in large part because employers are still struggling with understanding and implementing the provisions. Some small businesses had even considered reducing their workforces below the 50-employee threshold or cutting employee hours to escape penalties for not providing coverage. More >