Healthcare Law Blog

How Kentucky Got Lucky: The Success of kynect.gov

It is no secret that the federal HealthCare.gov has received less than rave reviews since its October 1^st roll-out. The states who have relied on the federal government to run their marketplaces have encountered numerous problems, from glitches to process delays to complete inaccessibility. Kentucky (the only southern state which opted to run its own health insurance marketplace and expand Medicaid), however, has shone like a beacon in the turbulent exchange introduction period. It is quite surprising that Kentucky, consistently near the bottom in health rankings and with approximately 625,000 uninsured citizens, would be the model for anything health care-related. Here is how Kentucky is leading the nation with its exchange site: More >

An Unlikely Consequence, cont.

On Tuesday, I discussed the recent trend of hospital layoffs of staff, administrative and professional alike, in order to reduce costs despite expectations of an unprecedented number of individuals seeking health care services under the ACA. More >

One Week In – Are Kentuckians Kynect-ing?

Everyone, especially those in the health care industry, waited with bated breath to see the nationwide launch of the online health insurance marketplaces on October 1st. The launch was plagued with website malfunctions and connectivity problems in some states, including Kentucky, but programs across the country welcomed people clamoring for a look at America’s new health care options. Proponents of the exchanges say that the glitches and initial setbacks are a good sign – the overwhelming traffic to the websites show that people are actively seeking health care. Health reform opponents see the initial problems as a sign that the exchanges, and health reform generally, are too cumbersome and complicated to implement effectively. 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.

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 >

Hot Topics in Healthcare

On June 26, 2013, McBrayer attorney Lisa English Hinkle presented "Hot Topics in Healthcare" at the Fayette County Bar Association's  Bench & Bar Conference. If you were unable to attend, but would like to know what's hot in the healthcare industry, you can access a PDF copy of the seminar presentation here.  More >

Tools for the Trade: Understanding HIPAA

As a result of the intricate details and requirements of the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), it comes as no surprise that HIPAA Privacy and Security Rules can cause challenges and confusion for even the most sophisticated providers. With this in mind, the U.S. Department of Health and Human Services (“HHS”) Office for Civil Rights (“OCR”) has recently provided tools meant to educate both consumers and providers on HIPAA. More >

Association Group Coverage Changes

Trade Associations in Kentucky are being asked to show that they meet ERISA “bona fide association” requirements in order to continue to provide group health insurance for their members under health reform requirements effective in 2014.  Such group health insurance may be a more affordable option for some businesses as new health reform requirements begin to take effect. More >