Open Enrollment is Open... Now What? PLANNING FOR THE NEW YEAR UNDER THE AFFORDABLE CARE ACT By Jennifer Searfoss, J.D., C.M.P.E. S tarting on January 1, 2014, the grand experiment of insuring more Americans begins in earnest. For the new year, 30 million Americans will receive standardized coverage through new health insurance exchanges (HIX) or state Medicaid program expansion. According to a PwC Health Research Institute analysis, these patients are going to be more racially diverse, more likely to be single, and less likely to speak English.1 These new patients will not only challenge our delivery system with a pent up demand for medical services, they will have different needs to effectively respond to their medical bills. Further, their lack of familiarity with health insurance and how network restrictions apply will require all parties involved in delivering care and facilitating payment to leverage educational opportunities to explain health insurance. Opportunity for Health Literacy in Health Cost Transparency the language and cultural diversity of this new patient population is certainly a new hurdle, yet according to the most recent study by the national assessment of adult literacy, only 12 percent of americans really understand their health status and medical bills.2 that means that a supermajority of patients find filling out paperwork a daunting task. Knowing this, it is easy to appreciate why forms have incorrect and incomplete information. What does that denote for you and your clients? it means that the information required to file claims may not be accurate. the Patient Protection and affordable care act (aca) includes a number of requirements to help the newly insured to better understand their insurance, but that does nothing for these beneficiaries once they become patients. a paper commissioned by the institutes of medicine found that medical organizations perform better when they clearly communicate with patients what health plans cover and the amounts individuals will have to pay out-of-pocket. essentially, they found that transparency is key for patients to understand their financial obligations. “no one is expected to order from a restaurant menu with no prices on it, but too often consumers are expected to make health care decisions without first knowing what it will cost them.”3 Best Practices for Transparency • financial obligation information should be provided prior to rendering care, especially for prescription drug regimens that may include long-term out-of-pocket costs. Patients can not truly consent to services if they do not know how much they will be responsible to pay. • this information should provide an estimate of costs showing what the health plan will cover and their expected out-ofpocket expenses. this means that, prior to patient intake, staff perform an eligibility transaction, validate coverage, and obtain information on out-of-pocket obligations such as deductible and copays by type of service. • in sharing information with patients, a form similar to an advance beneficiary notice can clarify what is covered and THE VITALS + 30 MILLION NEWLYAINSURED AMERICANS 32%will gain coverage from medicaid 45%from the individual exchanges 23%from their employers Source: Congressional Budget Office, “Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision,” July 2012. 10 hbma billing • november.december.2013
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