The Marketplace (Exchange) is a new way for consumers to shop for health coverage under the Affordable Care Act. As a provider, the Marketplace may have an impact on your patients and your practice. Therefore, it's important to understand how the Marketplace works, what options are available for your patients, and how it may impact the claims process for your practice.
Will the plans offered by different insurers be the same since they follow rules established by New York state?
Each insurer participating in the Marketplace must offer the state's standard plan at each metal level (platinum, gold, silver and bronze). The variations between insurers' standard plans will be limited to price, formularies, provider networks, and the availability of out-of-network coverage.
In addition, to the standard plans, insurers may offer up to three additional plans per metal level.
Yes. Each insurer will continue to have its own ID cards. We will include the metal level plan name on the ID card and use the following prefixes:
YJZ - Individual EPO
YJL - Individual POS
No. Most consumers cannot change their coverage unless there is a qualifying event (marriage, divorce, etc.)
Coverage options on the Marketplace include:
No. The plan types did not change, but there are new polivies that meet Affordable Care Act (ACA) requirements.
BlueCross BlueShield will pay commerical rates for the Marketplace products unless you have negotiated a unique fee schedule.
Yes. Please follow the same process for submitting claims.
The answer varies based on whether the member is receiving financial assistance (subsidy, tax credit).
It's business as usual for members who are not receiving financial assistance.
There is a new process for members receiving financial assistance.
- HEALTHeNET (wnyhealthenet.org) will be updated to alert you that a patient is in the grace period.
- Medical claims will be pended (based on regulations from the New York State Department of Financial Services).
- Pharmacy claims will deny (based on regulations from the New York State Department of Financial Services).