Physicians Brace: the Changing Insurance Landscape Under Georgia’s ACA Insurance Exchange

861958_hidoc-on-white.jpgIn Georgia, seven insurers have announced plans to participate in the Health Insurance Exchange that will exist by virtue of the Affordable Care Act (ACA). The ACA authorized creation of State health insurance “exchanges” (HIX) – an online market place in which consumers can shop for and buy health insurance. The following insurers have indicated they will participate in the Georgia HIX: Blue Cross and Blue Shield of Georgia, Kaiser Foundation Health Plan, Peach State, Alliant, Coventry, Aetna and Coventry. The insurance plans will debut as part of the Georgia HIX in 2014.

When the health insurance plans are available, small businesses, families and individuals will have a new way to get insurance. The ACA intends for consumers to be able to compare the benefits and costs of competing plans and use an online calculator to assist them in determining which plan is best for them. The ACA will expand health insurance coverage, increasing the number of insured patients. Presently, nearly two million non-elderly Georgia residents are uninsured. Purported benefits of the ACA that will affect Georgia patients and providers include: greater ease in obtaining coverage for individuals difficult to insure due to pre-existing conditions; continued cost-saving home- and community-care programs;greater resources for Medicaid, lowering costs of prescription drugs and raising reimbursement to some health care providers; enhanced preventive care coverage; and allowing young adults to stay on parents’ health plans
For physicians, however, more insured patients under the auspices of the ACA is not all good news. While much remains to be seen, some problems have been predicted. For example, some physicians may experience delayed payment under the ACA, under which individuals have a three-month grace period to individuals who have not paid their premiums. Health plans may hold off on processing claims who have not paid for two months. After three months, a health plan may deny claims and leave the doctor to seek payment from the patient. Under traditional insurance, the health plan would remain liable to pay the doctor even if the premium has not been paid. Patients are not accustomed to keeping up with and paying insurance premiums. Further, under the ACA the patient may be able to sign up for another plan in the HIX and begin seeing another doctor. Many of the newly insured patients will also be individuals who have not had insurance before (or for a considerable time) and may therefore involve more complicated health issues.

Physician reimbursement will be changed under the ACA. For example, the ACA’s reimbursement model is intended to be geared toward primary care with the Primary Care Incentive Program (PCIP). Under PCIP, for primary care services furnished on or after January 1, 2011 and before January 1, 2016, primary care doctors will be eligible for a ten percent incentive payment. The ACA also creates incentives and penalties tied to compliance with the Medicare Electronic Health Records Incentive Program and the Physician Quality Reporting System. Tying physician reimbursement to bench-marked measures of quality, cost, and patient satisfaction is in the works.

The full impact of the new health insurance options under the Georgia HIX upon physicians remain to be seen. More than likely, the changes on the way will result in a mixed bag of good and bad for doctors: some new opportunities and benefits and many new hazards and problems. The changes will begin in 2014.

Georgia Health Care Attorney

Our business law firm is committed to assisting health care providers in navigating the increasingly complex regulatory environment in which they are required to render care and conduct business. Kevin Little is a Georgia and South Carolina attorney, with 20 years of experience, who represents health care centers, ambulance services, laboratories, physician groups, elder care businesses and other health businesses and professionals. We have offices in Atlanta and Augusta, Georgia. Our law firm can be reached at (404) 685-1662 (Atlanta), (706) 722-7886 (Augusta), or

*Disclaimer: Thoughts shared here do not constitute legal advice.

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