Health Insurance Exchange Plans & Patient Balances

At Healthcare Data Management, we are in the process of actively learning as much as we can about the new health exchange insurance products in Maryland, and the impact that they may have on local physician practices. As information becomes available, we will  continue to provide you with pertinent information and updates. For today, we wanted to draw your attention to the importance of checking eligibility and benefits for all patients – especially for those patients with new insurance policies. In Maryland, there are four insurance carriers participating in the ACA-mandated health exchange marketplace: Kaiser, Carefirst, UHC, and Evergreen (a new co-opt insurance company in Maryland). There are approximately 45 plans that are offered through the marketplace, and they are categorized by Metals: Bronze, Silver, Gold, Platinum. The new insurance cards that are issued for these plans should specifically state the “Metal” on the insurance card. The plans exist on a spectrum, from very low premiums and high deductibles, to very high premiums and no deductible. What your front desk should be especially aware of is that patients with plans that are categorized as Bronze (and Silver), will have high patient responsibility when the claims process. Especially with the Bronze plans, there are significantly higher deductibles, co-insurance percentages, and overall cost-share for the patient (in exchange for a lower monthly premium). In addition to the collection of co-pays at the time of service, it is also permissible to collect co-insurances and deductibles at the time of service (unless you have an insurance contract that specifically forbids this – so double check those contracts!). By being proactive in collecting portions of patient’s high deductibles and or co-insurance at the time of service, you may avoid lost revenue from patients that do not pay their bills after-the-fact.

Below is a very basic summary of the various metals, and the catastrophic plans that are offered through the exchange. Attached, please find a sample insurance card; an overview of Carefirst BCBS health exchange plans; and an overview of Kaiser’s health exchange plans. (We are still waiting to receive more detailed information from UHC and Evergreen). For more information, check out the state’s website outlining the various plans:

  • BRONZE Plans: Low premiums, higher deductibles/co-insurance/cost-sharing for patient when claims process.
  • SILVER Plans: Slightly higher premium, modest deductible.
  • GOLD Plans: Higher premium, lower deductibles.
  • PLATINUM Plans: Highest premium, no deductible.
  • CATASTROPHIC: (ie: BlueChoice Young Adult Catastrophic Coverage)= very low premiums, burden of payment rests with patient. $6,350 out-of-pocket limit.