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What to Tell Patients About Open Enrollment


With the healthcare exchange open enrollment period starting Nov. 1, educating your patients about the facts is vital. released some important dates that you need to be aware of over the next few months. Open enrollment for the health insurance exchanges begins Nov. 1, 2015. This means that any qualified person, whether they have health insurance or not, can enroll and get a new plan. Why is this important to you?

There are several types of plans available and insurance companies are bombarding patients with propaganda about how they are the best. You can't watch any T.V. show without some insurance company running a commercial. Magazines are filled with colorful ads showing happy people, insinuating it's because they are members of a certain insurance plan. We all know it's a bunch of hooey and insurance companies just want the increased enrollment.

But, patients may be shopping for a plan that is more cost effective, or that covers an area of care that their current plan does not. They could also be looking at the provider network. Are you a preferred provider with insurance exchange plans? Choosing a new physician is a painful process for patients, particularly if they have been with a provider for a while, or are undergoing continued treatment.

When patients approach you, your back-office staff, front-office staff, clinical staff, or billing department, there are a few things you can and cannot say regarding the purchase of a new health insurance plan.

What you can do:

1. Tell the patient why you are a preferred provider for their current plan. (i.e., the plan is easy to work with, the practice gets paid correctly on time, etc.)

2. If asked if you are a preferred provider for another plan, you can answer yes or no. You can also direct patients to the plans' websites so they can do their own research.

3. You can explain the patient's current benefits. If a patient has a $5,000 annual deductible and out-of-pocket costs are capped at $10,000 (before the plan will pay 100 percent of allowable charges), this is something to consider. In this instance, if the patient has a copay of 20 percent, it may take a while for that 20 percent to add up to the $10,000 maximum (after the initial deductible has been met).

4. Provide a list of questions for the patient to ask the insurance company prior to signing up:

• Are you part of the ACA healthcare exchange plans?

• Is my current physician an in-network physician? If not, why?

• What is the deductible and out-of-pocket amounts?

• When does the plan start paying?

What you cannot do:

1. Tell the patient which plan to buy. Again, you certainly can tell them to review the plan's website or call a representative to see if you are an in-network provider. However, those websites might not be correct.


We experienced this problem just this week with a patient who believed a physician was listed as a Blue Shield in-network provider (with an ACA plan), but who was not. This is Blue Shields' way of building up their network to make it look more extensive. Many practices experienced this problem last year, and had the hard job of telling patients that all of their claims processed out of network, and they would owe 50 percent of costs. I know many physician offices lost a tremendous amount of money due to this insurance error.

Keep in mind, that if a patient is currently with a plan that is a PPO, and they chose an HMO or HSA, then their benefits will change, and how you collect from the patient will change.

Educate your staff now to what all of this means, because, starting Jan.1, 2016, you do not want to be stuck footing the bill, once again. If you have a staff member who manages contracts, it would be a great time for him to send out a memo, or hold a short meeting explaining to your staff which health plans you do take.

Here are the important dates to know:

• Nov. 1, 2015: Open enrollment starts - first day you can enroll in a 2016 insurance plan through the Health Insurance Marketplace. Coverage can start as soon as Jan. 1, 2016.

• Dec. 15, 2015: Last day to enroll in or change plans for new coverage to start Jan. 1, 2016.

• Jan. 1, 2016: 2016 coverage starts for those who enroll or change plans by Dec.15, 2015.

• January 15, 2016: Last day to enroll in or change plans for new coverage to start February 1, 2016

• Jan. 31, 2016: 2016 open enrollment ends. Enrollments or changes between Jan. 16 and Jan. 31 take effect March 1, 2016.

Plans and prices will be made available here in the next few weeks for patients.

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