Insurers and states will soon have flexibility to offer more affordable health plans — but there are significant implications for patient access.

“Lower premiums typically lead to reduced benefits, more non-covered services, and more restricted site-of-service limitations,” says Sandra J. Wolfskill, FHFMA, director of healthcare finance policy at the Healthcare Finance Management Association.

The HHS Notice of Benefit and Payment Parameters for 2019, recently issued by the Centers for Medicare & Medicaid Services (CMS):

  • returns important oversight authority to states regarding review of network adequacy;
  • eliminates the meaningful difference requirement for Qualified Health Plans, giving insurers more flexibility in designing plans;
  • provides states with more flexibility as to what benefits are included in plans.

“Under the final rule, insurers will be able to offer plans that are not subject to the ACA mandates requiring them to provide coverage for certain services,” notes Jolene Calla, Esq., vice president, healthcare finance and insurance for The Hospital and Healthsystem Association of Pennsylvania. For example, insurers won’t have to cover preventive care. Insurers can exclude coverage for pre-existing conditions, and charge more to cover older people or those with chronic and complex conditions such as cancer, heart disease, and diabetes.

Under the ACA, 10 essential health benefits are required. These include prescription drugs as well as maternity and newborn care. Now, states will be given more options as to what they can offer as essential health benefits.

“While these plans are likely to have lower monthly premiums, cutting consumer benefits under the language of affordability is not a sustainable model,” says Calla. This is because plans with limited coverage and high deductibles will attract younger and healthier populations. “The limited and catastrophic-coverage plans only work as long as consumers remain healthy,” Calla continues. However, these consumers may be one healthcare crisis away from financial hardship.

“Older and sicker populations will be left at the mercy of the marketplace, further driving up those costs,” Calla says. “This model could drive up the cost of care in the long term, and contribute to increases in hospital uncompensated care.” The ACA has priced many consumers out of the insurance market, according to CMS. However, cheaper plans likely mean higher out-of-pocket costs for patients — and possible lost revenue for hospitals.

“While the premiums for these plans often seem affordable, the benefits that they offer are usually less comprehensive than other plans,” says Mary Mullaney, director of hospital payment policies for the Association of American Medical Colleges in Washington, DC.

Patients often don’t realize the limits of the coverage until they actually use it. Consumer cost-sharing under the newer, more affordable plans likely will increase.

“That can contribute to patients’ reluctance to access services in lower-cost settings,” Mullaney cautions. “This may result in an increased use of emergency departments, which results in higher costs.”

Wolfskill says it’s “imperative” for patient access departments to take these steps:

1. Monitor the new plans offered through the healthcare exchange in your service area.

“Educate patient access staff to watch for new plans and payers that are not in the current insurance master,” Wolfskill offers. “When adding them, create a mechanism to track volumes, payment patterns, and self-pay balances after insurance.”

2. Ensure that when staff are verifying eligibility and effective date of coverage that they also verify benefits and limitations.

Sometimes patient access confirms that the insurance is valid, and everything seems fine — until the claim is denied because of coverage limitations. Another possibility is that the provider is out of network for the patient, which means higher deductibles, copays, or coinsurance issues. “Yes, the patient may be eligible, but benefits are a separate issue,” Wolfskill notes.

3. Create fresh plan codes for the new, affordable health plans.

This gives revenue cycle leaders a way to track overall plan performance, including shifting of any dollars into self-pay.

“It makes it easier to track patient out-of-pockets for these plans vs. the traditional HMO and PPO plans from other commercial carriers,” Wolfskill explains.

Revenue cycle leaders might discover that the new plans are less profitable due to increased bad debt or claims denials. If they do, says Wolfskill, “in future years, the provider has a solid history with which to negotiate rates with the payer.”

Earlier financial discussions with patients is “good for both the bottomline and the patient experience,” says Christopher Lah, senior director of patient access at Cincinnati (OH) Children’s Hospital Medical Center.

This is even more important if the new affordable plans result in higher out-of-pocket costs for patients.

“Most revenue cycle leaders will agree that working with the patient on the cost of care, prior to or at the time of service, goes a long way toward eliminating ‘sticker shock’ at the time of patient billing,” Lah says.

Price transparency is a hot topic with patients and hospitals alike, but good processes are needed. “There needs to be a coordinated effort with other service teams in the revenue cycle,” Lah offers.

Just handing patients a price estimate isn’t nearly enough. Most patients ask more questions, sometimes complicated ones, about what they owe and why.

“It only answers the question ‘How much?’ and leaves the customer hanging if they need more help,” Lah says.

Patient access employees often notice that patients are struggling financially when they’re provided with price estimates. That’s the perfect time to connect them with financial counselors. “It’s a powerful, but simple tool to add to your scripting — that they may qualify for assistance or some other option,” Lah says. He also recommends eliminating scripting that ends with employees stating something such as “you owe” or “you could owe” a certain amount. At that point, it’s a great time to talk about some possible alternatives, such as financial aid or charity care screening.

“Giving your patients the options upfront can help eliminate the risk of the experience becoming a situation stressor instead of a service enhancer,” Lah adds.

Transparency about costs is the future of healthcare, and patient access is front and center of this dramatic change. It’s all about education.

“Patients are exploring innovative ways to manage their personal costs within their healthcare benefits in a rapidly changing environment,” says Myndall V. Coffman, MBA, system director for patient access and scheduling at Baptist Health in Louisville, KY.

Patients need help understanding the costs associated with their newly purchased high-deductible health plans. “You would never go to the market and place things in the basket without understanding the cost, and healthcare is no different,” Coffman says.

That’s where patient access employees can step in to offer some explanations on insurance benefits and estimated costs.

“Price transparency and good patient communication are very important at Baptist Health,” Coffman says. Accurate cost estimates are just one part of that. Good resources must be available anytime a patient would like to discuss potential or outstanding balances.

“We want patients to understand their insurance coverage and their individual responsibility as well,” Coffman adds.

Some patients don’t understand what out of network means. They’ll need information to make good decisions. “Sometimes, this means working on an agreement with their insurance carrier to continue to provide care for the patient,” Coffman offers. Sometimes, patients may decide to instead schedule their service at an in-network facility.

“While some patients fully understand their coverage and coverage limitations, many do not,” Coffman explains. Most patients assume they can see any provider they want without worrying about costs. Coffman often hears patients saying things such as, “But I have insurance to cover it.”

If hospitals don’t engage in early financial discussions, patients won’t understand the costs of their care until after they receive it. “This can mean huge surprises after service,” Coffman warns. “It often causes anger and distrust toward the organization providing the service, as well as healthcare organizations in general.”

When accurate cost estimates are given early in the process, patients have the information they need on the front end to make good decisions. “They understand the possible difference in cost and the quality of the services being offered,” Coffman says.

Price estimates don’t tell the whole story. “Just because there may be a cheaper option available does not always mean the quality is the same,” Coffman notes. For instance, poor image quality on a diagnostic scan sometimes can result in repeating the scan for an additional cost.

This kind of information avoids surprise bills on the back end. “It ensures that the provider can initiate financial assistance options if appropriate or offer options for payment arrangements for the patient,” Coffman explains. If patients cannot pay, there are options available to ensure they can get the care needed for emergent procedures.

The department relies on insurance verification workflows, accurate price estimates, extensive staff education, and strong staff scripting to be as transparent as possible. “Patients and their families deserve these honest conversations prior to service,” Coffman says.