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Health Care Reform for Providers
Health Care Reform for Providers
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President Obama signed the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010, which set into motion changes that will impact the health care community for years to come. While it may seem as though the main focus of health care reform is directed toward consumers, the new law will also have an impact on health care providers.

Excellus BlueCross BlueShield is committed to keeping you informed as regulations are announced and business decisions are made. This section of the web site will serve as the repository for the latest PPACA provider updates and notifications, so be sure to visit frequently.

Click below for the latest PPACA updates and notifications:

Frequently Asked Questions (PDF)

Navigating Health Care Reform Guidebook (PDF)

Womens Health Preventive Services Notice (PDF)

Modifier 33 and Modifier PT Notice (PDF)

Initial Grace Period Notice (PDF)

Preventive Services Coverage Grid (PDF)

Impacts to Physicians & Hospitals

Excellus BlueCross BlueShield is dedicated to working with you to improve the health and well-being of patients. Together, we have the opportunity to shape our health care system and ensure high-quality care today and for future generations.

Third-Party Premium Payments

At our health plan, premium payments for members who purchase coverage through the NY State of Health marketplace are collected directly from the member. While we understand that hardships may arise, the federal government discourages health plans from accepting premium payments from health care providers and other third-party payers.

We will not accept payment of premium from health care providers and other third-party payers, EXCEPT for payments made on behalf of members by the following programs/organizations:

  • The Ryan White HIV/AIDS Program
  • Indian tribes, tribal organizations and urban Indian organizations 
  • State and federal government programs

Three-Month Grace Period

Under the Affordable Care Act, if an individual who obtains subsidized coverage through the Exchange fails to pay his or her premium (after having paid at least one month’s premium during the year), he or she has a three-month grace period before the policy can be cancelled. In accordance with this regulation, health plans must pay claims during the first month of the grace period only. During the subsequent two months, individuals will continue to receive premium bills and will be asked to pay any applicable cost sharing if they seek health care services. However, if individuals do not pay the premium in full for the remaining two months, claims with dates of service during this time will pend and may not be reimbursed.

Individuals who fall into the premium grace period may face a tax penalty for not having coverage, but they will not receive a fine, a premium rate increase or a repayment order (they would be required to pay for services rendered during the grace period if the provider seeks payment). While individuals who are terminated at the end of the three-month grace period for failure to pay their premium may not seek coverage on the Exchange for the remainder of the current plan year, these individuals will not be barred from purchasing another subsidized plan during the next open enrollment period.

What happens when an Excellus BCBS member enrolls in an Exchange product, receives a tax credit and just stops paying?

The chart below illustrates what Excellus BCBS is required to do to comply with the grace period rules and how these rules could affect your office or facility:

Excellus BCBS Must

Pay all claims for services rendered during the first month of nonpayment.

Notify Health and Human Services that the member has stopped paying.

When claims pend during months two and three, we must notify your office advising that claims are pending and may not be reimbursed.

Notify members:

  • When their payment is late.
  • If their coverage is terminated.

Give members 30 days advance notice of termination explaining the reason for termination.

Terminate the member retroactive to the end of the first month of the grace period after the third month of nonpayment.

Excellus BCBS Will

Suspend claims for services received during the second and third months of nonpayment*

If a provider calls to seek prior authorization, advise them of the member’s premium paid status if an individual is in the three-month grace period.

Allow providers to seek payment from the member if coverage is terminated for nonpayment.

New Health Plans and/or Increased Price Sensitivity May Bring New Risk to Reimbursement

With the passage of health care reform, physician payment continues to be a focal point. The majority of payment arrangements are based on fee-for-service or cost per services rendered. Payment models are evolving that will require increased risk for providers. Conversion from fee-for-service to other models, such as pay-for- performance, may reduce inappropriate or unneeded care.

Credit and Collection Challenges with High Cost-Share

With increased cost-sharing plans, patients are responsible for larger portions of their bill, and providers must collect funds directly from the patient.Providers can help ensure that money is collected in a timely manner by:

Possible Reimbursement Cuts Looming

The Medicaid expansion mandated by the Affordable Care Act is scheduled to take effect January 1, 2014. This mandate is projected to move an additional 16 million people to Medicaid. As a result, it is projected that states will still see a 2.8 percent increase in Medicaid cost due to the expanded enrollment.

Capacity to Meet Increased Demand

As the pool of insured people grows, more and more Americans will be looking for care, particularly from a primary care physician. Both physicians and hospitals are likely to experience an increase in patient load.

Currently, some areas in the nation face shortages of critical health care workers, including primary care physicians, nurses, behavioral health and long-term care workers, as well as public health and human service professionals. Moreover, this problem is anticipated to increase in the coming years. More than 64 million people currently live in a primary care health professional shortage area, and others live in smaller areas with health professional shortages. More than half of the counties in the U.S. have no behavioral health worker at all. With the implementation of health care reform and the resulting expansion of health insurance coverage, demand for services of primary care professionals will increase substantially.

These concerns come at a time when demand for services is increasing — particularly with an aging population with more frail seniors in need of care — and the health care system is grappling with quality of care concerns. Natural and manmade disasters can strain existing health care, public health and human service workforce capacity and require rapid identification and deployment of skilled professionals to affected areas. In addition, all health professions will need to be responsive to new challenges and realize the potential of new technologies. Innovative approaches, including improved preparation of primary care practitioners and the enhanced use of nurse practitioners and physician assistants, will be required to meet the increased demand. Moreover, new approaches using peer mentors, recovery coaches and care managers will be needed for persons with long-term care needs.

The HHS is addressing many of these workforce issues. Through implementation of the Affordable Care Act, HHS will fund scholarships and loan repayment programs to increase the number of primary care physicians, nurses, physician assistants, mental health providers and dentists in the areas of the country that need them most. With a comprehensive approach focusing on retention and enhanced educational opportunities, HHS is addressing the continuing need for a highly skilled, diverse nursing workforce. HHS is working with state, local and tribal governments to develop health workforce training, recruitment and retention strategies and to expand critical, timely access to care by funding the expansion, construction and operation of health centers throughout the U.S.

Providers, policymakers and consumers are likely to consider a broad range of strategies to address gaps in infrastructure and workforce: engaging students at younger ages, improving wages and benefits of direct care workers, tapping new worker pools, strengthening the skills that new workers bring at job entry and providing more useful continuing education and training. To learn more, visit

Care Delivery Models Are Evolving - Accountable Care Organizations

Health care reform provides incentives for physicians to join together to form &quotAccountable Care Organizations.&quot The goal is that through these groups, providers can better coordinate patient care and improve quality, help prevent disease and illness and reduce unnecessary hospital admissions.

If these organizations provide high-quality care and reduce costs to the health care system, they can keep some of the money that they have helped save. Additionally, a national pilot program will encourage hospitals, doctors and other providers to work together to improve coordination through payment &quotbundling.&quot

This means that hospitals, doctors and providers will be paid a flat rate for an episode of care rather than the current fragmented system where each service or test or bundle of items and services are billed separately to Medicare. It aligns the incentives of those delivering care, and savings are shared between providers and the Medicare program.

By January 2015, a new provision will tie physician payments to the quality of care they provide. Physicians will see their payments modified so that those who provide higher value will receive higher payments than those who provide lower quality care.

New Reporting Requirements for Physicians and Hospitals

Health care providers will have to adopt new methods of reporting, as the law establishes various new requirements, including quality measure reporting programs.

Need to Make Decisions as Employer Group Offering Coverage to Employees

Provider practices and hospitals are also employers, so just like other employer groups, decisions on coverage offerings will need to be made at your practice or facility.

Topic Definition
Accountable Care Organization (ACO)

These organizations coordinate patient care and provide the full range of health care services for patients. The health reform law provides incentives for providers who join together to form such organizations and who agree to be accountable for the quality, cost, and overall care of Medicare beneficiaries who are enrolled in the traditional fee-forservice program and are assigned to the ACO.

Actuarial Value

The amount that the health plan would pay for covered benefits as compared to the amount that the member would pay out of pocket for the benefits covered by the plan.

Catastrophic Coverage

A coverage option with a limited benefit plan design accompanied by a high deductible. The plan design is intended to protect primarily against the cost for unforeseen and expensive illnesses or injuries. These plans are attractive to young adults in relatively good health.

Consumer-Driven Health Plans

These health plans seek to increase consumer awareness about health care costs and provide incentives for consumers to consider costs when making health care decisions. These plans usually have a high deductible accompanied by a savings account for health care services. There are two types of savings accounts: Health Savings Accounts (HSAs) and Health Reimbursement Accounts (HRAs).


Health plan members are required to pay a portion of the costs of their care. Examples of these costs include copayments, coinsurance and annual deductibles.


The dollar amount that a plan member must pay for health care services each year before the insurer begins to reimburse for health care services. Beginning in 2014, deductibles for small group insurance plans will be limited to $2,000 for individual policies and $4,000 for family policies.

Employer Mandate

Beginning in 2014, pursuant to the health reform law, employers meeting size or revenue thresholds will be required to offer minimum essential health benefit packages or pay a set portion of the cost of those benefits for use in the Exchanges.

Essential Health Benefits

The health reform law places certain coverage requirements on essential health benefits, and provides a broad set of benefit categories that would be considered essential to a health benefits package – including hospitalization, outpatient services, emergency care, prescription drugs, maternity care, preventive services and other benefits.


The health care reform law creates Exchanges (competitive insurance marketplaces) in each state, where individuals and employers can shop for health plans.

Grandfathered Plan

A health plan that was in place on March 23, 2010, when the health reform law was enacted, is exempt from complying with some parts of the health reform law, so long as the plan does not make certain changes (such as eliminating or reducing benefits, increasing cost-sharing, or reducing the employer contribution toward the premium). Once a health plan makes sucha change, it becomes subject to other health reform provisions (e.g., appeals and cost sharing restrictions on preventive services).

Group Health Plan

Health insurance that is offered by a plan sponsor, typically an employer on behalf of its employees.

Health Insurance Portability and Accountability Act of 1996 (HIPAA)

This law sets standards for the security and privacy of personal health information. In addition, the law makes it easier for individuals to change jobs without the risk of extended waiting periods due to pre-existing conditions.

Health Reimbursement Account (HRA)

A tax-exempt account that can be used to pay for qualified health expenses. HRAs are usually paired with a high-deductible health plan and are funded solely by employer contributions.

Health Savings Account (HSA)

A tax-exempt savings account that can be used to pay for qualified medical expenses. Individuals can obtain HSAs from most financial institutions or through their employer. Both employers and employees can contribute to the plan. To open an HSA, an individual must have health coverage under an HSA-qualified high-deductible health plan that has deductibles of at least $1,200 for an individual and $2,400 for a family in 2010.

High-Deductible Health Plan

These health insurance plans have higher deductibles and lower premiums than traditional insurance plans.

Individual Mandate

A requirement that most individuals obtain health insurance or pay a penalty beginning in 2014.

Mandatory Benefits

A state or federal requirement that health plans provide coverage for certain benefits, treatment or services.

Medical Loss Ratio (MLR)

The minimum percentage of premium dollars a commercial insurance company must spend on the reimbursement of certain medical costs. The health reform law requires insurers in the large group market to have an MLR of 85 percent and insurers in the small group and individual markets to have an MLR of 80 percent (with some waivers granted to states to reduce the threshold for certain markets).

Out-of-Pocket Costs

Health care costs that are not covered by insurance, such as deductibles, copayments and coinsurance. Out-of-pocket costs do not include premium costs.

Out-of-Pocket Maximum

An annual limit on the amount of money individuals are required to pay out-of-pocket for health care costs, excluding premiums. The health reform law, beginning in 2014, prevents an employer from imposing cost sharing in amounts greater than the current out-of-pocket limits for high-deductible health plans ($5,950 for an individual policy or $11,900 for a family policy in 2010). These amounts will be adjusted annually.

Patient Protection and Affordable Care Act (PPACA)

Also referred to as the “health reform law,” this Act begins the implementation of a staged set of rules with an initial effective date of March 23, 2010. The law is intended to increase access to health care for more Americans, and includes many changes that impact the commercial health insurance market, Medicare and Medicaid.


A payment system where health care providers receive incentives for meeting or exceeding quality and cost benchmarks. Some systems also penalize providers who do not meet established benchmarks. The goal of pay-for-performance programs is to improve the quality of care over time.

Preexisting Condition

An illness or medical condition for which a person is diagnosed or treated within a specified period of time prior to becoming insured in a new plan. The health reform law prohibits the denial of coverage due to a preexisting condition for plan and policy years beginning after September 23, 2010, for children younger than 19, and for all others beginning in 2014.


The amount paid, often on a monthly basis, for health insurance. The cost of the premium may be shared between employers or government purchasers and individuals.

Premium Subsidies

A fixed amount of money or a designated percentage of the premium cost that is provided to help people purchase health insurance. The health reform law provides premium subsidies to individuals with incomes between 133 percent and 400 percent of the federal poverty level when they purchase policies through the exchanges beginning in 2014.

Preventive Care Services

Health care that emphasizes the early detection and treatment of disease. The health reform law requires certain health plans (excludes grandfathered plans) to provide coverage without member cost-sharing for certain preventive services.

Qualified Health Plan

Insurance plans that are sold through an exchange must have been certified as meeting a minimum benchmark of benefits (i.e., essential health benefits) under the health reform law.


Insurance purchased by insurance companies and employers that self-insure their employees’ medical costs, to limit liability or exposure to high claims or increased cost trends. The health reform law includes a temporary federal reinsurance program for employers that insure early retirees older than age 55 who are not eligible for Medicare.


Refers to a practice where an approved policy is voided from its inception by the insurer, usually on the grounds of material misrepresentation or omission on the initial application. Under health reform, rescissions are prohibited except in cases of fraud or intentional misrepresentation.

Section 125 Plan

These plans are otherwise known as a “cafeteria plan” offered pursuant to Section 125 of the Internal Revenue Code. Its name comes from a set of benefit plans that allows employees to choose between different types of benefits, similar to the ability of a customer to choose among available items in a cafeteria, and the employees’ pretax contributions are not subject to federal, state or Social Security taxes.

Self-Insured Plan

The employer assumes the financial responsibility of health care benefits for its employees in a self-insured or self-funded plan. Employer-sponsored self-insured plans typically contract with a third-party administrator to provide administrative services for the plan.

Small Business Health Options Program (SHOP)

SHOP is a competitive private health insurance marketplace where small businesses and their employees will have access to affordable coverage and the same insurance choices as members of Congress.

Small Business Tax Credit

The health reform law includes a tax credit equal to 50 percent (35 percent in the case of tax-exempt eligible small employers) for qualified small employers that provide health coverage to their employees. The tax credit is available to employers with 25 or fewer employees with average annual wages of less than $50,000.

Small Group Market

Businesses with typically two to 50 employees, or eligible employees depending on applicable state law, can purchase health insurance for their employees through this market, which is regulated by states.

Tax Credit

An amount that a person or business can subtract from the income tax that they owe. If a tax credit is refundable, the taxpayer can receive a payment from the government to the extent that the credit is greater than the amount of tax the payer would otherwise owe

The information provided here is not intended to advise you on how to comply with any provisions of the referenced legislation or related legislation or regulations, nor is it otherwise intended to impart any legal advice.