Health reform and your Kaiser Permanente patients
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Washington state's Health Benefit Exchange, called Washington Healthplanfinder, opened to the public on Oct. 1, 2013, and is one of the key components of federal health care reform.
Since Jan. 1, 2014, many residents throughout Washington have their health coverage through new plans sold inside and outside of the exchange.
Kaiser Permanente offers plans in the exchange and has members enrolled for 2014 in our individual and family HMO health plan products purchased in and outside the exchange. Kaiser Permanente also offers individual and family HMO and Kaiser Permanente Options POS plans directly to consumers outside the exchange.
Providers that currently have an HMO contract with Kaiser Permanente are included in the network for these plans. Participation in these plans is covered under current contracts and is automatic.
Although participating Kaiser Permanente providers will not need to do anything different — when seeing, treating, verifying eligibility, referring for services, or billing for Kaiser Permanente members that have purchased one of these plans — you and your staff may have questions.
Kaiser Permanente is committed to supporting its participating providers through resources, tools, and staff. If you have questions about exchange plans and your practice, contact your Provider Services consultant.
10 essential benefits
All plans in the individual and small business Washington markets — whether offered in the exchange marketplace or not — must:
- Include a comprehensive set of benefits called the essential health benefits , some never before included in health plans
- Fit into one of the metal level plans (platinum, gold, silver, bronze)
Additionally, individuals cannot be denied coverage based on a pre-existing condition, and health plans cannot place a yearly or lifetime dollar limit on essential health benefits:
- Ambulatory patient services
- Emergency care
- Hospitalization
- Maternity and newborn care
- Mental health and substance abuse disorder services, including behavioral health treatment
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services
- Pediatric services, including dental and vision care
For specific questions related to eligibility and coverage, contact our Provider Assistance Unit.
Documentation and coding
As health care reform continues to shift attention to providing value rather than volume of care, it is worth a reminder that accurate documentation and coding of your visits is becoming more critical than ever. Accurate documentation of what care was delivered and for what purpose that can be translated into a precise diagnosis code has always been pivotal in quality of care.
Accurate diagnosis capture is becoming a cornerstone in the new models of care where payments are based on reported risk-adjusted illness of the population. Both Medicare and the individual and family and Small group plans rely on this methodology. We ask that you continue to pay attention to being accurate when you document and code your visits.
Preventive services
The new health care law requires that some preventive services must be covered without copayments or co-insurance to meet deductibles when delivered by a network provider. This applies to all individual and small group plans that are non-grandfathered. For a list of covered preventive services under the law, visit HealthCare.gov .
Three-month grace period
Kaiser Foundation Health Plan of Washington will be accountable for meeting health plan requirements set forth in Washington Healthplanfinder's Carrier Enrollment & Payment Process Guide, which includes requiring plans to give a three-month grace period to members who receive the Advance Premium Tax Credit subsidy to pay for their coverage. Members cannot be terminated for non-payment during this period and are eligible to receive services as Kaiser Permanente members.
How it works
During the first month of delinquency, the member's claims are paid by the carrier. If no payment is received during the second and third months, the member's claims are held and not paid.
If premiums are not paid in full by the end of the grace period, any claims incurred in the second and third months are denied due to non-payment.
Kaiser Permanente notifies providers by letter of their patient's claim status when the patient enters the second month of the grace period.
Providers may seek reimbursement directly from the member at the end of the three-month grace period.
This extended grace period applies only to members who use the Advance Premium Tax Credit subsidy to purchase a health plan and have paid one full month's coverage.
Kaiser Permanente encourages providers to continue to see delinquent members as they may become current in their premiums; however, the member will be responsible for claims payment to the provider if their outstanding premiums are not paid in full by the end of the third month.
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