What Should I Do if My Doctor Says He or She Does Not Accept Obamacare?
We get this question all the time.
The answer is a little tricky.
The first thing to point out is that the term “Obamacare” is simply another name for the Affordable Care Act (ACA) which is the law passed in 2010 reforming our country’s health care system.
Obamacare is not a type of insurance, or a network, or a health plan, it is just a nickname for the new law.
Beginning January 1, 2014, all new individual and small-group health insurance plans must be compliant with ACA — no matter where you buy that coverage. Plans can be purchased either through a state- or federally run health insurance marketplace (called the Exchange*), or outside of the marketplace, directly from an insurance carrier.
If you do not have access to affordable health insurance from your employer and your income is below a certain level, you can get help paying for coverage if you by a plan on the Exchange.
In our experience, however, some plans offered on the Exchange have narrower physician networks than plans offered off Exchange — even the same plan from the same carrier. The carriers do this as a way to keep costs down for their Exchange plans.
Confusing terms: “Obamacare” vs “Exchange Plans”
So when your doctor says s/he does not accept Obamacare, s/he may be mixing up the terms “Obamacare” and “Exchange plans.”
The doctor may mean s/he is not in-network for plans purchased on the Exchange and therefore is not accepting patients with that type of coverage.
Why Doctors May Choose Not to Participate in Exchange Networks
Some doctors are not willing to accept the lower rate of reimbursement for medical care offered through plans sold on the Exchange.
Doctors may also be wary of treating patients with an Exchange plan because of the law’s grace period which prohibits insurance companies from canceling a policy for non-payment of premium for three months. But — and here’s why doctors are wary — the insurer must pay for care received only during the first month a premium is not paid. Yet the person’s coverage is still in effect for two more months. This essentially leaves the doctor on the hook for two months of medical care for which s/he may never get paid. Click here to read more.
Understand Your Policy
Getting back to the original question of what should you do if your doctor tells you s/he is not accepting Obamacare…
Check your policy carefully, including the list of providers in your network.
If your doctor is not in your plan’s network but you want to continue to see him or her, have a conversation with the doctor or office staff about which plans and carriers include him/her in their network.
If you don’t have an established relationship with your doctor, you could also choose to select a new provider who IS in your plan’s network.
Either way, it is very important that you understand all of the provisions of your health insurance plan. If you currently have an Exchange plan, your coverage will be expiring at the end of this year and you will have the opportunity to select a new plan. Pay careful attention when you make your choice for 2015 coverage.
As always, give us a call if we can be of assistance. You can reach us by phone at 1-800-867-0800 or email at jkatz@vamedicalplans.com.
*Residents of Virginia use the federal exchange, known as healthcare.gov. Maryland and DC have their own exchanges.
