The TMA is urging members to carefully review contracts for the new Health Insurance Marketplace – and ask for clarification on critical issues – before deciding whether to participate. Members are also asked to share information on the Marketplace contracts they have received with the TMA for advocacy purposes.Share contract info with the TMA
The Tennessee Medical Association works to stay abreast of developments with the Affordable Care Act and its impact on physicians and patients. See our available resources on the ACA and the Health Insurance Marketplace or contact the TMA Legal Department at 800-659-1862 for assistance or more information.
CHA Contract Reviewed
Open enrollment for the Marketplace begins October 1 and insurance companies are sending contracts to Tennessee providers, even though plans approved by the state still await CMS approval. Our Legal Department has reviewed the only full contract it has seen so far, from Community Health Alliance (CHA), as well as a Marketplace network “attachment” from BlueCross BlueShield of Tennessee (BCBST). Response deadlines are imminent or already expired but insurers may extend deadlines because of the short turnaround time that was given.
Points to Consider
Below are critical points and suggestions to keep in mind when reviewing and before signing Insurance Marketplace Network contracts, taken from the TMA’s review of the CHA contract:
Be sure to request a copy of the “Provider/Practitioner Administrative Manual/Program Requirements.”
Request an entire fee schedule before agreeing to participate.
Identify a limit on the number of medical records CHA may request to satisfy pre-certification requirements.
Watch for more information from the TMA.
Clarify the requirement that physicians be held accountable for healthcare professionals who are “associated” or “affiliated in any way.”
Several sections reference the CHA’s “TPA,” or third party administrator…
Ask for clarification on a provision that entitles CHA to direct Members to “selected” participating providers.
You may want to negotiate the 180-day requirement for termination notices.
Clarify language in the “Use of Marks or Symbols” section that prohibits you from using CHA’s name, symbol or service mark without prior written consent.
The BCBST attachment, called Network E, is for providers who already participate in BCBST’s Network S.
- The response deadline has already expired but again, there may be extensions granted.
- Because it is simply an attachment to the existing Network S, there is not much language to review as it incorporates most of the existing provider agreement by reference.
- As with the CHA agreement, we suggest requesting copies of BCBST’s provider manual and their various reimbursement policies to review before signing, as they are referenced numerous times in the attachment.