Health Insurance Exchange Enrollees Now Eligible to Receive Benefits – Providers Should Be Ready To Verify Patients’ Health Insurance Coverage

January 15, 2014 | By Lawrence J. Tabas

Beginning January 1, 2014, Americans who purchased a health insurance plan through the Health Insurance Marketplace (often referred to as the “Exchange”) on or before December 24, 2013 are now covered by those plans. Health care providers can expect to see an influx of new patients, many of whom may not be familiar with the coverage options of their new plans or the documentation they need to bring with them to appointments. As a result, providers should expect to spend a great deal of time and energy in the coming months verifying patients’ coverage.

The Centers for Medicare & Medicaid Services (“CMS”) recently provided guidance to providers on how to verify a patient’s coverage. The announcement, dated December 30, 2013, instructs providers in states with a federal Exchange to call the patient’s plan customer service line to verify coverage (You can access the CMS database of customer service numbers here).  In those states running their own exchanges, CMS suggests contacting the state to find out the best way to verify coverage. Despite these verification procedures, providers may find themselves scrambling in the early months to verify coverage as a result of the rocky implementation of the Affordable Care Act.

Despite reports that many of the technological glitches plaguing health insurance enrollment through, the federal Exchange website (the “Site”), have been resolved, there are still concerns that enrollment information provided through the Site is not being sent to insurance companies. As such, providers may need to deal with issues when a patient comes in for an appointment and the provider and patient discover that the patient’s purported insurance company never received the patient’s enrollment information.

Furthermore, the constant last-minute changes in the Affordable Care Act’s deadlines will likely lead to issues for insurers and providers alike in sorting out who is covered by which health plan and which services are covered for each patient. For example, the December 15, 2013 deadline to enroll in a plan with coverage beginning January 1, 2014 was delayed for over a week. This means that insurers had only a short window in which to determine who had successfully enrolled in a plan and to get those enrollees the documentation they would need for appointments with providers before coverage began on January 1, 2014.

Patients will expect providers to be equipped to address the issues associated with verifying health insurance coverage that the patients obtained through the Exchange. Therefore, providers need to be prepared. CMS has outlined strategies for providers that will allow providers to help patients in the transition to the Affordable Care Act era:

  • Reminding patients to keep all paperwork and receipts from all of their doctor’s appointments and the pharmacy;
  • Reminding patients to carry their insurance cards at all times; and
  • Instructing patients that if they do not have an insurance card, they should contact their plan to get one.

Issues facing providers are sure to evolve as more and more individuals become insured through the Exchange and seek health care services from providers under these health insurance plans.

The Health Law Gurus™ will continue to follow issues regarding health care providers’ responsibilities under the Affordable Care Act. We encourage you to share your experiences and thoughts about verifying coverage of patients’ with Exchange health plans with us and our readers in the comments section below.

Categorized In: Affordable Care Act (ACA)

About the Authors

Lawrence J. Tabas


Lawrence is the Chair for Obermayer’s Health Care Law Department and Election Law Practice Group. Lawrence’s Health Care Law legal experience includes the representation of Pennsylvania County governments in Behavioral Health Managed...

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