- Health plans participating in the HealthCare.gov exchange will pay about $16,000 a year to notify enrollees that a doctor they use has left the exchange, federal regulators predict.
- In addition, all qualified health plans must alert members of possible out-of-network charges if they seek care from an ancillary out-of-network provider in an in-network setting, under new standards set by the Affordable Care Act.
- Analysts at the CMS issued the estimates as part of a routine paperwork review filing.
To arrive at the $16,000 estimate, CMS assumed 375 notifications per health plan per year at a cost of about $42 per notice, plus 35% adjustment for fringe benefits and overhead costs.
The notices must be issued at least 30 days before a provider leaves a network to all patients who see the doctor on a regular basis or for primary care. Currently, 474 plans participate in the federal exchange and would have to comply with the requirement.
The notification of ancillary out-of-network provider charges must be sent out before the benefit is provided, and is intended to prevent those costs being counted against the annual limitation on cost sharing, CMS said. This provision takes effect in 2018 and would affect 575 qualified health plan issuers.
Assuming 28 million enrollees in QHPs in 2018 and six minutes to make the notification, at $54.87 an hour, CMS expects plans will send about 320,000 notices annually at a cost of 21, 334 hours and $1.2 million.