ACA Loophole Could Force Calif. Physicians To Cover Care Costs
A loophole in the Affordable Care Act could force California physicians to cover the full cost of certain health care services,Â the Sacramento Bee reports.
Details of Loophole
Under the ACA, families who obtain subsidized health plans through Covered California -- the state's health insurance exchange -- have a three-month grace period before the policy is cancelled if they fail to pay their premiums.
However, insurers are responsible only for paying claims during the first month of that grace period.
During the other two months, families are asked to pay their doctor's bill or their insurance premium if they seek health care services. If they do not pay either bill, physicians are left to cover the cost of the treatment.
Such families would face a tax penalty for missing payments, but they would not receive a fine, a premium rate increase or a repayment order.
In addition, they also would not be barred from purchasing another subsidized plan during the next enrollment period.
Observers Express Concern
Observers say that while some families might be unable to pay their premiums because of situations such as job loss or divorce, others might avoid paying to take advantage of the loophole.
Physicians argue that the loophole might prompt many doctors to avoid participating in Covered California next year. They say that a single prostate cancer patient's course of treatment can cost $93,000.
Paul Phinney -- president of the California Medical Association -- said the loophole "could be very problematic, even to the extent that it may cause some physicians to have to close their practice."
Leah Newkirk of the California Academy of Family Physicians said the financial implications of the grace period are especially acute for small or struggling practices.
Newkirk said, "I think in particular it will impact providers in rural areas and providers who are seeing disadvantaged populations, sort of precisely the people we want to encourage to (buy policies)."
State, Federal Response
Diana Dooley -- secretary of the state Health and Human Services Agency and Covered California trustee -- said, "I do think there's legitimacy to [physicians'] concerns." However, she said, "[a]t this point, it's speculation about how much of a problem it might be."
Dooley said state officials have discussed such concerns with the federal government, but that federal law provides no flexibility on the issue.HHS has acknowledged that nonpayment of premiums for certain subsidized policies would "increase uncertainty for providers and increase the burden of uncompensated care." HHS officials said that the agency will "monitor this issue moving forward and will continue to work on the development of policies to prevent misuse of the grace period" (Sanders, Sacramento Bee, 5/21). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.