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We have received phone calls from many individuals who signed up for health insurance through the Marketplace without a broker and are now struggling to find participating providers. Their key question: shouldn’t every provider who participates in a particular network be required to accept all patients enrolled in plans that use that network whether through the Exchange or through a regular individual policy?

The problem Marketplace clients are facing is that an increasing number of providers are deciding that they are not willing to accept all patients from a network. One of the main reasons for this is the Marketplace requirement regarding verification of active coverage.

Traditionally, if an insured has not paid premiums within 30 days of the due date, electronic systems at the insurance company reflect that the patient does not have active coverage. When the provider verifies coverage before services are provided they can charge the patient appropriately.

Marketplace contracts do not show an insured as inactive for several months later than normal. The result is that providers can be left holding the bag on unpaid services while individuals can unfairly game the system for thousands of dollars in claims.

So, what can Marketplace clients do to avoid the trauma of trying to find a participating provider after enrolling? Call any doctors they want to see BEFORE enrolling to ask if they are participating providers in the carrier network AND if they are accepting Marketplace patients. Calling each doctor’s office listed in the network to try to find one who will see us is incredibly time consuming and frustrating. Going through this when services are needed urgently is unbearable.

A little work before enrolling can save a lot of time when services are needed most.

Please feel free to contact us at Czajkowski Dumpel & Associates, Inc. – we are here to help YOU!