With a new year, providers and patients must get coverage organized

The new year will mean many changes in patients’ insurance coverage, requiring attention to detail and careful organization from both patients AND providers. Along with the traditional challenges that go with annual open enrollment, 2016 will bring some unique challenges related to the Affordable Care Act (ACA). 

In provider offices, billing and admissions staffers are facing lots of work. Organizations that serve patients with care episodes spanning between December and January will need to reconfirm eligibility to make sure patients haven’t become ineligible. Even in clinics, which don’t have the same problems with dates of service spanning the change of the year, failure to ensure that a patient’s payer information is current can result in delayed or lost revenue. (To learn more about these issues, download our Know the Facts flipbook.)

On the patient side, there could be work ahead as well. For patients who are eligible to purchase coverage on the ACA’s health insurance marketplaces, the December 17 deadline for coverage to kick in on January 1 has passed. However, late shoppers actually have until the end of January to enroll for coverage that kicks in on March 1. (This is another reason providers must be on their toes with eligibility confirmation even well past the new year.) Regardless of which cutoff date these patients make, by enrolling they’ll be preventing the headache of the ever-heftier penalties being charged at tax time:

  • Those who did not have insurance for 2015 will have to pay $325 per adult, or 2% of household income, whichever is higher.
  • Come tax time in 2017, people who didn’t have insurance for 2016 will pay $695 per adult, or 2.5% of income, whichever is higher.

The penalties are designed to be more painful with each passing year, and that may be the push that’s needed for the remaining uninsured population to get enrolled. People who continue to gamble by not having insurance will face a rude awakening when they file their taxes: They’ll have to pay the $325 penalty for 2015, and if it’s after January 31, 2016, it will be too late to buy a policy for the new year—locking them into the $695 penalty as well.

That can be a complicated message to get across, but insurers and navigators are still working hard to match these patients to plans and help them avoid the worst of the penalties. The ultimate hope is that they’ll then start showing up in providers’ offices to get the care they may have been delaying for years.