One of the most frustrating things I’ve seen in looking for a system to verify benefits and eligibility is that most systems are NOT verifying the group effective date when it comes to trying to obtain verification and eligibility of a patient with group health plan benefits. Why is this date so important? eligibilityBecause the Affordable Care Act provisions do contain some provisions to which grandfathered plans are NOT entitled to under the ACA. Plans prior to March of 2010 with no significant changes are considered grandfathered and NOT subject to all provisions of the ACA. As an example; a group health plan with an effective date of 3/1/2009 would NOT be obligated to pay well care or preventative services at 100% and without cost sharing. The policy was effective prior to the enactment of the ACA and was grandfathered thereby not mandating that they withhold all of the ACA standards. So how does this effect us medical billers? Simple. When we call to verify benefits and eligibility we are under the impression that we are gathering information to inform the patient of any out-of-pocket expenses they may have for their visit. With the Affordable Care Act, we have learned that there are many provisions that state a patient may not have an out-of-pocket copay or coinsurance for certain preventative care. However, what many of us don’t understand is that NOT all group health plans are subject to all provisions of the ACA. That is why it is imperative when verifying benefits on a patient with group health plan benefits that we obtain the effective date of the group.

Grandfathered Plans


Are Medical Billers obtaining Group Plan Effective Dates when Verifying Benefits?