Providers and the ACA

The Affordable Care Act (ACA) means a few things for health care providers. And AmeriHealth New Jersey wants to help you and your patients adjust to the changes as smoothly as possible. Physicians will start to see more patients for preventive services. The ACA is working toward payment based on the value, not the volume, of the care delivered. Patients will have more access to free services, while everyone, providers and patients alike, will see a shift in the way care is delivered, followed-up on and paid for.

Answering patient's questions

Your patients might have a lot of questions about health care reform and finding affordable health insurance in NJ. It's important that anyone who will speak directly with patients gets familiar with how the law affects the insurance policyholders and what changes they should be looking out for. Here are some resources that might be useful for your patients, as well as some questions you might need to answer.

Patient Resources:

  • Direct patients to for questions regarding Health Care Reform, subsidies or enrolling in a health plan on the Health Insurance Marketplace.

Patient FAQ

How has Health Care Reform changed my health insurance coverage?

The law has affected each plan differently, you should contact your insurance company to find out exactly what your plan covers and if there are any changes. Every private health plan must cover ten essential health benefits and all preventive care that your plan may not have been covered before. You might also see some changes in your premium and cost sharing.

Why have my copays changed?

Under the Affordable Care Act, preventive services are now covered 100%. That means no copay and no cost to you whatsoever; your insurance pays for everything. Your insurance company may have also adjusted your copays, premiums and other coinsurance to meet federal mandates and to make your plan more affordable. You should contact your insurance company with any specific questions.

Am I required to get a new plan on the Health Insurance Marketplace?

No, but you might find more affordable options there. If you don't purchase insurance, you'll most likely have to pay a fine from the government. You're considered covered under the Affordable Care Act if you have Medicare, Medicaid, CHIP (Children's Health Insurance Coverage), any job-based plan, any plan you bought yourself, COBRA, retiree coverage, TRICARE, VA health coverage or some other kinds of health coverage1.

How do I get a subsidy or shop for a plan on the Health Insurance Marketplace?

To shop for a plan on the Marketplace, you will need to do so during open enrollment. During that time period, visit our Individual and Family Plans website to shop for a new plan. Outside of open enrollment, you can only enroll in a plan on the Marketplace if you have a life changing event.

Key changes for providers

AmeriHealth New Jersey would like to provide you with some of the ways Health Care Reform can affect your medical practice. However, each health care provider is affected differently. The following are some pieces of the Affordable Care Act that could affect you.

The 90-day "grace period"

When a patient receives an advanced premium tax credit and fails to pay their premium, they enter a three-month grace period before their coverage gets cut off. However, insurance companies only have to pay claims for the first month and will withhold payment for the next two until the premium is paid in full. You and your patient could be left with a gap in payment if the premium does not get paid off within the three-month period. The insurer is required to notify you when a patient is entering the grace period, so you should get familiar with how your participating insurers will contact you 2.

Risk adjustment & accurate coding

In order to create a system in which payers and their provider network are compensated for the risk associated with the members they treat (i.e., risk-adjusted payments), complete and accurate coding is critical. It will provide better insight on the true risk associated with members and allows for a more accurate projection of medical cost, enabling your practice to obtain greater financial stability. It also allows you to analyze and evaluate the effectiveness of care management programs, reduce practice variation, and help drive better quality outcomes for members.

These steps might help you achieve the best results:

  • Standardize the medical documentation and coding process consistent with billing procedures
  • Adopt electronic health records and other technologies that support greater coding accuracy and efficiencies
  • Engage office staff and coders to ensure the best coding practices are being used

New out-of-pocket maximums

Members should not be charged any cost-sharing (i.e., copayments, coinsurance and deductibles) once their annual limit has been met. These limits are based on the member's benefit plan. While individual and group benefit limits may be lower, they cannot exceed the following amounts:

  • Individual: $6,850
  • Family: $13,700

Influx of preventive care visits

More patients will be showing up for annual physicals and "well-baby" visits since they're covered under the Affordable Care Act. This gives doctors a chance to catch health problems in their early stages.

Lifetime cap removed

The lifetime cap in insurance policies has been eliminated. That means doctors can continue to provide the care their patients need for as long as they need. This is especially helpful for pediatricians treating chronically ill children who often hit their lifetime cap at a young age.

Getting health insurance for your employees

Doctors with small private practices will be able to join together with other small businesses to purchase health insurance through competitive health insurance marketplaces

Quality measures

There are multiple quality measures, positive and negative, for physicians to make changes that comply with the Affordable Care Act. Below are just a couple:

  • Doctors who use electronic medical records in a way that improves patient care can receive up to $44,000 from Medicare and up to $63,750 from Medicaid. After 2015, doctors who choose to participate can also receive payments from Medicare but at a reduced rate3.
  • In 2015, hospitals with the highest rate of hospital-acquired infections will face a cut of 1% to their federal reimbursement rate. This will emphasize improved quality of care in hospitals with reduced complications from infections.

Medicare payment reform

Under the ACA, many health facilities are testing the following methods of payment designed by the CMS Innovation Center. The purpose is to reward value of care and reduce waste, ultimately slowing the rapid growth in health care costs.

The Hospital Value-Based Purchasing Program

This program rewards hospitals for providing high-quality care while reducing payments for those demonstrating poor performance. Value will be measured based on clinical process, patient experience and patient outcome, with the addition of efficiency in 2015.

Bundled payments

A voluntary pilot program is currently being tested with Medicare payments where you're paid a fixed amount to cover all services needed to treat a sickness or injury. If this method is successful, it may be more widely used.

To learn more about the CMS Innovation Center and their new models of payment, visit

Accountable Care Organizations (ACO)

Contractual organizations of primary care physicians, nurses and specialists work together to improve coordination of care and lower costs. The Affordable Care Act requires all Medicare patients to receive treatment through an ACO.

Medicare Shared Savings Program

A program that incentivizes health care providers to treat Medicare patients through ACOs. The federal government shares savings generated for those patients with the ACOs that meet quality standards.


New initiatives that reward hospitals for efficiently and accurately reporting procedures and outcomes.


New programs that pay providers based on the value of the care they deliver, not the volume. These encourage higher-quality care and more efficient care delivery.

Medicare funding

Hospitals can gain or lose 1% of Medicare funding depending on 20 factors that gauge quality versus quantity care, including patient satisfaction.

Readmission rates

The federal government can withhold a hospital's Medicare payments if too many patients return within 30 days of discharge.