From time to time, I receive some real good questions from the field on various administrative issues.  Here is a question I received recently regarding a client’s MarketPlace product:


I have had a number of clients come in with individual policies only to discover that most of these payers were actually being offered by what I thought were Medicaid Managed Care Plans (MCPs).  Are clients who buy on the MarketPlace actually buying Medicaid products?


In Ohio, the MarketPlace products are insurance plans that are offered on the Federal Insurance Exchange (often referred to as “ObamaCare”).  Many of our Medicaid MCPs also offer MarketPlace Products in various parts of the State of Ohio.  These products are considered commercial products.   Many providers have seen an increase in clients covered under these insurance plans because of current economic conditions.

This means that there may be different requirements for eligible providers, eligible services and billing from that which we usually see when we provide service to a Medicaid client.  It cannot be assumed that these plans will pay at the same rates or under the same provisions (eligible providers or services) as what we see under Medicaid.

From a private practice standpoint, it operates the same way as most other commercial insurance plans.  There are typically very large deductibles and co-insurance amounts.  In some case, reimbursement is based on Medicare reimbursement rates for your State. Some clinical services may require authorization. 

I highly recommend that your staff verify the client’s eligibility and benefits prior to the initial visit.  May sure you get your questions answered about how these products work. 

In addition, I might suggest that you review your current Agreements to see if your organization is contracted for this product line.

With nearly four decades of managed care experience, G&M Consulting understands the complexities of the different insurance companies’ product lines.  Please let us know how we can be of service to your organization!