Health Exchanges: Proactive Legal Strategies for Providers

Navigating Managed Care Contracts Issues, Out-of-Network Provider Coverage, Reimbursement, and Potential Bad Debt Exposure

Recording of a 90-minute CLE webinar with Q&A

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Conducted on Thursday, September 19, 2013

Recorded event now available

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Course Materials

This CLE course will provide counsel for healthcare providers and MCOs with a review of the new health insurance exchanges—how they will work and their anticipated impact on providers. The panel will provide guidance for counsel to providers to assist clients now to adapt to the healthcare exchange environment.


The Affordable Care Act requires that health insurance exchanges be operational by Jan. 1, 2014. With an anticipated 30 million people added to the health insurance market, counsel to healthcare providers must understand and prepare now for the legal risks and opportunities of exchanges for providers.

Counsel must review managed care contracts and other key areas that may require changes. Existing agreements may not work with the new products that plans will offer once exchanges go into effect. Counsel for out-of-network providers must examine the impact on coverage and reimbursement.

As health insurance exchanges go into effect, healthcare providers and managed care organizations should be up to date on the related federal and state law developments and understand how the exchanges will affect them.

Listen as our authoritative panel discusses the new health insurance exchanges and the risks and opportunities for healthcare providers. The panel will provide guidance on managed care contracting issues for providers, coverage and reimbursement for out-of-network providers, and the transition going forward.



  1. Exchanges basics
    1. Types of exchanges and exchange products
    2. Enrollees—who will obtain exchange coverage?
    3. Coverage on exchange plans
    4. The timeline to Jan. 1, 2014
  2. Provider risks and opportunities: bad debt and coverage
    1. Projected 2014 enrollment and the remaining uninsured
    2. Expanded safety net: exchange subsidies and Medicaid expansion
    3. Bad debt exposure
  3. Managed care contracting issues for providers
    1. Does a QHP need you? Network adequacy and essential community providers
    2. Are you already in? Broad base agreement language
    3. Tiered networks and the importance of steerage language
    4. QHP-specific terms and conditions
    5. Legally-required amendments
  4. Out-of-network providers: coverage and reimbursement
    1. Emergency services
    2. PPO products and OON cost-sharing
  5. Provider opportunities to facilitate enrollment
    1. Navigators, in-person assisters, and certified application counselors
    2. Open enrollment
    3. Special enrollment
    4. Grace periods
  6. Beyond 2014
    1. Transitioning from federal to state responsibility
    2. The SHOP Exchange
    3. Expansion of multi-state plans


The panel will review these and other key questions:

  • What are the legal risks and opportunities of health insurance exchanges for healthcare providers?
  • How will the exchanges impact coverage and reimbursement for out-of-network providers?
  • What are the key legal considerations for healthcare providers as the exchanges go into effect?

Following the speaker presentations, you'll have an opportunity to get answers to your specific questions during the interactive Q&A.


Martin A. Corry
Martin A. Corry

Director of Government Relations & Public Policy
Hooper Lundy & Bookman

He represents clients on health care matters before Congress and the Executive branch on legislative, regulatory and...  |  Read More

Katrina A. Pagonis
Katrina A. Pagonis

Hooper Lundy & Bookman

Her practice focuses on the representation of health care providers in matters relating to health care reform, as well...  |  Read More

Jack Ebeler
Jack Ebeler
Health Policy Alternatives

Before returning to HPA, he spent a year on the staff of the House Committee on Energy and Commerce, where he worked...  |  Read More

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