Samuel A. Collins
Question: I recently received a notice from my clearinghouse related to the One Big Beautiful Bill Act (OBBBA). It has me concerned, as I am hearing rumors of big changes coming as a result. Do you have some insight?
For most healthcare offices, the impact of the One Big Beautiful Bill Act (OBBBA) will be minimal unless your practice treats a significant number of Medicaid patients or patients enrolled through the Health Insurance Marketplace (exchange plans).
The impact is primarily coverage eligibility, enrollment verification, reimbursement pressure, and patient collections, rather than coding changes. The changes move protocols from simply coding services correctly to confirming that patients continue to qualify for the coverage being billed.
Medicaid
Beginning Jan. 1, 2027, many Medicaid expansion beneficiaries will be required to document work, educational participation or other qualifying activities (generally 80 hours per month) to maintain eligibility.
Billing and Administrative Impact: More patients may lose Medicaid eligibility during the course of treatment. Eligibility verification will become increasingly important and should be performed regularly.
The risk of claim denials due to coverage termination or eligibility changes will increase. States will conduct eligibility reviews more frequently, generally every six months rather than annually.
Retroactive Medicaid coverage will be reduced to one month in many cases, compared to the current three-month period. As a result, practices should implement routine eligibility verification processes and avoid relying on retroactive coverage to resolve unpaid claims.
Marketplace Plans
The law also imposes stricter eligibility and verification requirements for ACA Marketplace (exchange) plans and limits automatic re-enrollment.
Billing and Administrative Impact: Patients may experience more frequent coverage lapses or terminations. Insurance verification prior to treatment will become increasingly important. Patients who lose coverage may need to transition to self-pay arrangements. Insurance card changes, plan changes and eligibility verification issues are expected to become more common.
The Overall Impact
Current projections indicate that a significant number of individuals presently covered by Medicaid/Medi-Cal or marketplace plans may lose coverage due to the new eligibility, work and verification requirements.
For providers, the primary concern is not changes to coding or billing procedures, but rather ensuring that patient coverage remains active and verified at the time services are rendered. Regular eligibility verification and clear financial policies will become increasingly important to minimize claim denials and patient balance issues.
What You Should Do Now
- Verify Medicaid eligibility before every patient visit.
- Update financial policies and patient responsibility agreements.
- Obtain patients’ current insurance cards more frequently.
- Strengthen Good-Faith Estimate processes in your clinic.
- Establish payment plan policies for coverage-loss situations.
- Train yourself / staff to recognize Medicaid eligibility lapses.
- Monitor state Medicaid fee schedules and coverage policies periodically.
Editor’s Note: Have a billing question? Submit it via email to Sam at sam@hjrossnetwork.com. Your question may be the subject of a future column.
