Managers of the new health insurance exchanges should make participating plans collect all payments owed by member patients, according to a HCA Inc. representative.

Paula Flowers makes that argument in a comment letter submitted to the Exchanges Subgroup at the National Association of Insurance Commissioners (NAIC), Kansas City, Mo., on behalf of HCA, Nashville, Tenn. HCA is a for-profit hospital company.

The subgroup has been seeking comments on a draft of the American Health Benefit Exchange Model Act.

The subgroup has developed the model to implement Section 1321 of the Patient Protection and PPACA toolkitAffordable Care Act (PPACA), a component of the Affordable Care Act. Section 1321 requires the U.S. secretary of Health and Human Services (HHS) to work with the NAIC and member regulators, health insurers, consumer groups and others to set up a system of American Health Benefit Exchanges that will be used to distribute subsidized individual coverage, and a system of Small Business Health Options Program (SHOP) exchanges to distribute subsidized small group coverage. The exchanges are supposed to go into operation in 2014.

Interested parties have filed more than 100 pages of comments.

Two sets of provider comments have come from HCA and from the American Medical Association (AMA), Chicago.

Flowers says “qualified health plans” (QHPs) — plans that qualify to sell health coverage through an exchange — should agree to pay health care providers the contracted rate and should take responsibility for collecting the enrollee portion of a bill, such as any copayment or coinsurance payment that might be due.

Carriers have imposed higher cost-sharing arrangements in recent years in an effort to hold down premiums and discourage plan members from seeking unnecessary or overly aggressive care.

“HCA remains concerned that benefit plans continue to shift more and more costs to the patient in the form of copayments, deductibles and coinsurance – but that these patient expenses prove to be uncollectible and end up being written off to bad debt by the provider community,” Flowers writes in the HCA comment letter. “HCA believes that the new exchange environment creates an excellent opportunity to shift this collection risk/responsibility back to the insurer – which is where it most logically belongs.”

A QHP already send monthly bills and collects monthly premiums, adjudicates the provider’s claim to determine the enrollee’s out-of-pocket costs, and administers the benefit plan, Flowers says.

A QHP “needs to be accountable for the risk of non-collection of enrollee costs in order to accurately set premiums,” Flowers says.

Dr. Michael Maves has written on behalf of the AMA that exchange managers ought to

keep QHPs from treating cost-containment measures as quality measures.

Many Democratic senators have written to support efforts by the National Association of Dental Plans, Dallas, to ensure that stand-alone family and adult dental coverage can be sold through an exchange. Today, the text of the Affordable Care Act appears to guarantee only that pediatric dental coverage can be sold through an exchange.

Todd McCracken, president of the National Small Business Association, Washington, says the NAIC should think about how agents will fit into the SHOP exchange system for small businesses.

If agents are not part of the system, “who will assist employees in answering questions or to make changes to their policies?” McCracken asks. “How will other products in the commercial market interplay with an exchange, such as Section 125 plans, COBRA administration, health savings accounts, health reimbursement accounts, flexible spending accounts and wellness programs. In the current market, health insurance agents or brokers provide this and many other services to small businesses. Therefore, model language and the state establishment of exchanges should carefully contemplate the benefits of agents to small businesses and how all the actors and products small businesses engage can interact in the exchange.”