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TRANSCRIPT
What your health care team needs to knowabout Covered California.
Covered California
Agenda
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• Overview of ACA
• Overview of Covered CA
• Health Exchange Plans
• What Physician Practices Need to Know
• Question and Answer Session
The Fine Print
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Covered California has provided funding to educate physicians and their health care teams about health insurance reform and the new marketplace, Covered California.
This presentation will not discuss contract reimbursement rates.
Nothing in this presentation is intended to suggest that a physician should or should not contract with any plan, and decisions whether to contract with a plan must be made based on the specific individual situation of the physician.
• Network Adequacy Issues
– Provider directories
– Specialists and referrals
• Exchange / Mirrored Plans
– Names of Networks
– 2015 Names
• Grace Period Clarification
• Other practice management issues
Issues to be Addressed
Regulatory Response
In June, the DMHC opened an investigation regarding the accuracy of the Anthem Blue Cross and Blue Shield provider directories and whether they have violated any California laws.
The final report will be issued in the beginning of November prior to open enrollment.
Ultimately, CMA’s goal for the DMHC’s investigation is• better education to patients and physicians on the fact that the networks
are different from their larger commercial networks; and• the requirement that the plans take steps to confirm the adequacy of
their networks and the accuracy of their directories.
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Covered California’s Response
In 2015, Covered California will hold health plans accountable for consumers. Specifically, health plans must:
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1. Have sufficient clinicians (physicians, hospitals, other) to meet needs of enrollees2. Each enrollee receives a preventive, wellness visit annually3. Identify and proactively manage “at-risk” enrollees4. Determine enrollees’ health status…5. Promote the use of best practice models for continuity of care & care coordination6. Be transparent about plan performance at the point of enrollment, standard
measures of prevention, access and clinical effectiveness7. Be certified by the National Committee for Quality Assurance
Health Insurance Statusof Californians Under Age 65
www.chcf.org/aca411
Overview of the ACA
Insurance Market Reforms Guaranteed issue
– Ignores pre-existing conditions
– Health status
– No gender-based premiums
Guaranteed renewal– Health insurance cannot be dropped if sick
– No lifetime or annual caps on dollar value of services
Individual Mandate– Required to have public or private health insurance or pay
penalty
Overview of the ACA
Improvements in Affordability of Coverage
Expansion of Medi-Cal
Premium Assistance and Cost Sharing Reductions (CSR)
– available through State exchanges
– Metal Tiers
• Bronze, Silver, Gold, Platinum
• Catastrophic plan for < 30 year olds; or qualify for hardship waiver
– CSR – only in Silver tier
Creation of State Exchanges: Covered CA
Covered California
An “active purchaser” model which allows it to negotiate with insurers, decide which insurers can offer health plans through the exchange and set criteria for participating plans.
Behaves similarly to that of a large employer - negotiating and purchasing health coverage on behalf of its employees.
Contracted with ten Knox-Keene licensed health plans in 2014 to create a marketplace through which enrollees select a plan.
– Health plans contract directly with providers and the terms of those contracts are propriety to each plan.
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Covered California
Purchased through health insurance website or insurance broker
No Covered CA Logo
Mirror Plan Exchange PlanPremium Assistance & Cost Sharing Reductions
Identical ProductsIdentical Benefits
Identical Provider Networks
Purchased through Cov CA website or Cov CA Certified Insurance Agentor Certified Enrollment Counselor
Covered CA Logo
The Covered CA MarketplaceSacramento County San Francisco County Los Angeles County San Diego County
Anthem
Blue Shield
Kaiser Permanente
Western Health Advantage
Anthem
Blue Shield
Chinese Community Health Plan
Health Net
Kaiser Permanente
Anthem
Blue Shield
Health Net
Kaiser Permanente
L.A. Care Health
Plan
Anthem
Blue Shield
Health Net
Kaiser Permanente
Molina Healthcare
Sharp Health Plan
Medi-Cal Medi-Cal Medi-Cal Medi-Cal
The place to shop for health insurance.
Covered CA Enrollment as of April 17, 2014= 1,395,929
Subsidy-Eligible 88%
Unsubsidized 12%
Making Care More Premium Assistance
Eligibility is based on:
Number of People in Your
Household
Annual Household Income
1 $0 - $16,105
2 $0 - $21,708
3 $0 - $27,311
4 $0 - $32,913
5 $0 - $38,516
$16,106 - $46,680
$21,709 - $62,920
$27,312 - $79,160
$32,914 - $95,400
$38,517 - $111,640
Eligible for Premium Assistance
Eligible forMedi-Cal
Medi-Cal Expansion
New eligible population
Adults whose incomes are ≤ 138% of FPL
– No longer child-linked
– Eliminates asset tests
Uses Modified Adjusted Gross Income (MAGI) to determine eligibility
Expansion is in addition to the approximately 7 million Californians already insured through Medi-Cal.
Medi-Cal Enrollment as of Mar. 31, 2014
1,100,000 650,000 180,0000
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Enrolled Medi-Cal transitions from LowIncome Health Program (LIHP)
Express Lane
= 1.9 Million
2015Standard Bene�ts for Individuals
Bronze Silver* Gold Platinum
Deductible $5,000 Medical and drugs
$2,000 Medical None None
Primary Care Visit Copay
$60 (Three visits per year) $45 $30 $20
Generic Medication Copay
$15 $15 $15 $5
Emergency Room Copay $300 $250 $250 $150
Maximum Out-of-Pocket for Individual $6,250 $6,250 $6,250 $4,000
Maximum Out-of-Pocket for Family $12,500 $12,500 $12,500 $8,000
Copays are not subject to any deductible and count toward the annual out-of-pocket maximum.Blue corners indicate bene�ts that are subject to deductibles.
* Lower cost sharing is available on a sliding scale.
or less or less or less or less
Annual Income $16,106 – $17,504 $17,505 – $23,339 $23,340 – $29,174 $29,175 – $46,680
Deductible None $500 $1,500 Medical
$2,000 Medical
Primary Care Visit Copay $3 $15 $40 $45
Generic Medication Copay $3 $5 $15 $15
Emergency Room Copay $25 $75 $250 $250
Maximum Out-of-Pocket for Individual $2,250 $2,250 $5,200 $6,250
Maximum Out-of-Pocket for Family $4,500 $4,500 $10,400 $12,500
2015| SINGLE
SILVER PLAN (Eligible for Premium Assistance)
Copays are not subject to any deductible and count toward the annual out-of-pocket maximum.
Individuals Enrolled Across Metal Levelas of May 19, 2014
Minimum Coverage 1% Minimum Coverage 2% Minimum Coverage 2% Minimum Coverage 1%
Bronze , 26%
Bronze , 35%Bronze , 31%
Bronze , 28%
Silver , 62%
Silver , 54%Silver , 55% Silver , 63%
Gold , 6% Gold , 5%Gold , 6%
Gold , 5%Platinum , 5% Platinum , 4% Platinum , 6% Platinum , 3%
64,924 Enrollees 26,671 Enrollees 33,715 Enrollees
Individuals Enrolled Across Health Planas of May 19, 2014
Kaiser , 17.3%Kaiser , 21.2%
Kaiser , 46.1%
Anthem , 30.5%
Anthem , 60.4%Anthem , 16.1%
Anthem , 61.9%
Blue Shield , 27.3%
Blue Shield , 10.8%
Blue Shield , 22.7%Blue Shield , 29.7%
Health Net, 18.9%
Health Net, 4.6%
Health Net, 4.8%
Health Net, 8.5%Valley Health Plan, 2.9%
83% - premium assistance 89% - premium assistance84% - premium assistance
Understanding the Grace Period
Applies to subsidized patients for non- payment or premium delinquency
Health Plans are required to:
– Identify patient’s coverage as suspended or inactive the 2nd & 3rd month of delinquency
– Notify physicians who have submitted claims on patient in previous 2 months, as well as the patient’s assigned PCP
Understanding the Grace Period
Indicate suspension upon patient eligibility verification the first day of the second month
– Blue Shield – “Suspended”
– Anthem Blue Cross – “Suspended pending investigation”
– Health Net – “Delinquent”
Understanding the Grace Period
Best Practices: ALWAYS CHECK ELIGIBILITY– Verify as close to the time of service, every time a
patient comes in for service
– Print “eligibility screen” from health plan website
– Treat the situation as any other patient who has had a lapse in coverage
For non-emergent services, patient can choose to either pay cash for that visit or re-schedule their appointment.
What Medical Managers Need to Know
Best Practices: ALWAYS CHECK ELIGIBILITY– Know with which plans your practice participates
– Have defined policies for handling patients in the “grace period”
– Confirm appointment and eligibility with patients the day before – or day of – the appointment
– Although pre-authorization is obtained, re-verify eligibility within a few days of service or later.
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What Medical Managers Need to Know
Anthem Blue Cross
Network Relations – (855) 238-0095 or [email protected]
Blue Shield of California
Provider Services – (800) 258-3091
Health Net of California Provider Services –(800) 641-7761 or [email protected]
Valley Health Plan Provider Relations –(408) 885-2221, option #1
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Network Adequacy Concerns
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Specific detailed complaints:– Department of Managed Health Care (DMHC)
https://wpso.dmhc.ca.gov/contactform/– Covered California [email protected]– Office of Patient Advocacy [email protected]– CMA at [email protected]
Refer Patients to DMHC HMO Help Line: 1-888-466-2219
Special Enrollment –Qualifying Events
Consumers have 60 days after the qualifying event to enroll in a new plan or change health plans
Second EnrollmentNov 15, 2014 – Feb 15, 2015
Minimal Changes in 2015:– Adult dental plans will be offered through Covered CA– Children’s Health Plans will bundle medical plans with dental
plans– No changes in the Standard Benefit Design until 2016– Health plans formularies linked to the Covered CA website
Information after October 1st– Plan names will be the same (mirrored and exchange)– Adjustment in premium assistance as plan costs change
CMAF Resource PageCovered CA FAQs
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http://www.thecmafoundation.org/Programs/Covered-California
