Californias New Health Insurance Marketplace Amber Kemp, MBA Vice - - PowerPoint PPT Presentation

Covered California: California’s New Health Insurance Marketplace

Amber Kemp, MBA Vice President, Health Care Coverage

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Overview

• California’s Uninsured
• Medi-Cal Expansion
• Covered California Marketplace
• Resources

California’s Uninsured

California’s Uninsured

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The Remaining Uninsured

• Between 2.7 – 3.4 million Californians

under age 65 are predicted to remain uninsured by 2019

 Majority eligible for coverage through

the marketplace

 Almost half, between 1.4 – 1.5 million,

ineligible for coverage due to their immigration status

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Medi-Cal Expansion

Medi-Cal Enrollment

7 900,000

Medi-Cal Enrollment

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Enrollment

8.5 million previously enrolled

10.1 million currently enrolled

11.5 million 2014-15

projected enrollment

New Medi-Cal Benefits

Mental Health Substance Use Disorder Adult Dental

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Changes to Behavioral Health Services

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Simplified Eligibility & Enrollment

Self-Attestation is allowed Access to federal electronic verification hub Modified Adjusted Gross Income test Eliminate asset test Presumptive Eligibility is Expanded

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Hospital Presumptive Eligibility Program

• Effective January 1, 2014, presumptive

Medi-Cal eligibility for certain beneficiaries based on simplified hospital PE application.

 Children up to age 18  Parent-caretaker relatives  Pregnant women  Former foster care children  Newly eligible adults ages 19 through 64 with

incomes up to 138% FPL

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Hospital Presumptive Eligibility Program

• PE determination based only on income,

household size, and state residency

• PE determination conducted in real-time
• Self-attestation accepted
• Full-scope Medi-Cal benefits provided for a period
• f up to two months from the first day of month in

which the PE application was submitted

• Hospital must provide individual with application

for regular Medi-Cal

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Hospital Presumptive Eligibility Program – Enrollment Data

HPE Application – Cumulative Totals as of 6/14/14: HPE Applicants Approved: 68,765 HPE Applicants Denied: 2,248 HPE Web Portal Issues: 8,427 Total Web Portal Transactions: 89,440 HPE Provider Agreements – Cumulative Total as of 6/14/14: HPE Hospitals Approved for PE: 236 HPE Hospitals Denied for PE: 193 Total Received: 429

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Covered California Marketplace

Covered California Marketplace Income Eligibility and Coverage Options

Covered California Growth Projections

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California’s Uninsured Population is Spread Throughout the State

California’s expanse, diverse geography and mix of rural and urban areas are unique and present outreach challenges.

Figure depicts California’s subsidy-eligible population by region Source: CalSIM model, version 1.8

Covered California Enrollment

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Covered California Enrollment

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Covered California Enrollment Forecast

Individual Market 2014 2015 2016

Low (end of Open Enrollment) 1,200,000 1,300,000 1,400,000 Medium (end of Open Enrollment) 1,200,000 1,700,000 2,000,000 High (end of Open Enrollment) 1,200,000 1,900,000 2,400,000

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Covered California Health Plans – Individual Exchange

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Certification/Recertification Dates

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• Negotiations with renewal applicants/ new

entrant applicants by Covered California

July

• Proposed 2015 Covered California individual

market issuers, products and rates made public

August 1

• Regulatory rate review

August and September

• Individual market rates finalized

October 1

• Recertification training completed for enrollment

assistance personnel

October 1

• 2015 QHP & dental plan data loaded into

CalHEERS

October – November 14

• Open enrollment begins

November 15

Covered California Networks

• Narrow networks that include fewer

hospitals and physicians

• Insurers have limited provider networks to

hold down premiums

• Consumers likely to face limited access to

hospitals and physicians

• Issue not limited to California

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Essential Health Benefits

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• Ambulatory patient services
• Emergency services
• Hospitalization
• Maternity and newborn care
• Mental health and substance use disorder services,

including behavioral health treatment

• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic

disease management

• Pediatric services

Standard Benefit Plan Design

• All Covered

California Health Plans cover the same health care services.

• Benefit plans

have different levels of cost- sharing with the consumer through copays, deductibles, and coinsurance.

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Quality Rating System

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Provider Directory

• Inactive, due to errors in physician list
• Enrollees who selected plan based on the

provider directory encouraged to contact health plan to change providers

• Plans will resolve issues on a case-by-case

basis

• Enrollees who find resolution unsatisfactory

encouraged to contact Covered California customer service center

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Metal Coverage Tiers

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Covered California Metal Tiers of Coverage

Covered California Marketplace Income Eligibility

Covered California Enrollment by Metal Tier

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Cost-Sharing Reductions

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• Individuals must enroll in

a Silver-level health plan to receive cost-sharing subsidies.

• Out-of-pocket costs

(including maximum and deductible) become much lower when a Silver-level health plan is “enhanced” with federal cost-sharing subsidies.

• How much the plan is

“enhanced” is shown by the number next to the metal tier (e.g. “Enhanced Silver 87”).

Premium Assistance

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Consumers eligible for premium assistance (advance premium tax credits) have a choice of how to claim their premium subsidies:

• In advance:



Paid monthly directly to health plan



Consumer has risk of overpayment or underpayment if income fluctuates



If income changes, consumer is encouraged to timely report changes to Covered California

• Wait until taxes are filed

QHP Grace Period

• Grace Period

 90-day total period after nonpayment of

premium

 First 30 days; services are covered  Next 60 days; services covered retroactively

• nly if past due premium is paid

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Third-Party Premium Support

• HHS FAQ (Nov. 4, 2013)

 “Significant concerns” with provider premium

support

 HHS “discourages the practice”  Cites HHS’s regulatory authority over the

Exchanges and is silent on the federal anti- kickback statute

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Third-Party Premium Support

• HHS FAQ (Feb. 7, 2014)

 “The concerns [in the previous FAQ] would not

apply to payment from private, not-for-profit foundations if…they are made on behalf of QHP enrollees who satisfy defined criteria that are based on financial status and do not consider enrollees’ health status.”

 The premium and any cost-sharing payments

must cover the entire policy year.

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Covered California Consumer Tracking Survey

Easy or Very Easy 45% Difficult

• r Very

Difficult 29% Neither Easy or Difficult 26%

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Ease of Purchase

• n the

Covered California Website

Source: NORC: “Final Report: Covered California Consumer Tracking Survey” May 2016

Consumers’ Experiences Under the ACA – Cost and Coverage

• Consumers struggled to understand what services

were covered under their health plans, and their cost- sharing responsibilities.

• Consumers found it challenging to obtain costs and

coverage information that was accurate, consistent, and easy to understand.

• Consumers who encountered inaccurate or

ambiguous information about health plan networks were not satisfied with their health plan networks.

• Finding in-network specialists was more difficult than

finding in-network primary care physicians.

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Source: California HealthCare Foundation: “Patients and Providers Speak: Early Care Experiences Under the ACA” June 2014.

Consumers’ Experiences Under the ACA – Access to Care

• Appointments for specific conditions and routine care

were easy to get quickly, while specialty care appointments took longer.

• High deductibles led to delays in care.
• Consumers delayed care while sorting out network

scope and information challenges.

• Inaccurate provider network information meant that

consumers received care from providers who were not their first choices.

• Consumers, particularly in nonurban areas, may be

traveling long distances to see in-network specialists.

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Source: California HealthCare Foundation: “Patients and Providers Speak: Early Care Experiences Under the ACA” June 2014.

CMS Initiative: From Coverage to Care (C2C)

• National initiative to help

answer questions that individuals may have about their new health coverage.

• Print resources include

booklet titled, “A Roadmap to a Better Care and Healthier You,” discussion guide, and individual steps.

• Available in English and

Spanish

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Enrollment Dates

• October 1, 2013 – March 31,

2014

Initial Open Enrollment

• November 15, 2014 –

February 15, 2015

2015 Enrollment

• October 15 – December 7

each year

Subsequent Enrollment

• Accepted year-round

Medi-Cal Applications

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Resources

Helping Individuals Obtain Health Coverage Guidebook

• The guidebook includes

strategies California hospitals can use to help enroll individuals in health coverage programs under the Affordable Care Act.

• An electronic version is

available at www.calhospital.org/health- coverage-guidebook

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Fact Sheets: Covered California 101 for Hospital Staff

• Informational fact sheets about

the Covered California marketplace and relevant provisions of the ACA

• Can be used individually or as a

package to help educate staff, board members, volunteers and

• thers.
• Fact sheets are available at

www.calhospital.org/covered-ca- 101-fact-sheets

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CHA Portal - Covered California Marketplace Resources

• Resources to assist

hospitals and their staff in understanding California’s new health insurance marketplace are available at http://www.calhospital.or g/hcr-covered-california- marketplace-resources

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Amber Kemp, MBA Vice President, Health Care Coverage California Hospital Association (916) 552-7543 akemp@calhospital.org

Thank You