Covered California provides an overview and agenda for physicians about health insurance exchanges and Covered California. Key points include an overview of the Affordable Care Act, how Covered California works as an "active purchaser" of health plans, the types of plans available on the exchange including metal tiers, and enrollment statistics. It also discusses issues for physicians such as verifying patient eligibility and understanding grace periods for subsidized patients.

1. What your health care team needs to know
about Covered California.
Covered California

2. Agenda
www.thecmafoundation.org
• Overview of ACA
• Overview of Covered CA
• Health Exchange Plans
• What Physician Practices Need to Know
• Question and Answer Session

3. The Fine Print
www.thecmafoundation.org
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.

4. • 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

5. 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.
www.thecmafoundation.org

6. Covered California’s
Response
In 2015, Covered California will hold health plans accountable for consumers.
Specifically, health plans must:
www.thecmafoundation.org
1. Have sufficient clinicians (physicians, hospitals, other) to meet needs of enrollees
2. Each enrollee receives a preventive, wellness visit annually
3. Identify and proactively manage “at-risk” enrollees
4. Determine enrollees’ health status…
5. Promote the use of best practice models for continuity of care & care coordination
6. Be transparent about plan performance at the point of enrollment, standard
measures of prevention, access and clinical effectiveness
7. Be certified by the National Committee for Quality Assurance

7. Health Insurance Status
of Californians Under Age 65
www.chcf.org/aca411

8. 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

9. 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

10. 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.
www.thecmafoundation.org

11. www.cmafoundation.org
Covered California
Purchased through health insurance
website or insurance broker
No Covered CA Logo
Mirror Plan Exchange Plan
Premium Assistance & Cost Sharing Reductions
Identical Products
Identical Benefits
Identical Provider Networks
Purchased through Cov CA website or
Cov CA Certified Insurance Agent
or Certified Enrollment Counselor
Covered CA Logo

12. The Covered CA Marketplace
Sacramento 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.

13. Covered CA Enrollment as of April 17, 2014
= 1,395,929
Subsidy-Eligible
88%
Unsubsidized
12%

14. 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 for
Medi-Cal

15. 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.

16. Medi-Cal Enrollment
as of Mar. 31, 2014
1,100,000 650,000 180,000
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
Enrolled Medi-Cal transitions from Low
Income Health Program (LIHP)
Express Lane
= 1.9 Million

17. 2015
Standard Benefits for Individuals
Bronze Silver*
Gold Platinum
Deductible
$5,000
Medical and drugs
$2,000
Medical
None None
Primary CareVisit
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 benefits that are subject to deductibles.
* Lower cost sharing is
available on a sliding scale.
or less or less or less or less

18. 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 CareVisit
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.

22. Individuals Enrolled Across Metal Level
as of May 19, 2014
Minimum Coverage 1% Minimum Coverage 2% Minimum Coverage 2%
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

23. Individuals Enrolled Across Health Plan
as 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

24. 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

25. 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”

26. 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.

27. 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.
www.thecmafoundation.org

28. What Medical Managers
Need to Know
Anthem Blue Cross
Network Relations – (855) 238-0095 or networkrelations@Wellpoint.com
Blue Shield of California
Provider Services – (800) 258-3091
Health Net of California
Provider Services –(800) 641-7761 or provider_services@healthnet.com
Valley Health Plan
Provider Relations –(408) 885-2221, option #1
www.thecmafoundation.org

29. Network Adequacy
Concerns
www.thecmafoundation.org
Specific detailed complaints:
– Department of Managed Health Care (DMHC)
https://wpso.dmhc.ca.gov/contactform/
– Covered California consumerprotection@covered.ca.gov
– Office of Patient Advocacy contactopa@opa.ca.gov
– CMA at economicservices@cmanet.org
Refer Patients to DMHC HMO Help Line:
1-888-466-2219

30. Special Enrollment –
Qualifying Events
Consumers have 60 days after the qualifying event to enroll in a new plan or change health plans

31. Second Enrollment
Nov 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

32. CMAF Resource Page
Covered CA FAQs
www.thecmafoundation.org
http://www.thecmafoundation.org/Programs/Covered-California