Covered California: California’s New Health Insurance Marketplace Amber Kemp, MBA Vice President, Health Care Coverage
Overview California’s Uninsured Medi-Cal Expansion Covered California Marketplace Resources 2
California’s Uninsured
California’s Uninsured 4
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 5
Medi-Cal Expansion
Medi-Cal Enrollment 900,000 7
Medi-Cal Enrollment Enrollment 10.1 8.5 11.5 million million million 2014-15 projected previously currently enrollment enrolled enrolled 8
New Medi-Cal Benefits Mental Health Substance Use Disorder Adult Dental 9
Changes to Behavioral Health Services 10
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 11
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 12
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 of 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 13
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 14
Covered California Marketplace
Covered California Marketplace Income Eligibility and Coverage Options
Covered California Growth Projections 17
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 19
Covered California Enrollment 20
Covered California Enrollment Forecast Individual 2014 2015 2016 Market Low 1,200,000 1,300,000 1,400,000 (end of Open Enrollment) Medium 1,200,000 1,700,000 2,000,000 (end of Open Enrollment) High 1,200,000 1,900,000 2,400,000 (end of Open Enrollment) 21
Covered California Health Plans – Individual Exchange 22
Certification/Recertification Dates • Negotiations with renewal applicants/ new July entrant applicants by Covered California • Proposed 2015 Covered California individual August 1 market issuers, products and rates made public August and • Regulatory rate review September October 1 • Individual market rates finalized • Recertification training completed for enrollment October 1 assistance personnel October – • 2015 QHP & dental plan data loaded into CalHEERS November 14 November 15 • Open enrollment begins 23
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 24
Essential Health Benefits 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 25
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. 26
Quality Rating System 27
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 28
Metal Coverage Tiers 29
Covered California Metal Tiers of Coverage
Covered California Marketplace Income Eligibility
Covered California Enrollment by Metal Tier 32
Cost-Sharing Reductions 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”). 33
Premium Assistance 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 34
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 only if past due premium is paid 35
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 36
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. 37
Covered California Consumer Tracking Survey Ease of Neither Purchase Easy or Difficult on the Easy or 26% Very Covered Easy 45% Difficult California or Very Difficult Website 29% Source: NORC: “Final Report: Covered California Consumer Tracking Survey” May 2016 38
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. Source: California HealthCare Foundation: “Patients and Providers Speak: Early Care Experiences Under the ACA” 39 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. Source: California HealthCare Foundation: “Patients and Providers Speak: Early Care Experiences Under the ACA” 40 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 41
Enrollment Dates Initial Open • October 1, 2013 – March 31, 2014 Enrollment 2015 • November 15, 2014 – February 15, 2015 Enrollment Subsequent • October 15 – December 7 each year Enrollment Medi-Cal • Accepted year-round Applications 42
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