CMA, AMA and organized medicine were united in opposing Graham-Cassidy Last week, the latest effort to repeal the Affordable Care Act (ACA) collapsed, after three Republican Senators announced their opposition—Susan Collins (R-ME), Rand Paul (R-KY) and John McCain R-AZ). Further action is unlikely this year, as Senate Republican Leader Mitch McConnell (R-KY) said the Senate would now turn its focus to overhauling the tax code. However, several Republicans vowed to continue to work into next year to repeal the ACA. The California Medical Association (CMA), the American Medical Association (AMA) and all of organized medicine were united in opposing this harmful bill, which would have repealed the ACA’s insurance mandate, underfunded health insurance subsidies and made drastic cuts to the Medicaid program. The Graham-Cassidy block grant proposal would have been disproportionately harmful to states like California, which embraced Medicaid expansion and increased coverage under the ACA. Even states that initially came out ahead under the block grant framework would have experienced devastating funding cuts over time from the bill’s Medicaid funding caps on children, the elderly and the disabled. Millions of Californians would have lost their coverage, and many others would have been seriously underinsured. Patients without coverage seek more expensive care in overcrowded emergency rooms, passing costs onto states, counties, health care providers and taxpayers. These patients also put off treatment, ending up with more serious conditions that could have been prevented. These problems would be exacerbated by the reduction of subsidies currently provided to poor and middle class families. The Graham-Cassidy bill would also have allowed states to do away with pre-existing condition protections and other essential health benefits that keep Americans healthy. “Congress should engage with physicians and other medical experts on the front lines caring for patients to develop legislation that improves patient access to physicians, protects coverage for our most vulnerable populations and addresses affordability,” said CMA President Ruth Haskins, M.D. In the meantime, bipartisan negotiations have resumed in the Senate between Health Committee Chairman Alexander (R-TN) and lead Democrat Patty Murray (D-WA) to adopt reforms to stabilize the individual market, such as funding cost-sharing subsidies and reinsurance. CMA and AMA support this effort. It has been a long and difficult year for physicians who want to make constructive improvements to the health care system. While the ACA has its flaws, none of the House and Senate proposals thus far have met CMA’s principles for health care reform. CMA and the physicians of California will keep fighting for reforms that increase patient access to health care and maintain coverage for the millions of Californians insured through Medi-Cal and Covered California. October 13, 2017 CMA, General, Managed Care, Medi-Cal ACA, Affordable Care Act, Affordable Care Act (ACA) Repeal, Covered California, Federal Legislation, Federal Legislative Advocacy, Medicaid, Medi-Cal 0 0 Comment Read More »
Be prepared for Covered California changes in 2017 In 2016, Covered California, California's health benefit exchange, enrolled approximately 1.4 million individuals in qualified health plans. It is critical that physician practices understand their participation status, which products are being offered and what changes to expect in 2017. Some of the most significant changes for Covered California in 2017 are: All Covered California enrollees, including those with a PPO or EPO, will be assigned to a primary care physician. The assignment will either happen by January 1, 2017, or within 60 days of the enrollee’s effective date with the plan. United Healthcare will exit California’s exchange marketplace at the end of 2016, impacting approximately 1,200 enrollees. All other plans that offered coverage in 2016 will continue to do so in 2017. Three plans will be expanding into new regions this year: Molina is expanding its HMO coverage into Orange County (region 18). Oscar is expanding its EPO coverage into San Francisco (region 4); Santa Clara (region 7); and San Benito, Santa Cruz, and Monterey (region 8). Kaiser is expanding into Santa Cruz and Monterey (region 8). Anthem Blue Cross, which offered a PPO product in all geographic regions in 2016, will return to offering only its EPO product for individual/exchange enrollees in the following counties: Region 1: Northern counties Region 2: North Bay Area Region 3: Greater Sacramento Region 4: San Francisco County Region 5: Contra Costa County Region 6: Alameda County Region 7: Santa Clara County Region 8: San Mateo County Region 9: Santa Cruz, San Benito, Monterey Regions 15 and 16: Los Angeles counties Region 17: Inland Empire Region 18: Orange County Region 19: San Diego County Physicians are reminded that the Anthem Blue Cross EPO product does not offer member coverage for services provided by an out-of-network provider except in urgent/emergent situations. The change in product type from PPO to EPO may also result in changes to the provider network network and access to participating hospitals in each region. Click here to see which hospitals will NOT be participating in the Pathway PPO/EPO plans effective January 1, 2017. Physicians in affected counties who are currently contracted with Anthem for the exchange/mirror PPO product are encouraged to check the directory to confirm whether they will be part of the plan’s EPO network in 2017. Anthem Blue Cross will now only offer its PPO product in the five following regions for 2017. Region 10: Central Valley Region 11: Fresno, Kings, Madera counties Region 12: Central Coast Region 13: Eastern counties Region 14: Kern County There are some other minor benefit design changes for 2017, such as some increases and decreases to copays for different plan tiers and visit types. For more information, see the 2016 and 2017 standard benefit design grids. To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2017.” The tip sheet is available free to members at www.cmanet.org/exchange. December 14, 2016 Managed Care Covered California, Affordable Care Act, Exchange Plans, Health Insurance Exchange 0 0 Comment Read More »
Covered California announces plan offerings for 2017 Covered California, the state marketplace for health insurance under the Affordable Care Act, recently announced the qualified health plans that were approved to offer coverage in the exchange market for 2017. All of the plans that offered coverage in 2016 will continue to do so in 2017. Three of the plans will also be expanding into new regions this year. Molina is expanding its HMO coverage into Orange County (region 18) through delegated relationships with Monarch and Heritage Network Oscar is expanding its EPO coverage into San Francisco (region 4), Santa Clara (region 7), and San Benito, Santa Cruz and Monterey (region 8). Kaiser is expanding into Santa Cruz and Monterey through collaboration with Watsonville Community Hospital and Dominican Hospital for inpatient and ambulatory specialty care. Kaiser plans a phased expansion to include the opening of three medical offices in January 2017 and a specialty hub for enrollees to be added by 2020. For a complete listing of plans and product types offered by region, see the Covered California 2017 Plans Booklet (see page 31) at www.coveredca.com. August 8, 2016 Managed Care Affordable Care Act, Covered California, Exchange Plans, Molina, Oscar, ACA, Kaiser Permanente 0 0 Comment Read More »
Covered California announces sharp rate hike Covered California has announced an average 13.2 percent hike in insurance premiums for 2017, a sharp increase that is likely to reverberate nationwide in an election year. The California Medical Association (CMA) is concerned the premium increases may hinder the ability of some patients to obtain insurance and access necessary medical treatment. The rise in Covered California premium rates was driven largely by its two biggest insurers, which account for about half of its enrollment. Blue Shield of California said its average rate hike is 19.9 percent, the biggest statewide increase. Anthem, the nation’s second-largest health insurer, said it will be raising rates by an average of 17.2 percent for its Covered California plans. For the past two years, Covered California negotiated rate increases of around 4 percent for its 1.4 million enrollees. But that feat won’t be repeated for 2017, as overall medical costs continue to climb, and the two federal programs that help insurers with expensive claims are set to expire this year. The rate increases reinforce CMA’s concerns about market concentration and the further consolidation of some of the country’s largest health insurance providers — mergers we believe would only lead to less competition and higher costs for health insurance consumers. While we are encouraged by the expansion of some existing Covered California plans into additional California markets, we remain concerned that a few plans still control a majority of the Covered California market. CMA has cautioned that premium increases could leave patients without timely access to affordable care, particularly if higher premiums force them to switch to less expensive plans with higher out-of-pocket charges and narrower provider networks. The incentive to switch plans also raises concerns about the ability of patients to maintain continuity of care, as they may have to change physicians. Extraordinarily high premiums may also give some Californians, particularly those who are young and healthy, an incentive to leave Covered California and instead pay the federal tax penalty. This would result in a Covered California risk pool composed of sicker individuals, which could result in higher health costs and create a disincentive for health plans to participate in Covered California in future years. Keeping medical costs low requires a statewide effort, and CMA will continue to pursue solutions that promote access to affordable health care for all Californians. August 5, 2016 Managed Care Covered California, Exchange Plans, Health Insurance Exchange, Affordable Care Act 0 0 Comment Read More »
Physicians advised to check enrollment status of pregnant patients insured by Covered California In April, news broke that nearly 2,000 pregnant women with Covered California health plans were automatically – and without their knowledge or consent – transferred from their exchange plan to Medi-Cal, even though they were supposed to have the option to stay with Covered California. The problem, attributed by Covered California partly to a computer glitch, can be traced to a recent policy change. Usually, consumers are placed in either Covered California or Medi-Cal based on their income, with no choice in the matter. But the rules are different for some pregnant women whose household income falls between 138 percent and 213 percent of the federal poverty level, or roughly $22,100 to $34,100 for a family of two. Under the October policy change, women who are pregnant at the time they apply for health coverage and fall into this income bracket will automatically be placed into Medi-Cal. Previously, they had a choice between Medi-Cal and Covered California. Women in the affected income range who already have Covered California plans before they become pregnant are now supposed to be given the choice to remain in their subsidized exchange plans—which have out-of-pocket costs such as co-pays and deductibles—or move to Medi-Cal, which is free. The Covered California computer glitch, however, is moving these women into Medi-Cal automatically, without giving them the option to stay with their current plans. Covered California has promised to fix the problem, but the fix is not expected to go live until September. The California Medical Association (CMA) called representatives of Covered California for clarification and was advised that providers should check the eligibility of their pregnant patients to determine if the patient is still enrolled in a Covered California plan or if they have been migrated to Med-Cal. If the patient has been migrated, physicians should ask the patient if she intends to keep Medi-Cal or if she wants to be reinstated with Covered California. Patients who would like to be reinstated should call the Covered California “Pregnancy Escalation Line” at (800) 675-2607. This issue reinforces the importance of verifying eligibility each time the patient is seen to ensure the physician can be paid for services rendered. If the patient opts to switch back to Covered California and pays her premiums retroactively back to the cancellation date, the claims will be paid by the patient’s Covered California plan. However, if the patient opts to keep her Medi-Cal coverage and the physician is not a Medi-Cal participating provider, the physician will not be paid and cannot bill the patient. If a provider knows a patient has Medi-Cal coverage, regardless of whether the provider participates in the Medi-Cal program or not, California law prohibits them from seeking payment from the patient. Covered California has taken several steps to help reduce the number of women who are switched without their consent. The agency sent multiple written notices to the approximately 2,000 women that it identified as having been impacted by the glitch. The agency has updated its main website to give consumers more information about reporting a change related to pregnancy. It is also important to note that the exchange does not require members to report a pregnancy. Covered California patients only need to report a pregnancy if they are interested in other coverage options for pregnant women such as Medi-Cal or the Medi-Cal Access Program. June 8, 2016 Managed Care, Medi-Cal Covered California, Medi-Cal, Women's Health 0 0 Comment Read More »
Why it's important to verify your patients' eligibility and benefits for 2016 With the new year soon upon us, physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year means calendar year deductibles and visit frequency limitations reset. With open enrollment there may also be changes to patients’ benefit plans, or patients may even be covered by a new payor. The new year also brings a host of other challenges that could affect your ability to be paid: Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another. The Covered California open enrollment period began November 1 and runs through January 31, 2016. Covered California estimates it may enroll more than 300,000 new enrollees during the 2016 open enrollment period. However, existing enrollees also have the option to change plans and/or products. Along with the 10 existing plans, two new plans are offering coverage on the exchange in 2016. United Healthcare and Oscar are entering the exchange marketplace for 2016 in select regions. It’s important that physicians and their staff understand their participation status in the various exchange products offered in their areas in order to advise patients before scheduling as to whether they are participating in the patients' plans. For detailed instructions on how to check physician participation status, see CMA’s toolkit, Covered California: Know Your Participation Status, free to CMA members in our exchange resource center at www.cmanet.org/exchange. Contact information for each exchange plan is also included in the toolkit, should practices have additional questions about participation status. Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit. And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan), as do some employer-based plans. This reinforces the importance of verifying patient eligibility – particularly for exchange patients – each time they are seen. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice as your ability to collect can decrease significantly after the patient leaves the office. Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money. December 7, 2015 Managed Care Eligibility, Covered California, United Healthcare 0 0 Comment Read More »
United Healthcare issues amendment to physicians participating in Core network United Healthcare (UHC) recently issued a contract amendment to practices participating in the California health benefit exchange through its UHC Core network. The new contract language amends (or replaces) the prior Appendix 2 of the UHC participating physician agreements. UHC also advised the California Medical Association (CMA) that the only option for physicians who wish to opt out of the Core product network is to terminate the underlying UHC commercial agreement. There is no option to opt out of just the Core network. The Core network, introduced earlier this year, is a network being marketed to employer groups seeking lower premiums and used for its 2016 exchange product. This narrowed network will include approximately 45 percent of UHC’s PPO provider network. In April, UHC notified 19,000 practices included in its commercially contracted provider network, advising of their inclusion in the UHC Core network. UHC has been approved to offer exchange coverage in the five regions of California where fewer than three exchange health plans offered for 2016 including: Region 1: Northern counties (Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne and Yuba counties) Region 9: Central Coast (Santa Cruz, San Benito and Monterey counties) Region 11: Central Valley (Fresno, Kings and Madera counties) Region 12: Central Coast (San Luis Obispo, Santa Barbara and Ventura counties) Region 13: Eastern region (Imperial, Inyo and Mono counties) UHC Core exchange patients from these counties will be allowed to visit any participating Core provider throughout California. Regarding Section 7 of the amendment, CMA expressed concern to UHC that arranging for services 24/7 for solo or small group practices would not be feasible. In response, UHC clarified that a voicemail message or answering service directing patients with an emergency to the nearest emergency room or to call 911 would satisfy this requirement. For non-emergent situations, the requirement can be met by directing callers to an in-network urgent care center or giving them the ability to speak with a physician or qualified health care professional within a specified time frame. CMA has also asked UHC to clarify the requirements under Section 19 of the contract amendment, which includes language about conditions under which UHC will pay for services provided when a prior authorization is obtained, and whether it is consistent with Health & Safety Code §1371.8, which prohibits plans from rescinding or modifying authorizations after the provider renders the service in good faith pursuant to the authorization for any reason, including situations where the plan later determines the patient wasn’t eligible. UHC will be sending a welcome packet to Core participating physicians this month. The payor is also offering a number of one-hour webinars to provide more information about the United Healthcare Core product. Topics included are health plan overview, eligibility and benefits details, how to verify participation status and prior authorization requirements. To register for one of the webinars, visit www.UnitedHealthcareOnline.com > Tools & Resources > Products & Services > 2016 Health Plans Training. Physicians who are unsure about their participation in the Core plan network can contact UHC Network Management at (866) 574-6088. December 7, 2015 Managed Care Payor Contracting, United Healthcare, Covered California 0 0 Comment Read More »
Be prepared for Covered California changes in 2016 In 2015, Covered California, California's health benefit exchange, enrolled approximately 1.3 million individuals in qualified health plans. With Covered California estimating it may enroll an additional 300,000-plus during the 2016 open enrollment period (running November 1, 2015, through January 31, 2016), and two new plans in the mix, it is critical that physician practices understand their participation status, which products are being offered and what changes to expect in 2016. To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association (CMA) has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2016.” The tip sheet is available free to members at www.cmanet.org/exchange. November 9, 2015 Managed Care Health Insurance Exchange, Surviving Covered California, Covered California 0 0 Comment Read More »
DMHC fines Blue Shield and Anthem for provider directory inaccuracies On November 3, the California Department of Managed Health Care (DMHC) announced it had fined two of the state's largest health plans for inaccurate Covered California provider directories. Blue Shield of California was fined $350,000, while Anthem Blue Cross was fined $250,000. These two insurers account for almost 60 percent of patient enrollment in Covered California. Both insurers are also utilizing networks for their exchange/mirror products that are significantly narrower than their regular PPO networks. These narrowed networks, combined with inaccurate provider directories, have led to significant confusion and frustration for both physicians and patients. DMHC has directed both plans to improve the accuracy of their provider directories and to also reimburse enrollees who may have been negatively impacted. Blue Shield has already reimbursed more than $38 million to enrollees who incurred out-of-network costs. The fines were the result of a five-month investigation of the Anthem and Blue Shield Covered California networks, which found that more than 25 percent of physicians listed as participating in the plans’ directories were not taking these patients or they were no longer at the location listed by the companies. The audit also found that in both cases, auditors were unable to confirm Covered California participation status for more than 40 percent of physicians listed as participating in the plans’ directories – after three separate attempts to contact them using information in the directory. This hindrance to accessibility for such a substantial portion of listed physicians is a violation of state law, DMHC said in its report. According to the DMHC audit, only 58.7 percent of the physicians listed in Anthem's Covered California directory could be verified as accepting Covered California patients, which is consistent with previous California Medical Association surveys of physicians listed as participating in Covered California. DMHC found that 12.8 percent of physicians listed by Anthem were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory. DMHC has initiated a follow-up survey to determine if the plans have corrected the deficiencies identified in the initial survey reports. You can read the Blue Shield agreement here, and the Anthem agreement here. November 9, 2015 Managed Care Blue Shield, Covered California, Department of Managed Health care, Anthem Blue Cross 0 0 Comment Read More »
California has the most exchange enrollees in the U.S. California has enrolled more people through its Affordable Care Act (ACA) health insurance exchange of any state, with about 1.4 million enrollees as of June 30, according to new federal data. California surpassed Florida – with 1.3 million exchange enrollees as of the end of June – to have the highest exchange enrollment. Nationwide, 9.9 million U.S. residents signed up for the ACA. About 7.2 million consumers purchased coverage through the federal exchange and 2.7 million purchased coverage through state-based exchanges. Of those who purchased coverage in California, 9,302 people who just purchased catastrophic coverage; 350,225 bought a bronze plan; 895,657 bought a silver plan; 74,067 purchased a gold plan; and 64,316 bought a platinum plan. Covered California open enrollment for 2016 begins November 1, 2015, and ends January 31, 2016. For more information on the exchange’s 2016 offerings, click here. With so many patients relying on exchange plans for their health care, it is even more critical that physician practices understand their participation status. For help verifying your participation status, see the California Medical Association's (CMA) "Surviving Covered California" tip sheets. These documents are available free to members in CMA’s online resource library at www.cmanet.org/resource-library. CMA also continues to monitor the problem of health plan network directory accuracy. Last November, the California Department of Managed Health Care (DMHC) released the results of an audit of the Anthem Blue Cross and Blue Shield Covered California networks. Among other things, the audit found that 12.8 percent of the physicians listed on Anthem’s network were not accepting Covered California patients, while 12.5 percent were not in practice at the location listed in Anthem’s directory. In the case of Blue Shield, only 56.7 percent of the physicians listed in its Covered California directory could be verified as accepting Covered California patients. These inaccuracy rates were consistent with CMA’s and some county medical societies' own verification efforts and analyses. DMHC will be conducting a follow-up of its audit this fall to determine whether the health plans have resolved their inaccurate network directories. Physicians who are misidentified as participating in a Covered California network when in fact they are not, or whose information in a network directory is inaccurate, are urged to contact CMA’s Center for Economic Services at (888) 401-5911 or economicservices@cmanet.org. September 23, 2015 Managed Care Exchange Plans, Health Insurance Exchange, Affordable Care Act, Covered California 0 0 Comment Read More »
