AMA urges quick action to stabilize individual insurance market With the window quickly closing to properly price individual insurance products for 2018, the American Medical Association (AMA) is urging President Trump and Congressional leaders to commit to continued funding for the cost-sharing reductions that are critical to stabilizing the individual market. AMA, along with other groups representing insurers, hospitals, health plan purchasers and physicians, sent a letter urging quick action to deliver short-term stability and affordable coverage while broader marketplace stabilization efforts are developed. Nearly 60 percent of all individuals who purchase coverage via the exchange receive financial assistance to make health care affordable. These subsidies reduce out-of-pocket costs for patients who might otherwise be unable to afford health care services despite being insured. The funding helps those who need it the most access quality care: low- and middle-income consumers earning less than 250 percent of the federal poverty level. If the cost-sharing subsidies are not funded, Americans will be dramatically impacted: Choices for consumers will be more limited, leaving individuals with fewer coverage options. Premiums for 2018 and beyond will go up by at least 15 percent, both on and off the exchange. Higher premium rates could drive out of the market those middle-income individuals who are not eligible for tax credits. If more people are uninsured, providers will experience more uncompensated care, which will further strain their ability to meet the needs of their communities and will raise costs for everyone, including employers who sponsor group health plans for their employees. Hardworking taxpayers will pay more, as premiums grow and tax credits for low-income families increase. The California Medical Association shares the sentiments of the letter and looks forward to working with Congress and the Trump Administration to take positive actions to stabilize the health care marketplace. April 19, 2017 General, Managed Care ACA, Affordable Care Act, AMA, American Medical Association, Health Insurance Exchange, Insurance 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 »
Have you received a request to confirm provider directory information from BetterDoctor? The California Medical Association (CMA) has received an increasing number of inquiries over the past few weeks from practices concerned about the validity of requests for information from a company called BetterDoctor. SB 137, the new provider directory accuracy law, took effect July 1. The new law requires payors to ensure that their physician directories are accurate and up-to-date. BetterDoctor is a vendor working on behalf of 10 plans on a pilot project to ensure the accuracy of their physician directories, as required under the new law. Practices are encouraged to respond to the information requests, as the law also requires physicians do their part to keep their information up-to-date. (Click here to see the BetterDoctor template information request.) The ten plans included in the pilot are AltaMed, Anthem Blue Cross, Blue Shield of California, CareMore, Health Net of California, Humana, LA Care, Molina Healthcare, SCAN and Western Health Advantage. For more information on the pilot, click here. There may also be other pilot programs taking place on behalf of other payors that utilize other vendors. For more information about physicians’ obligations under SB 137, see CMA's new resource, “What Physicians Need to Know to Avoid Penalties Under the New Provider Directory Accuracy Law." September 22, 2016 Managed Care Health Insurance Exchange, Provider Directories, Provider Directory Accuracy Law, Exchange Plans 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 »
Ask the expert: If an exchange patient is in the 90-day grace period and fails to pay the premium, is the plan required to pay for services provided? Maybe. Under the Affordable Care Act, exchange enrollees who receive federal premium subsidies to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums. Insurance ID cards for exchange enrollees do not indicate whether the enrollee is subsidized, but Covered California recently reported that 90 percent of California exchange patients are receiving subsidies, so the likelihood of encountering a patient receiving subsidies is very high. In the first month of the grace period, federal law and California regulations require plans to pay for services incurred even if the patient fails to pay the premiums due by day 90 (CCR §1300.65.2(b)(1)(A)). But in months two and three of the grace period, plans can “suspend” coverage and pend or deny claims if the patient doesn’t true up on his or her premiums by day 90. However, in 2014, the California Medical Association (CMA) was successful in advocating that plans be required to clearly communicate through their real time eligibility and verification systems if an enrollee’s coverage is suspended during the second and third months of the grace period. Further, the regulation requires plans to reflect “suspended” coverage on day one of the second month of the grace period, and requires plans to use one of three eligibility status indicators to reflect suspended coverage – “coverage pending,” “coverage suspended” or “inactive pending investigation” (CCR §1300.65.2(b)(C)). If a plan fails to reflect suspended coverage using one of the above indicators on day one of the second month of the grace period, and a physician provides services to a subsidized enrollee, the plan is financially responsible for the claims incurred (CCR §1300.65.2(d)(5)). For this reason, it is extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible, and that the practices retain a printout of the eligibility verification and includes it as part of the patient’s chart. If a patient's eligibility verification comes back indicating his or her coverage is suspended, the practice can treat the situation as it would any other patient who has had a lapse in coverage. For non-emergency services, patients may be given the option to either pay cash at the time of service or reschedule to a later date. If a plan requests a refund for services provided during the first month of the grace period, practices should dispute the request in writing, citing California Code of Regulations section 1300.65.2 (b)(1)(A), which requires plans to pay for services incurred in the first month of the grace period. Practices should also contact CMA so that we can identify any systemic issues with the payor. If a plan requests a refund on a patient who was in the second or third month of the grace period, but the eligibility verification did not reflect suspended coverage, the plan is not entitled to the refund. The practice should submit a written dispute to the plan citing California Code of Regulations section 1300.65.2(d)(5). Again, please contact CMA if this happens, so we can identify any systemic issues. For more information, visit CMA’s exchange resource center at www.cmanet.org/exchange. In the resource center, you can download CMA's Surviving Covered California tip sheets as well as a number of other CMA exchange resources. CMA members and their staff also have FREE access to our reimbursement helpline at (888) 401-5911 or economicservices@cmanet.org. November 10, 2015 Managed Care Grace Period, Exchange plans, Health Insurance Exchange 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 »
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 »
Gallup poll says rates of uninsured continue to drop in most states According to a Gallup poll released Monday, the national uninsured rate has fallen to 11.7 percent, down from 17.3 percent in 2013. The poll shows that states that have expanded Medicaid under the Affordable Care Act – and have at least helped in the running of their health insurance marketplaces, rather than leaving it entirely to the federal government – have seen larger drops in uninsured rates. In the 22 states that took both of those measures, including California, the uninsured rate dropped to an average of 7.1 percent. California's uninsured rate dropped to 9.8 percent, down from 21.6 percent in 2013. In the 28 states that did not expand Medicaid or help run their marketplaces, the uninsured rate fell 5.3 percentage points. Through the first half of 2015, there are now seven states with uninsured rates that are at or below 5 percent: Rhode Island, Massachusetts, Vermont, Minnesota, Iowa, Connecticut and Hawaii. Previously, Massachusetts had been the only state to be at or below this rate. This data, collected as part of the Gallup-Healthways Well-Being Index, is based on Americans' answers to the question, "Do you have health insurance coverage?" The state-level data is based on daily surveys conducted from January through June 2015 and includes sample sizes that range from 232 randomly selected adult residents in Hawaii to more than 8,600 in California. Click here to read the report. August 17, 2015 Managed Care, Medi-Cal, Medicare Affordable Care Act, Health Insurance Exchange, Uninsured, ACA, Insurance 0 0 Comment Read More »
Anthem Blue Cross begins medical chart reviews in July In July, Anthem Blue Cross will begin chart reviews on enrollees who purchased Affordable Care Act (ACA)-compliant plans in either the individual and small group insurance markets (both on and off the exchange, known as “Covered California”). The records requests are a result of the commercial risk adjustment program created by ACA Section 1343. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population. Because the information reported by physicians and other providers is at the heart of payment adjustments, health plans must engage providers by requesting copies of medical records that accurately reflect diagnoses and/or underlying health conditions to comply with risk adjustment program requirements [77 Fed. Reg. 17220, 17241 (March 23, 2012)]. During the risk adjustment audit, Anthem will review diagnosis code data obtained from the medical records of ACA-compliant individual and small group patients. This is not a typical audit on the physician practice; rather, Anthem is looking to identify conditions/illnesses that demonstrate patients who are at risk for being sicker or patients who are predicted to be healthier. This information will be utilized to determine a risk score, which is a measure of how costly an individual is anticipated to be, and will be reported to the Centers for Medicare and Medicaid Services. If at the end of the annual risk adjustment assessment, Plan A has a lower risk average score than Plan B, then Plan A has to issue a payment to Plan B. In a nutshell, the program is intended to prevent payors from cherry picking only healthy enrollees. Anthem reports it will also utilize the data to better manage patient health conditions. Anthem has contracted with Inovalon, Inc., a secure clinical documentation service, to conduct the medical chart reviews. Inovalon will utilize several methods of collecting medical record information from physician practices, including: Scanned or faxed medical records that providers’ offices send to Inovalon Onsite medical record reviews by clinical personnel Automated medical record retrieval from the provider’s electronic health record (EHR) system (only upon authorization from the practice) In cases where fewer than six medical records are being requested for review, Inovalon will contact each provider’s office and request the information via fax or mailing of medical chart information. In cases where Inovalon is requesting more than six medical records to review, the company will contact the provider’s office and arrange a time convenient to visit the office to collect the appropriate information or to discuss accessibility of the information from the provider’s EHR system. Questions about the letter or the enclosures can be directed to Inovolan at (877) 448-8125 FREE. Anthem has also published an FAQ about the commercial risk adjustment records request. Questions about the initiative can be directed to Inovolan at (800) 390-3180 FREE or CRA@anthem.com. For more information on commercial risk adjustment, visit the California Medical Association website at www.cmanet.org. July 6, 2015 General, Managed Care Affordable Care Act, Anthem Blue Cross, Covered California, ACA, Health Insurance Exchange 0 0 Comment Read More »
Covered California board proposes to cut budget because of slower enrollment Due to tepid enrollment numbers, Covered California’s board of directors has proposed to spend $58 million less in 2016, slashing its marketing and outreach program by 33 percent. Open enrollment in Covered California fell short of its goal of 1.7 million this year, ending with the number of enrollees at 1.4 million. Additionally, the exchange must pay its own way in the future after receiving $1 billion in federal money. And while it still has some $290 million in reserve for 2016, the exchange projects that fewer than 1.5 million people will sign up for next year. Several factors contributed to the falling numbers of enrollees, but pundits say some uninsured still find the cost of health insurance unaffordable despite premium subsidies. Because state law prohibits Covered California from drawing on state general funds, its primary source of revenue is the $13.95 tacked onto every individual enrollee policy. The state will retain this fee, but it will be unchanged from the previous year in an effort to hold down premiums for enrollees. Maintaining the monthly fee will raise $233.2 million in revenue. Next month, the exchange’s board is expected to take a final vote on the proposed $332.9 million budget for the fiscal year starting July 1, 2015. Negotiations are also underway with health plans on their 2016 exchange products, for which initial rates have already been submitted. Despite the fact that California was one of the worst performing states in terms of the change in enrollment this year, with less than a 1 percent increase, Covered California projects that it will enroll 1.48 million next year and it hopes to reach nearly 2 million by 2019. This slight increase allowed Florida to overtake California as having the most exchange enrollees, though this is no doubt due to Florida having a larger potential subsidized enrollee population on account of its lack of an expanded Medicaid program. Some states reported significant enrollment increases – Connecticut reported a 39 percent increase, while New York saw a 10 percent increase. The exchange signed up nearly 500,000 new enrollees during its second open enrollment period, but it also lost a significant number of customers. It retained 65 percent of the reported 1.4 million people it originally signed up. People whose incomes fell were shifted to Medi-Cal (160,000), with fewer than expected enrollees migrating to Covered California from Medi-Cal. Health insurers also have predicted higher churn in the health exchange as the economy recovers and more people gain health care coverage through work. May 15, 2015 General, Managed Care Covered California, Health Insurance Exchange, Affordable Care Act 0 0 Comment Read More »
